Subacute Care/Hospital Forum

Critical Pathways: Leading from Hospital to Long-Term Care

To be an active and effective player today, the consultant pharmacist must understand the technical aspects of health care as well as appreciate the health care system as a whole. As changes in the health care industry continue, the lines between hospital, long-term care, and home environments are blurring. Patients-or residents-are moved quickly from one setting to another. The consultant pharmacist must work within a continuum of care by communicating with other providers and appreciating the need for standardization of care.

One example of current hospital efforts to standardize care is the development of critical pathways. These not only provide a roadmap for care, but they also facilitate documentation of care for payers.

Critical pathways, at times referred to as clinical pathways or multidisciplinary care plans, are one mechanism to ensure standard care for patients and to forecast outcomes. As diagnosis related groups continue to limit the length of hospital stays, some mechanism is needed for standardizing care for similar patients with similar conditions. As these patients are discharged from the acute care setting, many of them are put into step-down units, skilled nursing facility beds, or subacute care units. Again, their lengths of stay are limited in these settings. The critical pathway can again be used to standardize care and document outcomes.

The concept of standardized care has received varying degrees of acceptance from the medical community. As health care evolves, the concept of standardization of care will be not only preferred but mandated. In the long-term care setting, the shift toward standardized care presents opportunities for consultant pharmacists who take the lead. Those who choose not to lead will eventually find themselves struggling to catch up.

The first step in organizing a critical pathway team is the most crucial. It must be an interdisciplinary effort. The consultant pharmacist can function through existing pharmacy and therapeutics committees or quality assurance and assessment committees. The effort must truly be a step-by-step team process involving representatives of the following groups: pharmacy, medical staff, nursing, respiratory therapy, physical therapy, dietetics, and discharge planning.

The committee's initial objective is to identify the disease or condition to be examined. Working closely with the director of nursing and the admissions coordinator, the pharmacist should be able to focus the committee's attention on the most frequent admitting diagnoses (This step is important because agencies such as the Joint Commission on Accreditation of Healthcare Organizations make facilities document that the diagnoses are common or critical.) Once the disease is identified, the group must look at all aspects of residents' care. The committee must discuss the expected outcome as well as the treatment strategy.

A good way to start is by using the flow chart method. For Day 1 of the admission, list these items: recommended laboratory testing, activities, medications, consults, and patient education topics. For subsequent time periods (days or weeks), the resident's progress can be noted. Treatment decisions in response to events should be noted using a decision-tree format. Recommendations-along with pertinent current literature and information on standards of practice-should be listed.

Once the steps have been presented, the staff should review the plan to make sure it is outcome-specific. The plan must show that, if it is followed, the intended outcome can be reasonably expected to follow. This type of documentation is looked upon favorably by surveying organizations, including the Joint Commission by or managed care organizations looking to contract with long-term care facilities.

The preparation and use of critical pathways will benefit the resident by providing valid, up-to-date approaches to standardization of care. Their use will benefit the nursing facility by increasing its level of service, improving operating efficiencies and Joint Commission survey results, and aiding in contract negotiations with managed care organizations.

One facility administrative person should be responsible for follow-up documentation of critical pathways and their impact. Data will be needed so that improvements can be identified and made-and so the efforts of the team can be recognized.

Consultant pharmacists have an opportunity to be leaders in patient care through development of critical pathways in subacute and long-term care. They can play an active role through committee involvement that will help improve the standard of care, as well by aiding the facility in preparing for the increasingly important role played by managed care. The opportunity exists now for those pharmacists who will meet it.

Larry N. Owen, RPh, MBA
Pharmacy Systems, Inc.
6125 Frantz Road
Dublin, OH 43017