Ideally, one would like to see a measurement approach that:
The solution to this challenge is to create an assessment approach that incorporates the features designed to maximize these elements. To cover the broad spectrum sought and still be relatively quickly administered, an instrument should have multiple branch points. These permit the user to focus on the area along the continuum where the patient is most likely to function and to expand that part of the scale to measure meaningful levels of performance. Branching can also ensure that the assessment is comprehensive but not burdensome.
By using key questions to screen an area, interviewers can ascertain whether to obtain more detailed information in each relevant domain. Where the initial response is negative, they can go on to the next branch point. Reliability is more likely to be achieved when the items are expressed in a standardized fashion tied closely to explicit behaviors. Whenever possible, performance is preferred over reports of behavior.
One cannot expect to totally avoid the gaming of an assessment. If the patient knows that poor performance is needed to ensure eligibility, he or she may be motivated to achieve the requisite low level. One can use some test of reporting bias, such as measures of social desirability, but they will not prevent gaming the system or detect all cheating.
Clinical medicine seems headed inevitably toward electronic medical records. This step could represent a major advance in the care of older people, if the opportunity is properly harnessed. Simply reproducing the current unstructured information set in a more legible and transmissible format will not suffice. Structured information provides the vehicle for assuring a more systematic evaluation and follow-up of cases. By distinguishing between missing and normal values, it can provide the structure to focus clinicians' attention on salient items.
Computer technology can dramatically reduce redundancy. Properly mobilized, computers can provide the structure needed to assure a comprehensive assessment with no duplication of effort. Because they are interactive, they can carry out much of the desired branching and can even use simple algorithms to clarify areas of ambiguity and retest areas where some unreliability is suspected. Similar algorithms can look for inconsistency to screen for cheating.
Data stored on computers can be aggregated to display performance across patients by provider (eg, physician, nursing home, or agency). Data on a patient can be traced across time to look at changes in function and, in turn, can be aggregated.
The next important step in the progression is to move the focus from a single point of care to the linking of related elements of care. In an ideal system, patient information would be linked to permit tracing changes in status for that individual as they move from one treatment modality to another. Thus, hospital admission and discharge information, long-term care information, and primary care information would be merged into a common computer-linked record, which allows one to trace the patient's movements and status. The federal Office of the National Coordinator and other federal and state agencies are developing standards for transferring clinical information from one setting to another.
Finally, it would be desirable to have data on the process of care as well as the outcomes. This combination would permit analyses of what elements of care made a difference for which patients.
Such an approach to assuring quality is within our grasp if we are prepared to invest in data systems and to commit ourselves to collecting standardized information. It necessitates a shift in some of our fundamental paradigms from thinking about whether we did the right thing to deciding if it made any difference after all.
Two basic changes in thinking are necessary in order to establish an outcome-based philosophy, both of which are difficult for clinicians.
Thinking in the aggregate, using averages instead of examining each case: Outcomes do not work well for individual cases because there is always a chance that something will go wrong, and life does not provide a control group.
Attributing responsibility to the whole enterprise rather than placing blame on an individual: A pattern of poor outcomes will mandate closer inspection of the process of care, but outcomes per se are a collective responsibility.
Computerized records greatly facilitate the task of monitoring the outcomes of care. Ideally, such a record system should be proactive, directing the collection of clinical information to encourage adequate coverage of relevant material. Long-term care is actually ahead of acute care in this regard, with the federal requirement for computerized versions of the Minimum Data Set. Unfortunately, most of the systems in use are simply inputting mechanisms. They do not begin to tap the real potential of a computerized information system. Because long-term care depends heavily on poorly educated personnel for so much of its core services, the availability of an information support system, which can provide feedback and direction, is especially appropriate.
Computerization can provide both the flexibility and the brevity sought by using branching logic to expand a category when there is reason to explore it more thoroughly. It can avoid duplication by displaying data already collected by others while still permitting the second observer to correct and challenge earlier entries. More important, it can display information to show change over time, thus permitting both the regulators and the caregivers to look at the effects of care.
Once the data are in electronic form, they are easily transmitted and manipulated. It is not hard to envision a large set of data derived from these systematic observations that would permit calculations of expected courses for different types of long-term care patients. These could then be compared to individual patients' courses to assess the potential impact of care on outcomes.
The computer's ability to compare observed and expected outcomes extends beyond its role as a regulatory device. It could be a major source of assistance to caregivers. One of the great frustrations in long-term care, especially in the trenches, is the difficulty in sensing whether the caregiver is making a difference. Because so many patients enter care when they are already declining, the benefits of care are often best expressed as a slowing of that decline curve. Without some measure of expected course in the absence of good care, those who render care daily may not appreciate how much they are accomplishing and thereby may forgo one of the important rewards of their labors.
Displaying information about the change in patient's condition over time, which is a simple task for a computer, will assist the long-term caregiver to think more in terms of the overall picture, rather than a series of separate snapshots in time. Given the computer's ability to translate data into graphics, it is a simple procedure to develop pictorial representations of the changes occurring for a given patient or group of patients and to contrast those with what might be reasonably expected.
Again the effort is directed toward changing perceptions about older persons, especially those in long-term care. For too long, long-term care has worked in a negative spiral—a self-fulfilling prophecy that expected patients to deteriorate—serving to discourage both care providers and patients. Such an attitude is hardly likely to attract the best and the brightest in any of the health professions. As noted earlier in this chapter, nursing home patients are among the most responsive to almost any form of intervention. Any information system that can reinforce a prospective view of long-term care, especially one that can display patient progress, represents an important adjunct to such care.
Assessing Care of Vulnerable Elders (ACOVE) has also made a number of recommendations about steps in providing better care, but none are supported by strong evidence (Wenger and Shekelle, 2007), although they make good clinical sense. These recommendations are summarized in Table 4–4.
Table 4–4. ACOVE Recommendations ||Download (.pdf)
Table 4–4. ACOVE Recommendations
- All patients should be able to identify a physician or clinic to call for medical care and know how to reach them.
- After a new medication is prescribed for a chronic illness, the following should be noted at follow-up:
- Medication is being taken as prescribed.
- Patient was asked about the medication (eg, side effects, adherence, availability).
- Medication was not started because it was not needed or changed.
- If a patient is seen by two or more physicians and a new medication is prescribed by one, the other(s) should be aware of the change.
- If a patient is referred to a consultant, the referring physician should show evidence of the consultant's findings and recommendations.
- If a diagnostic test is ordered, the following should be documented at the next visit:
- Result of the test specifically acknowledged.
- Note that the test was not needed or not performed and why.
- Note that the test is pending.
- If a patient misses a scheduled preventive visit, there should be a reminder.
- When patients are seen in an emergency department (ED) or admitted to hospital, the continuity physician should be notified within 2 days.
- Patients discharged from hospital and who survive 6 weeks should have some contact with their continuity physician who should be aware of the hospitalization.
- When a patient is discharged to home from hospital and receives new chronic disease medication, the continuity physician should document the change in medication within 6 weeks.
- When a patient is discharged to home or to a nursing home from hospital and tests are pending, the results should be available within 6 weeks.
- When a patient is discharged to home or to a nursing home from hospital, there should be a discharge summary in the continuity physician's records.
- If a patient does not speak English, an interpreter or translated materials should be used.