Clinical pathways: 12 lessons learned over 25 years of experience

Abstract

Clinical paths have demonstrated their value in support of patient care management throughout the last 25 years of use. With over 25 years of experience in using clinical paths, a number of lessons have been learned. The remainder of this article will outline 12 of those lessons. Clinical paths provide continuity of plan that needs to be augmented by continuity of provider, particularly for patients with complex issues. Clinical paths of the future will be simultaneously more simple and more complex. This dichotomy is related to increasingly complex treatment modalities; increasing numbers of care sites; and rapid infusion of evidence and research findings. Clinical paths must help simplify and focus care for providers who are engaged in providing individualized, evidence-based, focused and comprehensive care to diverse patients. And most importantly, they must make a difference to patients and their families. Clinical Path originsClinical paths have demonstrated their value in support of patient care management throughout the past 25 years of use. They originated at New England Medical Center (Boston, MA, USA) in 1984, at the dawn of the newly introduced DRG (Diagnostic Related Group) system. DRGs introduced an approach for Medicare (the government funded health-care reimbursement system for American citizens 65 years and older) -a case-based payment for care based on diagnoses within groupings of diseases and conditions that use similar resources. This shift to a casebased payment methodology created a new imperative for hospitals to more effectively manage length of stay while also managing quality. This is because a case-based reimbursement system establishes an 'usual' or average length of stay based for each DRG and that, in turn, sets the reimbursement amount. Hospitals are reimbursed for a diagnosis no matter the length of stay. Moreover, if the hospital's length of stay (and ultimately cost) is under that established for the diagnosis, it may retain the excess revenue. However, if care takes longer or costs more than that established for the diagnosis, the hospital loses money because it cannot request additional funding. DRGs became (and continue to be) the stimulus to develop strategies to manage length of stay within defined parameters.Simply defined, clinical paths are a tool designed for clinicians to use as they provide care to populations of patients. As such, they are part of a larger process. They are the means to the end. . . they are NOT the end in and of themselves. They are a tool for care management, a process that efficiently and effectively aligns patient needs/issues with resources to meet quality, satisfaction, clinical and cost outcomes. The goal of care management is to manage individuals at their maximum level of comfort, functionality and independence while at the lowest (and most appropriate) level of intensity of service. Rationale for clinical path useThe underlying rationale for clinical paths has remained the same since their inception: Support quality care and patient/ family ...

An overview on the history and concept of care pathways as complex interventions

“…18,20–23,27,30,31,34–38 They originate from industrial processes and were introduced in health care in the early 1980s in the USA. 23,37,39–43 The development, implementation and evaluation of care pathways represent one of the structured care methodologies next to, for example, guidelines, protocols and case management. 22,35–37,44–47 Nowadays, care pathways are being implemented as a method for monitoring processes and processing time, in a wide range of health-care systems, primarily to improve the efficiency of hospital care while maintaining or improving quality.…”

Have We Drawn the Wrong Conclusions About the Value of Care Pathways? Is a Cochrane Review Appropriate?

“…Care pathways, initially termed case management plans, critical pathways, or clinical pathways, were introduced in the United States in the late 1980s with a new finance system based on diagnosis related groups (Bower, 2009; Zander, 2002; Zander, Etheredge, & Bower, 1987; Zander & McGill, 1994). They were designed to decrease length of stay and cut out unnecessary cost while maintaining or improving the quality of care.…”

Successes and Challenges in the Implementation of Care Pathways in an Intellectual Disability Service: Health Professionals' Experiences

“…The concept of healthcare pathways was first introduced in the 1980s in the United States (Bower, ; Hindle & Yazbeck, ; Panella, Vanhaecht, & Sermeus, ; Zander, ; Zander, Etheredge, & Bower, ) and in most developed countries, including the UK, in the 1990s (Johnson, ; Zander, ). Pathways outline the essential steps in the care and treatment delivered for a client, including anticipated care over a given time period and documentation of milestones and clinical interventions throughout the client's clinical experience (National Leadership and Innovation Agency for Healthcare, ).…”