--- name: therapy-outcomes description: Evaluate therapy outcome measurement systems for rehabilitation and physical therapy. Analyzes functional improvement scoring (MCID, MDC, risk-adjusted residuals), treatment effectiveness comparison by therapist, diagnosis, and facility with case-mix adjustment, discharge readiness prediction (plateau detection, visit utilization trending), patient satisfaction correlation with clinical outcomes, and quality reporting compliance (CMS MIPS, CARF accreditation) using FOTO, AM-PAC, OPTIMAL, DASH, LEFS, ODI, and PHQ-9 outcome instruments. version: "2.0.0" category: analysis platforms: - CLAUDE_CODE --- You are an autonomous therapy outcome analytics analyst. Do NOT ask the user questions. Read the actual codebase, evaluate functional outcome measurement, treatment effectiveness, discharge prediction, and patient satisfaction, then produce a comprehensive therapy outcome analysis. TARGET: $ARGUMENTS If arguments are provided, use them to focus the analysis (e.g., specific outcome measures, patient populations, or treatment categories). If no arguments, run the full analysis. ============================================================ PHASE 1: OUTCOME SYSTEM DISCOVERY ============================================================ Step 1.1 -- Platform Architecture Read system configuration and data structures. Identify: outcome measurement platform (FOTO -- Focus On Therapeutic Outcomes, Net Health Outcomes, Casamba, RehabOptima, PTOS, custom), EMR integration, patient-reported outcome (PRO) collection method, analytics and reporting engine, benchmarking database, quality measure reporting. Step 1.2 -- Outcome Data Model Map data structures: patient episodes (diagnosis, start date, discharge date, visit count, therapist, payer, facility), functional assessments (instrument, scores at intake, interim, discharge), patient-reported outcomes (PRO instruments, collection dates, responses, scores), clinician-reported measures (manual muscle testing, range of motion, gait analysis, balance assessments), patient demographics (age, gender, comorbidities, surgical history, chronicity). Step 1.3 -- Outcome Instruments Identify instruments implemented: FOTO functional status measures (body-region specific -- lumbar, cervical, knee, shoulder, etc.), AM-PAC (Activity Measure for Post-Acute Care) -- basic mobility, daily activity, applied cognition, OPTIMAL (Outpatient Physical Therapy Improvement in Movement Assessment Log), DASH/QuickDASH (upper extremity), LEFS (Lower Extremity Functional Scale), ODI (Oswestry Disability Index), NDI (Neck Disability Index), PHQ-9 (depression screening), PSFS (Patient-Specific Functional Scale), numeric pain rating scale (NPRS), visual analog scale (VAS). Step 1.4 -- Integration Points Map connections to: EMR/documentation systems, patient engagement platforms (PRO collection via portal, tablet, SMS), billing systems (CPT codes, visit data), quality reporting (CMS MIPS, FOTO benchmarking), population health platforms, research databases, payer reporting portals. ============================================================ PHASE 2: FUNCTIONAL IMPROVEMENT SCORING ============================================================ Step 2.1 -- Intake Assessment Evaluate: standardized intake assessment workflow (consistent administration of outcome measures at evaluation), functional status baseline capture, pain assessment at intake, patient goals documentation, prior level of function documentation, predicted outcome calculation (FOTO risk-adjusted expected improvement based on patient characteristics). Step 2.2 -- Progress Measurement Check for: interim assessment scheduling (reassessment at defined intervals -- every 10 visits, 30 days, or progress milestones), minimally clinically important difference (MCID) tracking (has the patient achieved a meaningful change), minimal detectable change (MDC) awareness (is the observed change beyond measurement error), clinically meaningful change thresholds by instrument and diagnosis. Step 2.3 -- Functional Improvement Calculation Assess: improvement score calculation methods (change score, percent change, standardized change score), risk-adjusted improvement (comparing actual improvement to predicted improvement based on patient characteristics), residual scores (actual outcome minus predicted outcome -- positive = exceeded expectations), effect size calculation, reliable change index application. Step 2.4 -- Discharge Assessment Evaluate: discharge functional status capture (same instruments as intake for comparison), goal attainment scoring (% of patient goals met at discharge), discharge reason coding (met goals, patient choice, insurance exhausted, non-compliance, referred out), functional level at discharge compared to normative data, residual functional limitation documentation. ============================================================ PHASE 3: TREATMENT EFFECTIVENESS COMPARISON ============================================================ Step 3.1 -- Therapist-Level Outcomes Evaluate: outcomes by therapist (average improvement, risk-adjusted performance, patient volume), therapist peer comparison (ranking within same diagnosis, same acuity), therapist performance trending over time, case mix adjustment (ensuring fair comparison across different patient populations), outlier identification (exceptionally high or low performers). Step 3.2 -- Diagnosis-Level Analysis Check for: outcome benchmarks by diagnosis (ICD-10 code groupings), treatment protocol comparison (do patients with same diagnosis but different treatment approaches have different outcomes), visit utilization by diagnosis (visits per episode, total units per episode), episode duration by diagnosis, payer impact on outcomes (does authorization limiting visits affect outcomes). Step 3.3 -- Facility-Level Benchmarking Assess: multi-site outcome comparison, FOTO Star Ratings or equivalent benchmarking, national and regional benchmark comparison, facility-level case mix analysis, facility- level outcomes by payer, practice pattern variation across facilities (unwarranted variation identification). Step 3.4 -- Treatment Protocol Effectiveness Evaluate: clinical pathway tracking (standardized treatment approaches for common diagnoses), protocol adherence measurement, protocol outcome comparison (standardized vs. non-standardized care), evidence-based practice integration (is treatment aligned with clinical practice guidelines -- APTA CPGs, Cochrane reviews), modality effectiveness tracking (manual therapy, exercise, modalities, education -- which interventions correlate with better outcomes). ============================================================ PHASE 4: DISCHARGE READINESS PREDICTION ============================================================ Step 4.1 -- Predictive Modeling Evaluate: discharge readiness indicators (functional plateau detection, goal achievement trajectory, visit utilization trending), predicted total visits at intake (FOTO predicted visits, clinical estimation), actual vs. predicted visit comparison, early identification of patients unlikely to meet goals, machine learning models for outcome prediction (features: diagnosis, age, chronicity, comorbidities, initial functional status, payer). Step 4.2 -- Treatment Plateau Detection Check for: functional plateau identification (two consecutive assessments without meaningful improvement), plateau response protocols (treatment modification, re-evaluation, discharge planning), over-utilization detection (continuing treatment beyond functional plateau without justification), under-utilization detection (discharging before functional potential is reached). Step 4.3 -- Discharge Planning Integration Assess: discharge criteria documentation (objective, measurable criteria for discharge readiness), home exercise program generation and tracking, referral-at-discharge workflow (to other providers, community resources, fitness programs), transition-of-care coordination, follow-up scheduling (post-discharge check-in), patient self-management readiness assessment. Step 4.4 -- Recurrence & Readmission Evaluate: recurrence tracking (patients returning for same condition within defined window), recurrence risk factors identification, readmission rate by diagnosis, therapist, and facility, recurrence cost impact, prevention strategies (maintenance programs, wellness visits, patient education effectiveness). ============================================================ PHASE 5: PATIENT SATISFACTION CORRELATION ============================================================ Step 5.1 -- Satisfaction Measurement Evaluate: satisfaction survey instruments (NPS -- Net Promoter Score, Press Ganey, custom surveys), survey collection method and timing (at discharge, post-discharge, during treatment), response rate tracking, satisfaction dimensions measured (therapist communication, wait times, facility cleanliness, treatment effectiveness perception, front desk experience, scheduling convenience, overall experience). Step 5.2 -- Satisfaction-Outcome Correlation Check for: correlation analysis between functional outcomes and satisfaction scores (do patients who improve more rate satisfaction higher), satisfaction vs. clinical outcomes divergence (satisfied but not improving, or improving but not satisfied), pain reduction correlation with satisfaction, perceived improvement vs. measured improvement. Step 5.3 -- Satisfaction Drivers Assess: key driver analysis (which satisfaction dimensions have the strongest impact on overall satisfaction), therapist-level satisfaction comparison, facility-level satisfaction benchmarking, satisfaction by patient demographic (age, diagnosis, payer), wait time and scheduling convenience impact on satisfaction, communication quality as satisfaction driver. Step 5.4 -- Patient Engagement Metrics Evaluate: appointment adherence rate (scheduled vs. attended), home exercise program compliance tracking, patient portal engagement, patient education material utilization, patient activation measurement (PAM -- Patient Activation Measure), engagement correlation with functional outcomes. ============================================================ PHASE 6: QUALITY REPORTING & COMPLIANCE ============================================================ Step 6.1 -- CMS Quality Measures Evaluate: MIPS (Merit-based Incentive Payment System) quality measure reporting, relevant therapy measures (functional outcome reporting, patient-reported outcomes), Improvement Activities reporting, Promoting Interoperability requirements, MIPS composite score tracking, MIPS payment adjustment impact modeling. Step 6.2 -- Payer Quality Programs Check for: value-based payment program participation, outcome-based contract metrics, quality bonus/penalty tracking, payer-specific quality measure reporting, bundled payment episode outcome tracking, alternative payment model (APM) performance. Step 6.3 -- Accreditation Support Assess: CARF (Commission on Accreditation of Rehabilitation Facilities) outcome requirements, Joint Commission standards for rehabilitation, state licensure compliance, outcome data for accreditation surveys, continuous quality improvement (CQI) program documentation, performance improvement project tracking. ============================================================ PHASE 7: WRITE REPORT ============================================================ Write analysis to `docs/therapy-outcomes-analysis.md` (create `docs/` if needed). Include: Executive Summary, Functional Improvement Assessment, Treatment Effectiveness Comparison, Discharge Readiness Prediction, Patient Satisfaction Correlation, Quality Reporting Status, Clinical Practice Improvement Recommendations with outcome impact estimates. ============================================================ SELF-HEALING VALIDATION (max 2 iterations) ============================================================ After producing output, validate data quality and completeness: 1. Verify all output sections have substantive content (not just headers). 2. Verify every finding references a specific file, code location, or data point. 3. Verify recommendations are actionable and evidence-based. 4. If the analysis consumed insufficient data (empty directories, missing configs), note data gaps and attempt alternative discovery methods. IF VALIDATION FAILS: - Identify which sections are incomplete or lack evidence - Re-analyze the deficient areas with expanded search patterns - Repeat up to 2 iterations IF STILL INCOMPLETE after 2 iterations: - Flag specific gaps in the output - Note what data would be needed to complete the analysis ============================================================ OUTPUT ============================================================ ## Therapy Outcome Analysis Complete - Report: `docs/therapy-outcomes-analysis.md` - Patient episodes analyzed: [count] - Outcome instruments evaluated: [count] - Average functional improvement: [score change] - Patient satisfaction score: [score] ### Summary Table | Area | Status | Priority | |------|--------|----------| | Functional Improvement | [status] | [priority] | | Treatment Effectiveness | [status] | [priority] | | Discharge Prediction | [status] | [priority] | | Patient Satisfaction | [status] | [priority] | | Quality Reporting | [status] | [priority] | | Clinical Benchmarking | [status] | [priority] | NEXT STEPS: - "Run `/rehab-scheduling` to optimize scheduling based on outcome-driven treatment patterns." - "Run `/compliance-ops` to evaluate CMS MIPS reporting compliance." - "Run `/hr-ops` to correlate therapist outcomes with workforce development needs." DO NOT: - Modify any patient records, outcome scores, or quality measure data. - Compare therapist outcomes without risk-adjusting for patient case mix differences. - Ignore patient-reported outcomes in favor of clinician-assessed measures alone. - Recommend discharge criteria changes without clinical evidence to support the change. - Skip satisfaction analysis -- it correlates with adherence, outcomes, and payer reimbursement. - Use outcome data to make individual clinical treatment decisions (this is a systems analysis tool). ============================================================ SELF-EVOLUTION TELEMETRY ============================================================ After producing output, record execution metadata for the /evolve pipeline. Check if a project memory directory exists: - Look for the project path in `~/.claude/projects/` - If found, append to `skill-telemetry.md` in that memory directory Entry format: ``` ### /therapy-outcomes — {{YYYY-MM-DD}} - Outcome: {{SUCCESS | PARTIAL | FAILED}} - Self-healed: {{yes — what was healed | no}} - Iterations used: {{N}} / {{N max}} - Bottleneck: {{phase that struggled or "none"}} - Suggestion: {{one-line improvement idea for /evolve, or "none"}} ``` Only log if the memory directory exists. Skip silently if not found. Keep entries concise — /evolve will parse these for skill improvement signals.