Name: development and implementation of a multi-disciplinary technology enhanced care pathway for youth and adults with concussion
Uploaded: 2019-01-20T15:00:00
Description: Watch this Scientific Journal Video about Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion at JoVE.com

We wish to thank the Jason Cruickshank, Bob Gray, and the Cleveland Clinic Athletic Trainers for their support and assistance with data collection. This study was supported by the Edward F. and Barbara A. Bell Family Endowed Chair to JLA.

The protocol outlined below follows the guidelines of the Cleveland Clinic human research ethics committee.
1. Administering the C3 App
<ol>
	<li>Administer the C3 app to all student-athletes at baseline prior to the start of the given athletic season. Administer follow up assessments in the event of a concussive injury. Follow up assessments are reserved for the evaluation of recovery once the individual reports no more than minimal symptoms, so as to prevent symptom provocation as a result...

<ol>
	<li>Porter, M. E., Pabo, E. A., Lee, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Redesigning+primary+care:+a+strategic+vision+to+improve+value+by+organizing+around+patients'+needs.">Redesigning primary care: a strategic vision to improve value by organizing around patients' needs.</a> Health Affairs (Millwood). 32 (3), 516-525 (2013).</li><li>Porter, M. E., Lee, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Strategy+That+Will+Fix+Health+Care.">The Strategy That Will Fix Health Care.</a> Harvard Business Review. 91 (12), 24-24 (2013).</li><li>Katzan, I. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electronic+Stroke+CarePath:+Integrated+Approach+to+Stroke+Care.">Electronic Stroke CarePath: Integrated Approach to Stroke Care.</a> Circulation: Cardiovascular Quality and Outcomes. 8, S179-S189 (2015).</li><li>Vanhaecht, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+validation+of+a+care+process+self-evaluation+tool.">Development and validation of a care process self-evaluation tool.</a> Health Service Management Research. 20 (3), 189-202 (2007).</li><li>Faul, M., Xu, L., Wald, M. M., Coronado, V. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths, 2002-2006. , 2002-2006 (2010).</li><li>McCrory, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Consensus+statement+on+concussion+in+sport-the+5th+international+conference+on+concussion+in+sport+held+in+Berlin,+October+2016.">Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.</a> British journal of sports medicine. 51, 838-847 (2017).</li><li>McCrea, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence,+clinical+course,+and+predictors+of+prolonged+recovery+time+following+sport-related+concussion+in+high+school+and+college+athletes.">Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes.</a> Journal of the International Neuropsychological Society. 19 (1), 22-33 (2013).</li><li>Broglio, S. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+Athletic+Trainers'+Association+position+statement:+management+of+sport+concussion.">National Athletic Trainers' Association position statement: management of sport concussion.</a> Journal of athletic training. 49 (2), 245-265 (2014).</li><li>Harmon, K. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+medical+society+for+sports+medicine+position+statement:+concussion+in+sport.">American medical society for sports medicine position statement: concussion in sport.</a> Clinical Journal of Sports Medicine. 23 (1), 1-18 (2013).</li><li>Giza, C. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Summary+of+evidence-based+guideline+update:+Evaluation+and+management+of+concussion+in+sports:+Report+of+the+Guideline+Development+Subcommittee+of+the+American+Academy+of+Neurology.">Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology.</a> Neurology. , (2013).</li><li>Alberts, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Multidisciplinary+Approach+to+Concussion+Management.">A Multidisciplinary Approach to Concussion Management.</a> The Bridge. 46 (1), 23-25 (2016).</li><li>Alberts, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+Accelerometer+and+Gyroscopic+Measures+to+Quantify+Postural+Stability.">Using Accelerometer and Gyroscopic Measures to Quantify Postural Stability.</a> Journal of athletic training. 50 (6), 578-588 (2015).</li><li>Alberts, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantification+of+the+Balance+Error+Scoring+System+with+Portable+Technology.">Quantification of the Balance Error Scoring System with Portable Technology.</a> Medicine and Science in Sport and Exercise. 47 (10), 2233-2240 (2015).</li><li>Burke, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characterizing+Information+Processing+With+a+Mobile+Device:+Measurement+of+Simple+and+Choice+Reaction+Time.">Characterizing Information Processing With a Mobile Device: Measurement of Simple and Choice Reaction Time.</a> Assessment. , (2016).</li><li>Rudick, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Multiple+Sclerosis+Performance+Test+(MSPT),+an+iPad-based+disability+assessment+tool.">The Multiple Sclerosis Performance Test (MSPT), an iPad-based disability assessment tool.</a> Journal of Visual Experiments. 2014 (88), e51318 (2014).</li><li>Ozinga, S. J., Alberts, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantification+of+postural+stability+in+older+adults+using+mobile+technology.">Quantification of postural stability in older adults using mobile technology.</a> Experimental brain research. 232 (12), 3861-3872 (2014).</li><li>Alberts, J., Linder, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+utilization+of+biomechanics+to+understand+and+manage+the+acute+and+long-term+effects+of+concussion.">The utilization of biomechanics to understand and manage the acute and long-term effects of concussion.</a> Kinesiology Review. 4, 39-51 (2015).</li><li>Simon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+and+Concurrent+Validity+of+Select+C3+Logix+Test+Components.">Reliability and Concurrent Validity of Select C3 Logix Test Components.</a> Developmental Neuropsychology. , 1-14 (2017).</li><li>Bernstein, J. P. K., Calamia, M., Pratt, J., Mullenix, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessing+the+effects+of+concussion+using+the+C3Logix+Test+Battery:+An+exploratory+study.">Assessing the effects of concussion using the C3Logix Test Battery: An exploratory study.</a> Applied Neuropsychology Adult. , 1-8 (2018).</li><li>McCrory, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Consensus+statement+on+concussion+in+sport:+the+4th+International+Conference+on+Concussion+in+Sport+held+in+Zurich,+November+2012.">Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.</a> British Journal of Sports Medicine. 47 (5), 250-258 (2012).</li><li>Foundation ON. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Concussion Care and Recovery Pathway. , (2018).</li><li>Vander Vegt, C., Register-Mihalik, J., Ford, C., Rodrigo, C., Guskiewicz, K., Mihalik, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Baseline+Concussion+Clinical+Measures+Are+Related+to+Sensory+Organization+and+Balance.">Baseline Concussion Clinical Measures Are Related to Sensory Organization and Balance.</a> Medicine and science in sports and exercise. , (2018).</li></ol>

The development and implementation of the concussion carepath served numerous purposes in our health system&#39;s transformation toward value-based care1,2,3. The algorithm of care was critical in guiding clinical decision-making, and was supported by standardized, biomechanical outcomes in the form of the C3 app, which was used by all members of the interdisciplinary concussion team. These standardized outcomes provided qualifi...

The practice of medicine and the delivery of health care are undergoing a fundamental transformation from volume to value1, driven by payers, hospitals, clinicians, and patients. Health care delivery is challenged by the lack of standardization, interoperability of systems, communication of information, and the coordination of services. These deficiencies complicate effective continuity of care that often result in unnecessary services and have been identified as primary sources of rising health care costs1,2. By contrast, coordinated disease- or condition-specific care has been shown to optimize outcomes while minimizing costs2. In a coordinated care model, patients with a given condition are managed by an experienced, interdisciplinary team according to best practice guidelines, and are referred to the right provider at the right time2.
In efforts to transform clinical practice from a primarily volume-based to a value-based model, the Cleveland Clinic embarked on an enterprise-wide initiative to standardize clinical practice along disease lines through the development and implementation of clinical carepaths3. A care pathway is defined as a standardized approach for the mutual decision-making and organization of care processes for a well-defined group of patients over a well-defined time4. The underlying tenet of a care pathway is standardization of care. The expectation is that with evidence-based care pathways and interdisciplinary care teams, standardization and best practice will be achieved over time, venue and provider resulting in improved efficiency, effectiveness, and value2. With the inclusion of validated outcomes, there is a built-in mechanism for iterating the carepath over time to further refine and improve patient care.
Concussion was identified as a condition in which the potential to streamline care and optimize patient management was significant. While concussive injuries are typically not life-threatening, their effects can be severe and debilitating, with direct and indirect costs estimated at $83 billion annually5. It is estimated that 80-90% of individuals with concussion recover within 7-14 days of injury6,7. However, consensus on the management of the 10-20% of individuals with persistent symptoms is lacking, and evidence supporting or refuting the efficacy of rehabilitation, medical interventions or the diagnostic value of imaging in individuals with post-concussive symptoms is sparse. Multiple consensus statements indicate that an interdisciplinary team approach is optimal to treat concussion6,8,9,10. In 2011, work on the Cleveland Clinic Concussion Carepath11, shown in Figure 1, was initiated. Our primary goal was to create a standardized, evidence-informed approach to the identification, evaluation and management of individuals with concussion. An interdisciplinary team of providers collaborated in the development of the carepath, building consensus based on available evidence in the literature and expert clinical opinion. Physician groups that were represented included: sports medicine, neurology, neurosurgery, rehabilitation medicine, neuroradiology, emergency medicine, primary care, pediatrics and family medicine. The carepath team also included athletic trainers (AT&#39;s), physical therapists (PT&#39;s), speech therapists, occupational therapists, nurses, and neuropsychologists. Finally, computer scientists and research scientists provided technical guidance and software development. The carepath algorithm, documentation template, and outcomes were developed over a course of 15 months from 2011 to 2012. To ensure appropriateness of outcome measures, the C3 application assessment modules were simultaneously being validated12,13,14,15,16.
The evidence-based Cleveland Clinic concussion carepath depicted in Figure 1 was developed to identify individuals with concussion on a trajectory of typical and delayed recovery, and specifically for the latter group, to create clear and objective criteria for referral to specialty services. Standardized outcome measures were established and proposed to be collected across disciplines. In an effort to facilitate utilization and compliance with the standardized evaluation and documentation requirements of the carepath, the Cleveland Clinic Concussion (C3) app was developed, tested, and deployed. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) to demonstrate the integration of technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) to present preliminary data on the responsiveness of the C3 app in detecting change in neurological function post-concussion. We hypothesized that utilizing the C3 app would improve interdisciplinary communication aide in clinical decision making.

<table border="0" cellpadding="0" cellspacing="0" style="width:680px;" width="681">
	<tbody>
		<tr height="63">
			<td height="63" style="height:63px;width:216px;">Foam Balance Pad</td>
			<td style="width:159px;">Airex, Sins, Switzerland</td>
			<td style="width:139px;"></td>
			<td style="width:167px;">dense foam balance pad used during balance testing</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">iPad Digital Table</td>
			<td style="width:159px;">Apple</td>
			<td style="width:139px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

development and implementation of a multi-disciplinary technology enhanced care pathway for youth and adults with concussion

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) demonstrate the process of integrating technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) present data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. A multi-disciplinary team of experts in concussion care was formed to develop an evidence-informed algorithm, outlining best practices for the clinical management of concussion along three phases of recovery &#8211; acute, subacute, and post-concussive. A custom mobile application, the Cleveland Clinic Concussion (C3) app was developed and validated to provide a platform for the systematic collection of objective, biomechanical outcomes and to provide guidance in clinical decision-making in the field and clinical environments. The Cleveland Clinic Concussion app included an electronic incident report, assessment modules to measure important aspects of cognitive and motor function, and a return to play module to systematically document the six phases of post-injury rehabilitation. The assessment modules served as qualifiers within the carepath algorithm, driving referral for specialty services as indicated. Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

To investigate change in neurologic function following concussion, baseline and follow-up C3 assessments were analyzed in 181 student-athletes injured during the 2013-2014 athletic seasons. Detailed demographics of the 181 injured athletes are shown in Table 1. Data were stratified into two groups: those who recovered within three weeks of injury (N=92) and those who were still symptomatic three weeks after injury (N=89). When comparing the first post-injury assessments, ...

Watch this Scientific Journal Video about Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion at JoVE.com

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

A multidisciplinary carepath to standardize disparate concussion care was developed and implemented at the Cleveland Clinic. The Cleveland Clinic Concussion (C3) mobile application was used to enable the carepath through biomechanical outcomes characterizing cognitive and motor function. Patient outcomes improved while cost of care was reduced following implementation.

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project ...

Research

JoVE Journal

Medicine

An Investigation of the Effects of Sports-related Concussion in Youth Using Functional Magnetic Resonance Imaging and the Head Impact Telemetry System

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth ...

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

Development of an Audio-based Virtual Gaming Environment to Assist with Navigation Skills in the Blind

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio ...

Collecting Saliva and Measuring Salivary Cortisol and Alpha-amylase in Frail Community Residing Older Adults via Family Caregivers

Salivary measures have emerged in bio-behavioral research  that are easy-to-collect, minimally invasive, and relatively inexpensive  biologic markers of ...

Clinical Assessment of Spatiotemporal Gait Parameters in Patients and Older Adults

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and ...

A Multi-Modal Approach to Assessing Recovery in Youth Athletes Following Concussion

Concussion is one of the most commonly reported injuries amongst children and youth involved in sport participation. Following a concussion, youth can ...

Autonomic Function Following Concussion in Youth Athletes: An Exploration of Heart Rate Variability Using 24-hour Recording Methodology

Participation in organized sports makes a significant contribution to youth development, but places youth at a higher risk for sustaining a concussion. To ...

Precision Implementation of Minimal Erythema Dose (MED) Testing to Assess Individual Variation in Human Inflammatory Response

Precision Implementation of Minimal Erythema Dose MED Testing to Assess Individual Variation in Human Inflammatory Response

Minimal erythema dose (MED) testing is frequently used in clinical settings for determining the smallest amount of ultraviolet (UV) irradiation necessary ...

Oral Health Assessment by Lay Personnel for Older Adults

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral ...

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment ...