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Critical Pathways In Home Care
by Bonnie Westra, RN, PhD

Critical pathways are clinical management tools which:

• Define desired client outcomes and goals,
• Direct collaborative practice,
• Provide for coordination and continuity of care involving clients and families, and
• Focus on reducing resource requirements.

In this article, common ingredients in a critical pathway, some problems encountered in applying this tool to home care, and an example of how these can be overcome, are examined.

Critical Pathways

Originally, critical pathways were developed for use in hospitals to reduce hospital lengths of stay while maintaining or improving outcomes of care. More recently, critical pathways have been used in home care.

Usually critical pathways have been established for clinical conditions which have variation in treatment and are either high risk, high volume, or high cost. These clinical conditions have been described either in terms of a medical treatment such as a total knee arthroplasty, or as a medical condition such as an acute myocardial infarction.

Critical pathways serve both as a plan of care and as a documentation system which is coordinated by a single professional, usually a nurse case manager. It is the responsibility of the case manager to assure that planned events happen as expected.

Documentation is done by all care providers, usually charting by exception. When interventions occur on time, and outcomes are achieved, the critical path is signed for each day/visit. If interventions or outcomes vary from what is expected, these are documented along with the reasons the variations occurred.

Variations usually are described as client, provider, and system variances. Client variances are those factors attributable to the client which prevented the intervention from occurring or the outcome from being achieved. An example would be an inability to progress ambulation because of dizziness.

Provider variances would include deviations from the plan of care due to the caregiver not showing up for a visit or the caregiver forgetting to bring essential equipment. System variances are deviations from the plan of care due to the home health agency or external influences. These might include such issues as scheduling problems or denial of care by a third party payor. Corrective action for individual variances are determined by the case manager, in collaboration with the team. Variances across individuals with the same condition are analyzed by team members to improve the overall quality of practice.

Issues for Home Care

Several issues need to be considered in development of critical pathways for home care:

The first is determining which clinical conditions are most appropriately treated with a critical pathway Given that critical pathways often are used to reduce resource utilization (such as length of stay), it would seem most appropriate to use them for high volume home care clients who are post-acute care, such as many Medicare clients.

A second issue addresses which disciplines in home care should be involved in developing a critical pathway. In home care, nurses and home health aides may be the only disciplines actually providing care. However, one needs to consider that physicians are involved in ordering care and insurers in determining reimbursement for care. A critical pathway may serve to educate physicians in a pictorial manner exactly what occurs at each visit and to justify to reimbursement sources why each visit is essential. In more complex cases, development of a critical pathway may involve therapists, social workers, nutritionists, or perhaps even nurses from other agencies.

In hospital settings, critical pathways most often use "days" as the time frame for determining when interventions need to occur. In home care, the time frame used for a critical pathways would best be stated in terms of visits or weeks/months, since nurses may not visit clients on a daily basis. However, if a critical pathway were developed for clients who have daily care or even 24-hour a day care, then days or hours might be necessary for determining when interventions need to occur.

Standardized Language

Perhaps one of the more controversial issues, regardless of setting, is how standardized nursing language fits into critical pathways. One of the major trends in health care is the use of electronic transmission of data to regulators and reimbursement sources. In addition, there is a major thrust toward developing an electronic medical record which may be used across settings. Data which can not be coded most likely will not be included, or will be too cumbersome to be useful.

Standardized nursing data are essential to validly describe what occurs in home care. It is suggested elsewhere in this newsletter that, of the standardized nursing languages currently available, the Omaha System, developed by the VNA of Omaha, offers the best combination of thoroughness and ease of use.

Three components of the Omaha System, each related to a nursing process element, can be used for critical pathways. These include the Problem Classification Scheme (nursing diagnoses), Intervention Scheme (interventions), and the Problem Rating Scale for Outcomes (outcomes). The Omaha System provides valid and reliable data to describe practice in home health care and has proven to be useful across disciplines.

Under the Omaha System, the components of a critical pathway would include a problem list with a critical path of interventions and expected client outcomes. The outcomes are goals the client must achieve to demonstrate that the problem was resolved. The critical path specifies interventions in a time-ordered sequence for all disciplines providing care.

During implementation, each intervention would be checked off by the appropriate caregiver and any variances noted. In this way, essential activities are completed in a timely manner, all team members know what to expect in collaboration with others, and outcomes are achieved while using resources as efficiently as possible.

Citation: Westra, B. (1993). Critical Pathways In Home Care, The Quality Messenger, 1(1), 1, 6, 8.

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