Spring/ Summer 2007

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Improvement in Oral Medication Management: The Impact of Standardized Patient Assessment

One of the most common issues identified by home health providers regarding the Oral Medication quality measure is the lack of a standardized assessment process for all disciplines answering M0780. The following protocol was included in the Medication Management Best Practice Intervention Package in March 2007. You are strongly encouraged to share this resource tool with your staff and are urged to include this information in any educational programs you develop to address standardizing the assessment process for this quality measure.

MEDICATION ASSESSMENT PROTOCOL*

Purpose: To provide a standardized approach to evaluating patient ability to administermedications.

Instructions Clinician Observation/Assessment
- Ask patient to demonstrate hows/he takes his/her medication.
- Ask if the patient has any help to prepare or select the appropriate medications.		 - Observe the patient performing preparatory activity (e.g., gathering medication supplies or moving to area where medications are routinely stored/organized).
- Is the process organized?
- Identify compliance aids used.
- If the patient does have assistance, determine (through observation and interview) if the assistance is necessary.
Once the medication supplies are assembled (or accessed):
- Ask the patient to describe how s/hewould proceed with taking his or her medicines (i.e., ask specifically, "What would you do first? Second?" etc.)		 - Is the process appropriate as described?
- Correct dosage, time, and frequency?
- Check the patient's response against the directions for his or her specificmedications.
If ability to sequence the multi-step medication administration task is not evident:
- Ask the patient to demonstrate a multi-step medication administration task (e.g., "Please show me how you would open your medicine bottles and take your medication.")		 Does the patient demonstrate ability to appropriately complete all steps in the task?
- Select the appropriate bottles
- Open each one and select the correct dosage prior to closing lid(s)
- Take medication as directed
- Close lid(s) and return bottles to storage area.
Check adherence:
As part of the comprehensive assessments AND On an ongoing basis.		 Reviewcalendar, diary, list, pillbox, etc. to determine compliance.
- Select one medication with known start date and count pills to verify compliance.
- Does patient have any established daily routines which are, or could be, tied in to medication administration?
*Source: www.homehealthquality.org
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HHQI Campaign Knowledge Nuggets

HHQI - Change of Agency Information Tips

HHQI - Change of Agency Information Tips Changing HHQI Campaign Contact and Agency Information:
Do you have a change in your primary or secondary contact for the HHQI Campaign?

Complete the Home Health Agency Change of Information form found on the "For Home Health Agencies" page at www.homehealthquality.org. Fax per instructions on the form.

Is your agency address on the HHQI Campaign Web site up-to-date?

Your agency address can only be modified through your state OSCAR/ASPEN coordinator. For more information about the procedure, go to the "For Home Health Agencies" page at www.homehealthquality.org and click on "View the instructions for address only change."

What is the value of tracking "Hospitalizations by Day of the Week" on Home Health Quality Improvement (HHQI) Campaign Reports?

These questions could be used when conducting an analysis of the referral trends and staffing patterns affecting your agency's ACH rate:
Referral Patterns - Have you identified that complicated, high-risk patients are discharged at the "end of the week" or prior to a holiday? Are these patients rehospitalized within days of the start of care?
- Have you investigated trends in hospitals, nursing homes, physician offices, and clinic referral practices?
Answers to the above questions can help to address concerns with your referral sources during cross-setting meetings that may be conducted by your home health agency leadership.
If your agency receives a large number of referrals from hospitalists, set up a meeting to discuss the issues you are seeing at discharge from the hospital and admission to home care.
Staffing Patterns - Have you identified that staffing on a particular day or during certain seasons impacts your ACH rate, such as summer vacations and holidays?
- Are the majority of patients being admitted on a certain day of the week? Are on-call, regular or weekend-only staff involved?
- Could Monday/Tuesday admissions have been prevented if a telephone call or visit was made over the weekend?
Benchmark reporting, can be used to address staffing issues and trends that influence patient safety.
High-Risk Patient Patterns - Are a majority of patients being hospitalized on certain days of the week? Consider implementing telephone monitoring for high-risk patients on the days of the week with the highest occurrence of hospitalization.

HHQI National Campaign Teleconference Audio Available

The 70-minute audio recording of the HHQI National Campaign "Strategies for Success" Teleconference is now available. If you missed this live event, go to www.homehealthquality.org to hear representatives from home health agencies and a physician give practical application scenarios for using the campaign data and interventions. Home health leaders share how the national campaign is an opportunity to excel as the home health care community works toward the united vision of reducing "avoidable" hospitalizations.

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Senior Leadership Support of Quality Improvement Initiatives

The support and involvement of senior management in an agency's quality improvement initiatives cannot be emphasized enough. Agency supervisors and staff will respond to the operational and clinical areas that the senior leaders discuss and value. The following strategies for senior leaders can be used to demonstrate commitment to the home health agency's Outcomes-Based Quality Improvement (OBQI) initiatives:

Your interest and discussion of improvement efforts and their importance to the agency is a great accelerator for improvement. By demonstrating your commitment to the success of the strategies, interest will be cultivated on all levels of the organization.

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IPRO Home Health Quality Award Recipients

Each year IPRO recognizes outstanding performance by health care providers and stakeholders throughout New York State with our Quality Awards Program. This year's honorees, which included hospitals, home health agencies, nursing homes, physician offices, and health care professionals, were announced at IPRO's Annual Meeting, held June 5, 2007 at the LaGuardia Marriott Hotel, East Elmhurst, New York.

List of Home Health Quality Award Recipients
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Immunizations - Who's Responsibility Is It?

Assessing for influenza and pneumococcal immunization status and intervening is the responsibility of all health care providers. Inpatient facilities, outpatient clinics and home health care are all challenged to support this very important health initiative. The Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and the Office of Disease Prevention and Health Promotion's Healthy People 2010 have identified immunizations as a top priority for our nation's health care agenda.

Why is this initiative so important? Streptococcus pneumoniae and influenza together are the seventh leading cause of death in the United States among persons aged 65 years and older.

Epidemics of influenza are responsible for an average of 36,000 deaths per year in the US, 90% of which occur among those aged 65 and older. Pneumococcal infection causes an estimated 1.4 million hospitalizations for pneumonia annually in the US for persons aged 65 and older.

Since August 2005, IPRO, in contract with CMS, has collaborated with New York State home health providers to support the CMS comprehensive cross-setting effort to improve influenza and pneumococcal immunization rates of Medicare beneficiaries. The measurement goal established by CMS for the home health provider community involves the assessment of influenza and pneumococcal immunization status during the comprehensive patient assessment.

In December 2005, CMS requested that IPRO provide the baseline Influenza and Pneumonia Immunization Survey to all NYS Medicare-certified home health providers to determine immunization practices at the agency level. The baseline survey, completed by 98% of the NYS providers, indicated that 68% of the agencies had already incorporated assessment for both immunizations into the comprehensive patient assessment. We are now in the re-measurement period and CMS has requested that the same survey tool be re-distributed to assess statewide improvement for inclusion of the influenza and pneumococcal vaccine into the comprehensive patient assessment. The target goal set by CMS for NYS is a statewide rate of assessment for both immunizations of at least 80%.

This survey was forwarded to all NYS Medicare-certified home health agencies on 6/07/2007 with the request that the completed survey be returned to IPRO by 8/31/2007. The survey was provided in hard copy format so that it could be faxed to IPRO and in electronic format available at http://www.ipro.org/survey/hha-immunization/hha-index.php. Completion of the survey tool does not require agencies to administer either of these immunizations.

An Immunization Toolkit specifically created for the home health community can be found on the MedQIC website, which offers multiple resources related to patient and staff education, patient eligibility and communication tools across provider settings. Agencies can access this tool kit at www.medqic.org.

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Application of Human Factors Principles

As part of the Centers for Medicare & Medicaid Services (CMS) 8th Scope of Work (SOW), fifty-three New York State agencies volunteered to work on developing quality initiatives with the IPRO Home Health Project Team, as part of a Clinical Identified Participant Group (IPG). This IPG has been submitting quarterly internal monitoring reports that measure how the direct care staff at their agency incorporates best practice behaviors into the daily care they provide to patients.

Very often, there are one or two best practices that staff has difficulty adopting. Investigation into the causative factors impacting staff adoption of these practices has shown the primary reason to be failure of the agency to reinforce the behavior with their clinicians and provide ongoing feedback on the agency's progress towards improved care management. The most common response to this issue is re-education of the staff.

Dr. Sarah Fraser, an international healthcare improvement expert, contends that changing behavior requires more than re-education and in-services. She has determined that it can take up to 21 times of repetition before an individual can adopt a new behavior, and that is if the necessity for the change is fully understood.

Human Factors is the science of designing tools, tasks, information and work systems to be physically and mentally compatible with the abilities of the human users while taking into account work environment variables that affect the direct care staff's ability to successfully implement the best practice.

Let's look at an example of a situation where Human Factors principles could be applied. An agency implements a best practice that requires the supervising nurses to perform a case conference with the admitting nurse within 24 hours of the start of care (SOC) visit. After one month, the agency's internal monitoring reports evidence of 25% compliance with this best practice. When the Quality Improvement Coordinator (QIC) meets with the supervising nurses to investigate the reason the SOC case conferences are not being performed, s/he is informed that the supervising nurses do not always know when patients are being admitted and not all supervising nurses were documenting case conferences with the admitting nurses. In response to this finding, the QIC meets again with the supervising nurses to develop a case conference documentation form that will become part of the clinical record. The QIC also requests that the intake supervisors provide a list of patients admitted to the agency on a daily basis. The next month the internal monitoring results for this best practice show increased improvement to 80%. This example demonstrates how applying Human Factors science when investigating reasons for a low compliance rate helps to define what system changes need to be made to improve compliance.

According to the science of Human Factors, there are three types of errors, which can explain why the desired behavior is not executed, they are:

In order to identify which of the errors have been made, and need to be corrected, it is essential to understand why the error occurred in the first place. To correct the errors, situational and environmental factors within the home health agency need to be considered by all involved parties before a plan for correction can be developed. The table below outlines the interventions an agency may utilize to correct the compliance errors related to the staff performance of the Plan of Action's best practices:

ERROR TYPE MAY work MAY NOT work
Planning The planning is not correct - Memory Aids
- Training
- Creating a process/procedure		 - Punishment
- Rewards
- Reminders
Why? Staff believes they are acting correctly.
Execution The plan is correct, but there is a failure in execution - Prompts
- Reminders
- Memory aids		 - Punishment
- Rewards
- Training or education of skilled staff
Why? Intended to correctly complete task
Violation Intended deviations from practice-negative consequences are unintended - Redesign work to eliminate frustration
- Use policies and rules only
- when necessary
- Provide positive feedback for desired behavior		 - Training and education
- Reminders
- Prompts
- Memory Aids
- Punishment
Why? Violations are a product of consequences; positive consequences are strongest

In summary, by incorporating Human Factor science principles into home health agency outcome-based quality improvement (OBQI) projects, an agency can better understand how issues related to human behavior and work design can impact the successful implementation of the OBQI Plan of Action. Human Factors principles can drive staff performance, identification of areas and the types of errors likely to occur when implementing a new best practice and the development of interventions to reduce the likelihood of the errors occurring and still meeting agency, staff, and patient needs.

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Home Health Compare Update - June 28, 2007

On 6/28/07, CMS completed the quarterly update to Home Health Compare reflecting the January 2006-December 2006 reporting period data. For the first time since the 11/03/03 launch of Home Health Compare, the New York State average for emergent care has decreased to 24% from 25% in all previous quarters, while the national rate remained unchanged at 21%. The NYS average is equal to or better than the national rate for five of the 10 quality measures (Transferring, Oral Meds, Pain Management, Urinary Incontinence and Dyspnea). In addition to Emergent Care, the NYS average improved in comparison to the previous quarter for four quality measures (Oral Meds, Bathing, Urinary Incontinence and Dyspnea). The NYS average remained the same in comparison to the previous quarter for Ambulation, Transferring, Pain Management, Acute Care Hospitalization and Discharge to Community.

The following Home Health Compare Quarterly Update Comparison Grid provides details on the quarterly comparison of the NYS average to the national average for the 10 publicly reported quality measures.

Home Health Compare Quarterly Update Comparison Grid
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Home Health Compare: Do You Know How Your Agency Compares?

The Centers for Medicare & Medicaid Services (CMS) updated Home Health Compare on 6/28/07 with data reflecting the January 2006 to December 2006 reporting period. Please keep in mind that there is a three-month delay in data reported on Home Health Compare due to the time adjustments that CMS made in December 2006. In light of this delay, we encourage you to focus on the most current agency risk-adjusted data available to you (4/2006-3/2007) reflected on the IPRO Agency Trend Reports, which are forwarded to your agency on a monthly basis.

OBQI Risk-Adjusted Outcome Report Home Health Compare
Purpose of Report To provide agencies with performance data to use for quality improvement and monitoring of performance changes over time To provide consumers with data to compare outcome performance among home health providers
Home Health Agency Quality Measure Agency observed outcome rate (not risk-adjusted) Agency risk-adjusted outcome rate
National Reference Rate Agency-specific reference rate based on outcome rate of national population, risk-adjusted to reflect patient case mix of each agency Single national reference rate serves as a common reference for all agencies (average outcome rate for all patients serviced by providers across nation)
State Reference Rate Not applicable Individual state outcome rate (average risk adjusted outcome rate for all patients serviced by providers in a specific state)
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