Abstract
‘Caremaps [Clinical pathways] are like microwave ovens: five years from now, members of all disciplines will marvel at how they ever got along without them. Of course there will always be some that refuse to accept innovation or who are technophobic. Most people, however, will readily incorporate useful, practical new products into their daily lives.’ Zander [1]
In order to achieve several of the key objectives of the RANZCP Strategic Plan, four clinical practice projects are being undertaken overseen by a project group chaired by the President of the RANZCP, Dr Janice Wilson. One of these projects concerned clinical pathways. With Commonwealth Government support, the RANZCP initiated a scoping exercise to examine the potential use of clinical pathways in mental health. This exercise was completed over a twelve-week period from July to September 1998 at the University of Queensland and a series of recommendations, which are included in this article, have been submitted to the RANZCP for consideration.
CLINICAL PATHWAYS
Pathway techniques were first developed for use in industry as a tool to identify and manage ratelimiting steps in the production process. Clinical pathways in the health context are typically developed by a multidisciplinary team to identify and describe the anticipated clinical management and interventions along a time-line.
They have been defined by Coffey [2] as ‘an optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure, designed to better utilise resources, maximise quality of care, and minimise delays’. Typically clinical paths are developed for high volume, high risk, high cost and high interest diagnoses, procedures and events [3,4].
Medical and surgical care settings in Australia and internationally have attempted to overcome some of the barriers to achieving optimal care delivery despite fiscal pressures by incorporating existing practice parameters and guidelines into clinical pathways. Clinical pathways have varying formats and are known by a variety of names including critical paths, care paths, integrated care maps, care pathways, case management plans, managed care pathways and care continuum pathways.
In 1996, over 90% of acute care hospitals in the United States were involved in some kind of clinical pathway development or application [5]. No similar data are available for Australian hospitals; however, anecdotal evidence would suggest that there is considerable activity in acute care settings in both the public and private sectors.
Clinical pathways define multidisciplinary staff members' responsibilities, time-lines and patient outcomes. Additionally, clinical pathways promote quality patient care by incorporating existing standards, practice guidelines, and research findings, eliminating unnecessary diversity and providing a mechanism to monitor quality of care based on patient outcomes. For a variety of reasons relatively little work has occurred in mental health in either Australia or internationally in relation to clinical pathways.
ARE CLINICAL PATHWAYS APPLICABLE TO THE MENTAL HEALTH SETTING?
The National Mental Health Plans [6,7] identify the need for stakeholders to work cooperatively in finding ways of providing high quality care in a cost-efficient manner, utilising existing resources. Can the introduction of clinical pathways assist in achieving these goals?
The mental health service environment is acknowledged to be complex. Does this issue prohibit the development of clinical pathways or rather provide a challenge to develop innovative approaches? Why should mental health professionals, and particularly psychiatrists, not become leaders in understanding how to apply this model in a complex health care environment?
There are two main barriers to be overcome. The first relates to the evolving design of mental health services along a continuum of care with increasing focus on integrated services and the smooth transition through a range of agencies. A primary challenge for pathway development in mental health will be to involve all stakeholders, including consumers, in the development process. This will involve the extension of pathways across the entire episode of care. There is very little work published in this area.
The second issue is that the nature and outcomes of mental illness are difficult to define, predict and evaluate. Nelson has commented that ‘Much of the care process in mental health is cognitive. Key aspects of therapy are often less visible to observers and more difficult to measure. For clinical status, patient reports and ratings are critical; there is less reliance on physical findings. Patient assessment is highly dependent on the patient's verbal statements. Relatively little assessment is based on physical examination and laboratory tests’ [8].
Is it therefore too difficult to design clinical pathways in mental health?
While it is recognised that mental health care delivery is complex and individualised, it is clear that there are commonalities and interventions that occur for the majority of patients regardless of diagnosis. For example, when a patient presents to a service, interventions may include initial triage, assessment, referral or admission, baseline observations, explanation of rights and responsibilities and family contact. Common interventions also occur within a diagnostic framework.
Clinical pathways provide an opportunity for these interventions to be incorporated into a clinical tool, creating a transparent process of treatment for patients, carers and clinicians by making what is implicitly known explicit. The clinical pathway identifies the complex issues and special needs of the individual patient so that modifications to the process can be tailored accordingly.
The sparse international literature in mental health clinical pathways has focused on diagnostic-related groups such as psychoses and affective disorders, various procedures such as ECT, or events such as the assessment and admission process. At present, while there is some early work on ‘continuum care pathways’ for medical patients that may be useful, this approach in mental health is largely uncharted territory.
The literature points to physician involvement in pathway development as ‘crucial’ to its success [3,9,10]. It is consistently reported that specialist medical practitioners who are involved in patient care need to be at the front line in the development of clinical pathways. It would appear that pathways that are developed from either a medical academic approach with little input from clinicians who are directly involved with the patients or pathways that are developed by nursing staff without medical support, are ‘doomed to fail’. Instead, all relevant disciplines need to be ‘equal partners’ in the process [11,12].
The challenges presented by the introduction of clinical pathways to mental health are numerous. Given that the literature suggests that the most successful strategy is for local development of pathways, the issues of medical and management support, training, multidisciplinary collaboration and the cultural change necessary for this process to be successful, will require considerable resources and careful planning.
SCAN OF ACTIVITY
A scan of activity in Australian and New Zealand mental health settings revealed a total of ten sites that are involved in ‘pathway-like’ activity and a further six sites that are in the preparatory stages gathering knowledge and/or the resources to proceed. These projects have focused on issues such as depression, dual diagnosis, relapse of schizophrenia, and the suicidal patient. The majority of work at this stage has been developed by inpatient services.
In discussions held with approximately one hundred mental health clinicians, academics and managers during the project, several themes emerged:
Interest and enthusiasm from those who had some knowledge of the topic and an acknowledgment that this model provides exciting and far-reaching opportunities for mental health service provision.
The desire to know more about clinical pathways and how they may be useful.
Considerable confusion about terminology and differing formats, models, frameworks and approaches that are discussed in the ‘clinical pathway’ literature and the broader mental health literature.
Some concern about the medico-legal implications of clinical pathways and whether they become ‘rules’ which if ‘broken’ increase the legal vulnerability of the clinician.
Some concern about whether mental health is too complex for clinical pathway development with multiple ‘special needs’ and dual diagnoses.
The consistent recognition that while clinical pathways may bring efficiencies and cost containment in the long term, in the short term they are resource intensive.
The issue of managed care and the fear of clinical pathways being used to cost services.
A clear message from the private sector that they are interested in collaboration with the public sector on clinical pathway development and that they see considerable opportunities in terms of training, information sharing and support.
A concern about the need for the development of appropriate information technology to support clinical pathway implementation, with particular focus on the evaluation components such as variance analysis.
RECOMMENDATIONS
Based on information gathered from an international literature search and survey of over 100 mental health professionals across Australia and New Zealand, the following recommendations have emerged from this project and have been presented to the RANZCP for consideration:
Consumers, carers and other relevant stakeholders must be involved at all levels of the pathway development and implementation process through local consumer representatives and groups such as the Mental Health Council of Australia and appropriate bodies in New Zealand.
Clinical pathways are a potentially useful model for mental health services to improve the quality of service delivery. While there is considerable interest and enthusiasm for the model, the literature in mental health is cumbersome, with few clear guidelines on strategies for development and implementation. It is therefore recommended that a manual (similar in concept to the NHMRC ‘Guidelines for Guidelines’ document) and a multimedia kit (similar to the ‘Staying Alive’ kit), to serve as a national framework for local pathway implementation be developed to assist clinicians and other stakeholders in developing clinical pathways at a local level. This manual and kit must be regularly re-evaluated.
That a series of workshops be delivered to both public and private stakeholder groups with the aims of:
Introducing and explaining the manual and kit on clinical pathways.
Fostering collaboration and networking between the sectors and disciplines around the common issue of clinical pathway development.
That the implementation of clinical pathways be explored within each service as a major focus of quality improvement and that services be encouraged to pilot one or more clinical pathways in a range of settings. The process of pathway development requires local content within the national framework. After evaluation demonstrating benefits to consumers and mental health services, it is recommended that the implementation of clinical pathways for appropriate events, clinical conditions and procedures be included in the National Mental Health Service Standards.
In the inevitable and rapidly developing move towards a comprehensive computer-based information system for mental health service delivery, a prime opportunity exists to investigate the inclusion of clinical pathways into broader information systems. This work would greatly facilitate the transition to clinical pathway implementation and it is recommended that there is national support and coordination of appropriate development of information technology tools to support pathway development work.
Priority for the development of clinical pathways, which will incorporate relevant clinical guidelines, in the following areas is recommended:
In a range of geographical and cultural mental health settings and across continuums of care such as the inclusion of primary care agencies and integrated teams
For high risk, high cost ‘events’, clinical conditions and procedures such as:
Triage and assessment
Intensive Care
ECT
Schizophrenia/early psychosis
Depression
Bipolar affective disorder
Youth suicide
Dual diagnosis
Anxiety
Eating Disorders
Early dementia
That research be carried out in the mental health services setting to assist in creating a ‘change environment’ conducive to the development of clinical pathways which includes reference to multidisciplinary roles, communication within disciplines and culture and change within an organisation. Funded and evaluated local pilot projects are required with a view to their becoming demonstration projects.
That the Commonwealth develops an appropriate multi-stakeholder national forum and a national clinical pathways network with representatives from each state, as well as the Mental Health Council of Australia, to promote, facilitate and resource the process of local pathway development, implementation and evaluation, through collaborative efforts.
Acknowledgements
The authors would like to thank the many stakeholders who kindly provided information relevant to this project.