By: Nathaniel Israel, PhD
EPISODES: STRUCTURE, FUNCTION, MANAGEMENT
*Episode—a container or set of parameters which define when a series of actions are expected to take place and when interventions have ceased
A building block of understanding a person’s care is being able to assign an Episode of Care to a person. Nearly all reports are based on expectations for, and the execution of, specific treatment-related activities with the hope that they lead to particular transformational outcomes. However, not all data systems create or manage episodes in a clear and consistent manner. Following our last post Unpacking the Standard Reports: Design for Decision Support, this post aims to highlight the core issues that need to be addressed in creating or managing EPISODES in a data system.
I. Episodes of Care: an Example
Let’s begin with an example of episode-based expectations for treatment events. In this example jurisdiction, there is an expectation that after a referral, a screening is completed within 10 days. After the screening is completed, a referral for a particular type of care is made. Then the expectation is that a full assessment will be completed, and appropriate care will be provided. When care is provided, treatments are expected to address specific targets which are objective, measurable, and amenable to change. Re-assessments and updated treatment plans provide evidence as to whether the specific targets are being addressed as intended. Discharge is expected to occur when treatment targets are achieved, or a different type of care is more appropriate (see Figure 1).
All of these expectations are linked to each other. Each action and subsequent state creates the expectation of the following action, from referral to discharge. Any interruption in this causal chain has to be dealt with in a systematic way in order to understand and manage care in a system.
Episodes provide a ‘unit’ to all of these coordinated, interdependent actions. Episode-based rules are required to insure that all episodes have a consistent meaning, and that exceptions are handled in ways which are justifiable to regulatory and funding bodies as well as end users. Episodes become especially important in complex healthcare systems, and for clients receiving care which is coordinated across multiple persons or providers. The more complex the care or organizational context in which care is delivered, the more important it is to be able to understand precisely what has been delivered, by whom, per which expectations, and leading to what outcomes. Without the ability to disentangle these actions and their providers we lose the ability to manage and meet expectations for transformation.
Because persons receiving care, persons providing care, and system requirements are all subject to change, both a defined episode structure and tools for managing episodes are required. Tools for managing episodes include both the routine assignation of opening and closure to an episode, assignation of reasons for opening and closure of an episode, as well as functionality designed to address clerical errors or record-keeping anomalies. The most frequently used tool in this list is an episode opening or closing function.
II. Defining an Episode
An Episode must specify the following design criteria:
- criteria for an episode opening,
- criteria for an episode closing,
- and, criteria for associations with an episode.
Episode opening is typically automatically triggered in a system once a specific authorizing action has occurred. Increasingly in systems across the country, a referral for service eligibility is that triggering event. Episode closing also must meet specific criteria. These are often event-related, though they may also be time-related. For instance, discharge or drop-out from services are events which signal the closing of an episode. Episodes may also be time or location limited. Exceeding a time limit, or changing location may trigger the end of an episode. Both opening and closing criteria for an episode need to reflect local practice; they need to map to care as it is provided (or as it is required / intended to be provided, so long as these conditions can be managed when exceptions occur).
Associations with an episode may include the specific individual or team responsible for providing services / supports, the organization with which that person is associated, the geographic region within which care is provided, and the entities who provide administrative and policy functions associated with care. These associations must be defined as they have implications for table relationships in relational databases, and can be used to filter data and reports at each level of the system to provide people with the information they need to manage their decisions and practices (the ‘Management’ in TCOM).
Taking the time to define the conditions for episode opening, closing, and the associations linked to an episode of care allows one to structure your data in a meaningful way. Specifically, it provides people with the information they need to make informed decisions about how well the system is working, at multiple levels, to facilitate the transformation of human lives.
III. Tools for Managing Exceptions in Episodes
Failure to follow procedures for episode opening, closing, and reporting at the practitioner level may be intentional or unintentional, but leads to the need for administrative tools to be able to manage non-compliant episode structures. Administrative closure of an episode is one example of an instance in which administrative tools may be routinely used to manage non-compliance. Practitioners may also engage in behaviors knowingly or unknowingly which created invalid episodes. For instances, double-entering the same client’s screening or assessment results may open up two episodes of care simultaneously when only one episode of care is being provided. Tools for deletion of such duplication are necessary to keep the episode structure consistent and allow for meaningful comparison of practices and outcomes across episodes. Additionally, there may be instances in which information about or within an episode needs to be preserved for record-keeping, but violates rules needed for use in reporting across episodes of care. For instance, a regulatory body may require that a partially-completed assessment is retained in the electronic record, when a practitioner who begins the assessment leaves the organization without completing it. Yet such an incomplete document may need to be suppressed when reports are run, as it is not appropriate for use in comparisons.
In order to generate reports which consistently reflect the treatment provided, its duration, and its effects, a suite of tools are required to manage episodes. These tools are most efficient when they are designed based on the types of exceptions which most frequently occur within a given system. These tools are often a mix of functions which practitioners, administrators and data analysts can apply to data in order to insure that episodes have a consistent structure and meaning when used in analyses.
In summary, use of an episode is necessary to make sense of whether expected service activities are occurring with a client, and what effect those activities are having. A consistent episode structure is necessary to insure that comparisons made are equivalent (‘apples-to-apples’) comparisons. Because changing personnel and system demands result in some episodes not being able to be closed in the expected manner, specific tools to address these episodes can be used to insure that comparisons across episodes remain meaningful for informing policy and practice. Contingencies likely to arise with children and youth served in human service systems, and the desired functions (tools) for addressing those contingencies, are outlined in the table below (Table 1). This table can be used to start a conversation with practitioners, supervisors, quality improvement leads and report developers regarding how to manage these situations and to insure that the effects of intervention are appropriately tracked and attributed to persons providing care.
Once a clear set of procedures are developed and implemented for managing episodes in a data system, you will find that the reports you develop are better able to identify where and to what extent persons served are experiencing transformation. The data you provide within an ‘episode’ structure are better defined, easier to communicate, easier to understand, and give people credit for the transformation they help create!
For more information on this post and the Standard Suite of Reports, contact Dr. Nathaniel Israel at nisrael@chapinhall.org
*Click HERE to view the pdf of the original report
