The Calvary Hospital Home Health Agency is an arm of the only accredited acute care hospital in the United States caring solely for advanced cancer patients. Calvary Home Health serves adult patients with all diagnoses, although the majority are patients with cancer or circulatory/cardiac disorders. The agency's hospice component serves adult patients with any terminal diagnosis.
When the agency targeted pain management as an opportunity for improvement, they recalled the Outcome-Based Quality Improvement (OBQI) Process training they had received through IPRO as part of the CMS Home Health Quality Initiative. Putting that process to work, they identified "Improvement in Pain Interfering with Activity" as the appropriate quality measure on which to focus their quality improvement efforts.
"Since the inception of the Outcome-Based Quality Improvement Process, IPRO has provided numerous exceptional training sessions to the agencies involved," said Nancy D'Agostino, Calvary Hospital Home Health Administrator. "The value of the OBQI Process in improving patient care and patient outcomes was understood from the beginning. The training made selecting the appropriate indicator to monitor an easier and less stressful process."
When work on the pain management quality improvement initiative began in October 2001, only patients with a cancer diagnosis and who identified pain as a problem received comprehensive pain assessment. By January 2002, all home care patients were being thoroughly assessed for pain on admission to the service. A pain level of 3 or greater, and/or an "unacceptable pain level" at any time, also triggered comprehensive pain assessment, with reassessment performed on every visit.
The change in strategy yielded positive results: for the period January 2002 through November 2003, Calvary Home Health demonstrated statistically significant improvement in the current agency rate (72.2%) compared with the prior year agency rate (52.3%) and national reference (58.1%) for the "Pain Interfering with Activity" Quality Measure.
How did it happen? After reviewing and evaluating existing pain management tools, an interdisciplinary Pain Management Committee created a new, standardized Pain Assessment Tool and implemented a series of staff education programs on revised pain policies and protocols.
There were obstacles. Although internal monitoring for the first six months of 2002 revealed 91% compliance with completion of the Pain Assessment Tool on all home visits, during the second half of the year, the compliance rate actually fell, to 85%.
Investigation revealed that the new tool was viewed by staff as an additional documentation requirement -- another form that needed to be completed by staff members already coping with too much paperwork. The team looked for ways to streamline the pain assessment tool, eventually incorporating it into the clinical visit note. This simple change improved staff buy-in, and by January 2003, internal monitoring showed 100% compliance with the use of the tool.
In March, 2004, D'Agostino and Rissa Aurich, Director of Quality Management, were asked to present Calvary Home Health Agency's experience at regional educational conferences sponsored by IPRO. "The IPRO representatives were available to assist with any problem or as a resource while we were developing our Plan of Action. The IPRO 'Resource Binder' and other materials were very helpful and useful to our agency" D'Agostino noted. "We are proud to have our OBQI efforts recognized by IPRO and to be able to share our Plan of Action as a demonstration and training resource" added Aurich. For more information, contact Sara Butterfield, Project Manager, Home Health at sbutterfield@nyqio.sdps.org or 518-426-3300, extension 104.