Question
Outcome measures have been around for a while now. Are they beneficial and what can they assist with?
Answer
Outcome Measures help clinicians to:
•Make function objective. Rather than stating to your patient, "I think you look really good today, you're walking better" which is an observation type of statement to our patient, we can track and make more of an objective measure. For example, "you walked 'X' gait speed and today you are walking 'this' gait speed. It makes it a little bit more tangible for us as clinicians and also for our patients.
•Track progress within the practice setting and across the continuum over time. If your patient is moving from acute care to outpatient and you share a medical record, you can see how they did on the Berg in the inpatient facility and track improvement.
•Identify when a plan of care (POC) is effective or not effective. The only way we know our interventions are working is to identify via outcome measures, pre, intermediate, and post-measurement. Outcome measures help us to know, yes, this intervention is working, and they are getting better. Outcome measures are objective; it's not my opinion.
On the other hand, an outcome measure can determine if your intervention is not working, I might need to shift gears. Maybe we need to stop doing that specific intervention and start focusing on, family training or focusing on more wheelchair mobility. If they're not responding to gait and they're not making any improvements, maybe we need to shift gears. It is very important to have those objective measures and data to support your clinical decision-making. Outcome measures are a way to check yourself and make sure, okay, I've given this my best go, this patient isn't making any progress.
•Enhance communication with clinicians in various settings. Outcome measures can provide a clear picture of how patients are going to present. This is extremely helpful when filling in for a colleague who is on vacation and you're taking over their patients' plan of care for the week. Outcome measures will assist in understanding how the patients will respond to therapy, and progressing their plan of care forward. For example, if you know their most recent Berg score, 10-meter score, and 6-minute walk test, you can get a clear picture of the patient when you are used to using these measures consistently.
If you're doing a quick handover and notice that the patient's postural assessment scale for stroke is a seven, you know they need a lot of help just to sit up right now if you are familiar with that test. Outcome measures help to identify a profile of a patient.
•Justify reimbursement. The need to justify reimbursement and progress happens a lot in inpatient rehabilitation, especially with patients who may not be making the locomotor gains as quickly. An outcome measure can show that things are improving, it's just not translating maybe into one component, such as gait. Outcome measures are objective and we can use those measures to help justify the need for a wheelchair if the patient is not a good functional ambulatory. For example, having a 10-meter walk test with a score that's very slow can aid in that justification for the wheelchair prescription that you prescribed for your patient.
On the other hand, if your patient is a really great ambulator, that could be justification for higher level activities or trying to push them to outpatient quicker to get the patient where they need to go to get the best level of care. You can use outcome measures in either direction.
•Direct POC and guide interventions. We direct our plan of care and guide our interventions based on these outcome measures. We all know what to do with a stroke patient, but if we don't utilize outcome measures, we can cruise along with their plan of care and keep them on schedule. When we assess with outcome measures and treat with intention and purpose to include things such as, "what are my prognostic values, how long can I anticipate my patient will be here, and what kind of equipment should I anticipate that they may need", they help hone in these critical elements to make your plan of care more seamless and to help guide that plan to make it the most efficient. We all know that length of stay is getting shorter and shorter and we are trying to drive maximal outcomes in the shortest amount of time.
•Improve patient outcomes/buy-in. When its been three weeks and your patient is frustrated and he or she doesn't feel like they are walking very well or getting any better, having something objective in the electronic medical record system showing them progress can help overcome some of those obstacles that patients often have when they just want to be independent again. For example, you can state to your patient, when you came here you were a 16 and now you're a 45 on the Berg. It can help paint a better picture of the process of their recovery and the gains they are making. Showing them the upward trend is often very helpful.
•Make clinical predictions. The Berg Balance scale (BBS), for example, can help predict the level of ambulation. If using high-intensity gait training (HIGT), a BBS score as low as 5 can predict recovery of walking at contact guard assist or better. A score of greater than 29 is predictive of community ambulation following 4 weeks of inpatient rehabilitation while a score greater than 12 is predictive of regaining ambulation following 4 weeks of inpatient therapy.
•Assist with discharge planning. Outcome measures can assist in clinical decisions. For example, the postural assessment scale for stroke (PASS) can help determine if the patient needs to go to a skilled nursing facility (SNF) after an acute care discharge with a score of 9.5. A score of 32.6 is discharge home with outpatient while a score of 15.7 is discharged to inpatient rehab.
This Ask the Expert is an edited excerpt from the course, Managing Stroke Patients During Inpatient Rehabilitation: Using Evidence to Guide the Plan of Care, by Christina Voigtmann, PT, DPT, NCS
