Measuring up: what are outcomes and why are they important?

Nursing Homes, Jan, 2005

So why is the word "outcomes" creating a buzz in rehabilitation therapy these days? After all, everyone knows what outcomes are. Following her hip replacement, Mrs. Winterbottom goes into therapy, and after treatment she is able to walk. Great outcome. The nursing facility did its job, and Mrs. Winterbottom tells everyone what wonderful therapy she received. The story is warm and fuzzy and makes everyone feel good.

But real therapy outcomes are more than anecdotal stories and testimonials. Real therapy outcomes mean the benefit of therapy is actually measured on a national scale using hard data and benchmarked statistics over hundreds of thousands of patient records. Real outcomes are about reports customized to each patient and facility that relate measured functional gains to length of stay and the efficiency of therapy services from a variety of perspectives.

In other words, real therapy outcomes could reveal that Mrs. Winterbottom was rated at 0.5 for gait when she began therapy. After 21 days of treatment, she was rated at 3.0, which placed her above the national average for similar hip replacement patients. Further reports might reveal that the entire facility has a higher intensity of treatment (reflected in a higher percentage of the upper RUG categories) with shorter lengths of stay than the national average and that their patients are discharged to higher levels of independence and are much more likely to return home.

With this outcome information, the facility now can prove it did its job and justify the level of therapy provided. Mrs. Winterbottom is right on when she tells everyone what wonderful therapy she received.

"We are in an age of increasing responsibility to justify what it is we are doing," says Audrey L. Holland, PhD, Regents Professor Emeritus at the University of Arizona. "There is a need to gather evidence to suggest that treatment is beneficial and economically feasible. Outcomes measurement is beginning to make a difference."

Today's healthcare is all about gatekeepers--people who control access to the patient and/or to reimbursement. "Whether to the physician, the family, the federal government, or even the nursing staff, we must be able to prove our impact in some measurable way," says Bill Goulding, director of outcomes and appeals management for Aegis Therapies. "When we simply say that someone has increased his independence and ability to dress his upper body, that's meaningful to the patient, but it's not measurable. Gatekeepers need some justification to proceed with the plan of therapy."

How Do You Measure?

Outcomes objectively document the level of functional abilities assigned at the time of admission and the level of those abilities upon discharge. But how do you measure that level? "From a theoretical standpoint, any measure that is valid and reliable works," says Reg Warren, PhD, who, as principal at SeniorMetrix in Boston, has been involved in studies on the cost-to-outcomes relationship on a national level. "The point is to use that measure in a large enough scale so that compared data can be created between providers. If each therapy develops its own measure, the problem is that you can't go outside the use of that measure to compare your patients' outcomes with national or regional standards."

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For example, suppose Sunny Mountain Nursing Home has developed its own measurement scale. When our Mrs. Winterbottom tries to evaluate care at Sunny Mountain compared with care at Shady Forest Home in order to decide which facility to enter, the numbers mean nothing to her, especially if Shady Forest, too, has its own measurement scale.

Similarly, referral sources looking at the two facilities would have no idea how their patients would fare either by diagnosis, length of stay, or functional level at discharge. "One of the biggest problems with outcomes is that you must have a measure with interrater reliability," says Goulding. "If someone in Dubuque scores a patient at 2.5 level, someone in Boston should be able to evaluate the patient on the same scale and arrive at exactly the same score."

For that to happen, a scale must have reliability and validity. Several scales are currently in use, each with its own pros and cons. The Functional Independence Measure (FIM) is probably the most widely used scale in rehabilitation, certainly in acute rehab settings.

But according to Professor Holland, the FIM doesn't quite do the job for long-term care. "The Rehabilitation Outcomes Measure (ROM), marketed by Accu-Med Services (www.accu-med.com), is a better scale for nursing homes than the FIM," she says. "It is more refined, covers more areas, and asks more questions. It's much more specific in dealing with questions of language cognition, for example. And it will become an even better scale as it is more broadly used."

One advantage of the ROM, according to Mark Besch, vice-president of clinical services for Aegis, is that it is specific to skilled nursing facilities. "When balancing dollars and treatment worth, it's important to look at data from the same setting and from the same regulatory environment," he says. "The FIM scale is the largest overall, but it is not all post-PPS data and not all skilled nursing facility data."