Strengthening Information Capture Strengthening Information Capture

in Rehabilitation Discharge in Rehabilitation Discharge

Summaries Summaries ––

An Application of the An Application of the SiebensSiebens

Domain Management ModelDomain Management Model

Mario Perez MD, Woojae Kim MD, Beny Charchian MD MS, Eric Y Chang MD, Li-Jung Liang PhD, Armen Dumas MD, Hilary C. Siebens MD, Hyung Kim MD

Department of Physical Medicine and Rehabilitation, VA GLA Healthcare System, Los Angeles CA

Department of Medicine, UCLA School of Medicine,Los Angeles, CA and

Siebens Patient Care Communications, Seal Beach, CA

AAPM&R Annual Assembly, San Diego, CA Nov 15, 2014

Acknowledgements

� Harriet Aronow, PhD

� Carol Stein, OTR

� Crystal Barker, RN

� Agnes Wallbom, MD

� Milena Zirovich, MD

� Steve Figoni, RKT, PhD

Introduction

� Limitations in medical communication

�Lengthy reports, obscure essential clinical issues

�Lack of standardized discharge summary formats

�Lack of clear organization

�Unstructured, with inadequate information capture

Introduction

� Siebens Domain Model Management SDMM (2001)

�Provides a framework for organizing the documentation of care

�Consistent with Engel’s biopsychosocial model (1977) and Stineman’s biopsycho-ecological model (2007)

�Organizes patient’s health-related strengths, problems and issues into four domains

See final slide for references.

SDMM: The Four Domains

I. Medical/Surgical Issues

• Symptoms

• Diseases

• Prevention

II. Mental Status/ Emotions/ Coping

• Communication

• Cognition

• Emotions

• Coping/ Behavioral Symptoms

• Spirituality

• Personal Preferences/ Advance Directives

III. Physical Function

• Basic ADLs: Home Mobility, Self Care

• Intermediate ADLs: Medication management, meals, community mobility

• Advanced ADLs: Vocational, Avocational

IV. Living Environment

• Physical - Type of Home

• Social - Family Support/ Coping

• Financial & Community Resources

©Hilary C Siebens MD 2005

Hypotheses

1) Reliable and valid scoring of SDMM domains and sub-domains in discharge summaries is possible

2) Traditional inpatient discharge summaries do not adequately communicate important aspects of rehabilitation care

3) Use of the SDMM will improve organization and documentation of rehabilitation care through increased capture of relevant care items

Methods

� Setting: Acute Rehabilitation Unit

� Design: retrospective chart review

� In July 2008, residents started using the SDMM in the inpatient rehabilitation unit

� Discharge summaries randomly chosen from final week of residents’ inpatient rotation

� 20 traditional (historical controls) reports

� 20 SDMM reports

� scored using SDMM Documentation Review Form

Methods

� The research team established scoring rules and a scoring methodology for the SDMM Documentation Review Form

� Review form Inter-rater reliability established with % agreement and Fleiss’ kappa statistic

� Global Scores and Individual Domain Scores (4) reflecting % of items present were calculated for each report

Methods

� Descriptive statistics (mean, standard deviation) for these 5 scores compared between traditional and SDMM reports using 2-group t-test

� Main outcome measures: Global Scores and Domain Scores

� Yes = mentioned

� No = not mentioned

� N/A = not applicable

Documentation Review Form

Documentation Review Form

� Yes = mentioned

� No = not mentioned

� N/A = not applicable

Case Demographics

Historical Control Post-SDMM Implementation

• 1 female, 19 male (N=20)• 75% orthopedic• 15% neurologic• 10% medical complexity

• 1 female, 19 male (N=20)• 80% orthopedic• 15% neurologic• 5% medical complexity

Results: Global and Domain Scores

Traditional Reports(N=20)

% of items present

SDMM Reports(N=20)

% of items presentp value

Global Score 34 53 < 0.0001

Results: Global and Domain Scores

Traditional Reports(N=20)

% of items present

SDMM Reports(N=20)

% of items presentp value

Global Score 34 53 < 0.0001

Domain I Score

81 92 0.0413

I. Medical/Surgical Issues

Results: Global and Domain Scores

Traditional Reports(N=20)

% of items present

SDMM Reports(N=20)

% of items presentp value

Global Score 34 53 < 0.0001

Domain I Score

81 92 0.0413

Domain II Score

9 47 < 0.0001

II. Mental Status/ Emotions/ Coping

Results: Global and Domain Scores

Traditional Reports(N=20)

% of items present

SDMM Reports(N=20)

% of items presentp value

Global Score 34 53 < 0.0001

Domain I Score

81 92 0.0413

Domain II Score

9 47 < 0.0001

Domain III Score

25 34 0.0621

III. Physical Function

Results: Global and Domain Scores

Traditional Reports(N=20)

% of items present

SDMM Reports(N=20)

% of items presentp value

Global Score 34 53 < 0.0001

Domain I Score

81 92 0.0413

Domain II Score

9 47 < 0.0001

Domain III Score

25 34 0.0621

Domain IV Score

11 33 < 0.0001

IV. Living Environment

Results

� Improvement in overall information captured, the Global Score, was observed (34% to 53% for Traditional vs. SDMM reports, respectively; p<.0001)

� Information captured within each domain was also improved from traditional reports

Results: Individual Items

� In Domain I, 1 item showed significant change: mention of lifestyle risk factors (29% to 72%)

� In Domain II, increased mention of cognitive/communication status (35 to 80%), emotions (15 to 60%), and coping (5 to 45%)

� Power of attorney for health and medical directive remained low, but showed some increase in SDMM reports (5 to 15% and 5 to 30%, respectively)

Results: Individual Items

� In Domain III, items discussed regularly in both report types: basic ADLs (95% to 100%) and home mobility (90 to 84%)

� Improvement seen in IADLs (5% to 35%) and community mobility (15 to 30%), but all other items remained <15%

� In Domain IV, most items 20% or lower except increased mention of physical home setting (35 to 56%) and social supports (45 to 75%)

� Very few items scored as not applicable (4% in traditional, 7.5% in SDMM reports)

Conclusions

� Reliable and valid scoring of SDMM domains was possible through physician use of standardized scoring form

� Traditional rehabilitation discharge summaries lacked information relevant to rehabilitation care

Conclusions

� Traditional reports emphasized medical aspects of hospitalization, but often lacked discussion on mental status, emotions, coping, physical function, living environment

� Using the SDMM in discharge summaries led to significant increase in overall information capture, with the greatest increase in areas of mental status/emotion/coping and environment

Implications

� SDMM can serve as teaching framework for rehabilitation residents and as a simple checklist of topics to be considered in documentation

� Facilitates efficient and comprehensive organization of relevant information

� Improve patient care, safety, and communication between providers

References

• Siebens H. Applying the Domain Management Model in treating patients with chronic disease. Jt Comm J Qual Improvement 2001;27:302-314.

• Siebens H. Proposing a Practical Clinical Model. Topics in Stroke Rehabilitation 2011;18:60-65.

• Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36.

• Stineman MG. Untangling function: measuring the severity, type and meaning of disabilities. Eura Medicophys 2007;43:543-9.

• Provincial Interim Report, Regional Geriatric Programs – Geriatric Emergency Care. rgp.toronto.on.ca.

• Weed LL. Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record As a Basic Tool. Chicago:Year Book Medical Publishers; 1969.

• Clark GS, Kortebein P, Siebens HC. Aging and Rehabilitation. In: DeLisaJ,Gans B, eds. DeLisa’s PM&R: Principles and Practice. 5th Edition. Wolters Kluwer Health: J.B. Lippincott Company 2010, pp. 1545-1585.