Winter 2007

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Centers for Medicare & Medicaid Services' Home Health Quality Improvement National Acute Care Hospitalization Campaign

Centers for Medicare & Medicaid Services' Home Health Quality Improvement National Acute Care Hospitalization Campaign

On January 11, the Centers for Medicare & Medicaid Services (CMS) launched the Home Health Quality Improvement (HHQI) National Campaign at a National Summit held at CMS' Baltimore, Maryland headquarters.

The HHQI Campaign seeks to unite the home health community and key stakeholders with a shared vision to reduce "avoidable" hospitalizations and improve the quality of care for home care patients. It is intended to be a grassroots campaign that will reach individual home health agencies at the clinician level.

The CMS measurement goal for the year-long campaign is to reduce the average acute care hospitalization (ACH) rate across all home health agencies participating in the Campaign by a 5% relative improvement from their beginning baseline ACH rate to their rate at the end of the campaign.

State Associations and Quality Improvement Organizations (QIOs) nationally are combining resources as "Local Area Networks for Excellence" (LANEs) to support providers in this initiative. In New York State, IPRO, the Continuing Care Leadership Coalition (CCLC), the Healthcare Association of New York State (HANEW YORK STATE), the Home Care Association of New York State, Inc. (HCA), and the New York State Association of Healthcare Providers (HCP) have partnered in a proactive state-wide campaign to assist providers in reducing acute care hospitalization (ACH) rates. The New York LANE is responsible for sharing campaign promotional materials, helping agencies register for the campaign, and disseminating intervention materials and monthly campaign reports to registered home health agencies.

Agencies enrolling as Campaign Partners will receive monthly Intervention Packages, containing educational tools and resources, best-practice guidelines, success stories and other resources targeting reduction of avoidable acute care hospitalization. These Intervention Packages, available via download from the Campaign Web site, will provide resources to agency staff across clinical disciplines, as well as support, administration and management staff. Your agency will receive an e-mail message notifying you when the each month's Intervention Package becomes available on the Campaign Web site.

The monthly Intervention Packages will focus on specific best practices or strategies that have demonstrated success in reducing "avoidable" hospitalizations. They will have two tracks: one for agencies currently using the best practice or strategy and one for those agencies not using that practice or strategy. Resource materials will include a home health agency self-assessment, an action sheet, a specific best practice or strategy to reduce avoidable hospitalization within your agency and educational materials appropriate for all disciplines within your agency. The educational materials will be in self-study module format for use with direct-care staff. The first Intervention Package is scheduled for availability in March 2007.

Registered agencies will also receive, by mail, monthly individualized agency-specific state and national benchmarking reports that will include actual and risk-adjusted ACH rates broken down by month, along with case mix characteristics of hospitalized patients.

In addition, the New York LANE will be sponsoring educational learning sessions on a monthly basis for all campaign registrants, to provide guidance and support on implementation of the interventions provided and interpretation of the agency-specific reports.

As of February 12, 2007, 143 (77%) of the New York State home health providers had registered on the Campaign Web site to participate in this exciting initiative! Nationally, more than 4,100 home health agencies have registered to participate.

Agencies interested in obtaining additional information about the HHQI National Campaign or in registering for participation can access the Campaign Web site at http://www.homehealthquality.org.

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Home Health Compare Updates 2007

The December 21, 2006 update of data to Home Health Compare reflected ONE month more recent data than the period posted with the September 2006 Home Health Compare release. This differed from previous quarterly Home Health Compare updates, in which the data was THREE months more recent. This change for the December 21 update was related to the Deficit Reduction Act of 2005, which required agencies to submit OASIS data for a 12-month time period (07/2005-06/2006) to qualify for the 2007 market basket update. The December 21 CMS update of data to Home Health Compare matches the same report time period of 07/2005-06/2006 as utilized for the 2007 market basket update.

In comparison to the September update, the New York State average increased for the ambulation and urinary incontinence quality measures; the remaining New York State rates remained unchanged. The national average improved for the transferring quality measure. Acute care hospitalization, emergent care and oral medication management remained unchanged for both New York State and the national average for this one-month reporting period update.

The Home Health Compare Web site is refreshed quarterly. In 2007, refreshes are scheduled to occur as follows:

REFRESH DATE REPORTING PERIOD
March 29, 2007 October 2005 - September 2006
June 28, 2007 January 2006 - December 2006
September 27, 2007 April 2006 - March 2007
December 20, 2007 July 2006 - June 2007

Access the Home Health Compare Web site at http://www.medicare.gov

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Home Health Setting Targets-Achieving Results (STAR) Web Site

The Centers for Medicare & Medicaid Services (CMS) designed the Home Health STAR (Setting Targets--Achieving Results) Web site to assist home health agencies in reviewing OBQI and Home Health Compare data, to provide a Web-based location to record target goal rates for their Plans of Action and measure improvement for the 11 publicly reported quality measures.

Setting targets to accelerate quality improvement is now an integral part of quality improvement for both home health and nursing home providers. Targets are concrete, measurable goals with timeframes. They are tangible, meaning that they are planned, documented and used as a frequent reference to check to see whether your quality improvement project is progressing as planned. Setting target rates for your Plans of Action should be an annual activity for all of the quality measures you are working to improve.

Only your agency can determine a target goal for your Plan of Action that is meaningful for your agency. Your Quality Improvement Team and Administration should work together to set your goals for quality improvement. Of course, setting a target will not, in and of itself, lead to improved outcomes; however, targets can increase awareness of specific topics and encourage agencies to focus resources on improving care. Targets can motivate staff within your agency to "raise the bar" for quality. Once targets are set, it is very important to share them with your agency staff to ensure buy-in and achievement of the target goals.

The IPRO Home Health Project Team is working with all New York State home health agencies to establish target goals for their Plans of Action. Agencies accessing the STAR Web site (http://www.medqic.org/HH/STAR) can review the available benchmark data and set target goals for their Plans of Action. Once agencies have entered their selected target goal, the Home Health STAR Web site is able to generate a Trend Graph comparing the agency's current rate to the state average, national average, prior observed, current observed, and established target rates. Because the Home Health STAR Web site is housed on the MedQIC Web site, agencies must be registered on the MedQIC Web site in order to use the Home Health STAR Web site.

Although it is easy to access Home Health STAR, access instructions must be carefully followed. An IPRO Home Health STAR Webex training session for New York State home health agencies held on July 19, 2006 is available on the IPRO Website at http://providers.ipro.org/index/hhqi-20060719. The presentation slides and instructions for registration to MedQIC and Home Health STAR are posted in this section and are available for download. We strongly encourage you to listen to the recorded event to gain a better understanding of the benefits of the Home Health STAR site. If you have not yet accessed the STAR Web site, contact a member of the IPRO Home Health Project Team for your agency's Home Health STAR Agency Security Key number. You will need this information in order to register for the STAR Web site.

If you have not visited the Home Health STAR Web site to establish target rates for your agency, we strongly encourage you to log on to the site within the next two weeks to set these targets for 2007.

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Implications for Home Health Agency Organizational Culture Change

A survey containing three open-ended questions was sent to 700 home care nurses. The nurses were asked to list the characteristics of home care agencies that were most important to their professional practice and job satisfaction. The ten most important characteristics were:

A survey containing three open-ended questions was sent to 700 home care nurses. The nurses were asked to list the characteristics of home care agencies that were most important to their professional practice and job satisfaction. The ten most important characteristics were:

  1. Support for education. This included the agency's orientation program, scheduled in-services, opportunities to attend conferences, and tuition support.
  2. A knowledgeable and supportive front-line manager. This characteristic included being accessible and available to answer questions or assist with problem-solving; good interpersonal skills; knowledgeable about the community; knows the regulations and practice standards; is honest and fair with staff.
  3. Dedication to quality care. These responses included a patient-centered philosophy within the organization, with the patient as the priority; adherence to practice and ethical standard; and a reputation as an agency that provides good quality care.
  4. A strong supportive administration. This included the presence of strong administrators who support staff, and who are experienced, enthusiastic, and passionate.
  5. Good communication between staff and administration. Respondents used descriptors such as honest, direct, timely, and consistent; an administration that listens and hears the staff's concerns.
  6. Flexible work schedules. Nurses are able to provide their input into developing schedules.
  7. A competitive salary and benefit package. Salaries are comparable to those in other practice settings and there is evidence of regular increases.
  8. Reasonable workloads. Patient assignment, including travel, visit, documentation, and case coordination, can be completed during a regular workday.
  9. Staff input in decision-making. Including staff in agency committees, in making policy decisions, and seeking staff input in problem-solving processes.
  10. Adequate staffing. Most respondents did not comment further, but a few comments were related to having sufficient nursing staff to prevent nurse overload or burnout.

Source: Flynn, L. (2003). "Agency Characteristics Most Valued by Home Care Nurses." Home Health Care Nurse, 21(12), p. 812-817.

The Nursing Work Index-Revised (NWI-R) survey measures the degree to which a set of traits that support nursing practice is present in hospital work environments. Research has indicated that work environment traits that are supportive to home care nurses in their practice are similar to those traits that hospital nurses value. The NWI-R survey was sent to 700 nurses. The ten (10) traits that were rated highest were:

  1. A supervisory staff that is supportive.
  2. Working with nurses who are clinically competent.
  3. Not being placed in a position of having to do things that are against my nursing judgment.
  4. A nurse manager who is a good manager and leader.
  5. A good orientation program for newly employed nurses.
  6. Freedom to make important patient care and work decisions.
  7. An administration that listens and responds to employee concerns.
  8. Good relationships with other departments.
  9. The Plan of Care is accessible and up-to-date for all patients.
  10. Enough registered nurses are on staff to provide quality patient care.

The above categories can be categorized into either structural or process traits. Structural traits are easily addressed by improvement strategies related to care delivery such as flexible scheduling, additional training, electronic documentation, and changes in the office setting. Process traits are more difficult to address because they related to interpersonal relationships between agency leaders and staff. Items 2, 5, 9, and 10 are structure-related traits and the others are process-related traits. Examples of improvement strategies that address process traits are management development programs, establishment of effective communication systems, and reasonable workloads for managers so they have time to mentor and coach their staff.

In summary, enhanced nurse retention evidenced-based strategies include the following organizational culture concepts:

Source: Flynn, L. (2005). "The Importance of Work Environment: Evidence-based Strategies for Enhancing Nurse Retention". Home Healthcare Nurse, 23(6), p. 366-371.

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Improving Communication and Collaboration with Physicians

The following tips are offered to support your agency's efforts in improving communication and collaboration with physicians when promoting the benefits of home health care and the care management your staff is able to provide for their patients.

When your agency initiates a promotional campaign with physicians, keep in mind the "Three P's": Preparation, Planning and Presentation.

Preparation
Planning
Presentation
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IPRO Home Health Educational Opportunities: First Quarter 2007

The IPRO Home Health Project Team will continue sponsorship of the statewide Home Health Shared Learning Teleconference Series presentations in 2007, addressing clinical and organizational culture change strategies to improve patient outcomes and reduce avoidable acute care hospitalizations.

This shared learning teleconference series, initiated in September 2006, identifies strategies and interventions targeting the complex issues involved in reducing avoidable acute care hospitalizations, including communication with physicians and collaboration across health care providers to support improvement in patient-centered care transitions. The presentations also include information on the importance of data management, utilization of rapid cycle quality improvement, telehealth/teletriage and organizational culture change to support improved care management. The teleconference series incorporates presentations by New York State home health providers who will review their quality improvement initiatives and the interventions that have contributed to their success in decreasing their acute care hospitalization rates and improved patient outcomes. The purpose of this teleconference series is shared learning among your peers to support your agency's Outcome-Based Quality Improvement efforts.

IPRO Home Health Educational Opportunities are posted to the Home Health section of the IPRO Web site at http://providers.ipro.org/index/homehealth. You will find presentations, along with fax-back registration forms and call-in information, in the Upcoming Events section. Participation is free and you are welcome to join any conference calls that may be of interest to you. Each call is taped and available on our Web site within one week of the presentation.

We strongly encourage you to take advantage of this educational opportunity and also to include the administrative and senior management representatives of your organization.

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IPRO Telehealth Data Collection Tool Release

IPRO, in close collaboration with the Home Care Association of New York State Telehealth Taskforce, has developed a Telehealth Data Collection Tool. This Microsoft Word-based tool identifies standardized measures for providers to utilize to determine the value of telehealth technology. The standardized data collection process across providers will be very beneficial in identifying outcome and cost factors involved in telehealth care, a powerful element in the future of community-based care.

The Telehealth Data Collection Tool incorporates the following important design elements:

The standardized data collection measures include comparison of patient information for the12-month period prior to telehealth to the post-telehealth period for measurement of the frequency and reasons for emergent care and acute care hospitalization episodes and length of stay. The 12-month period prior information permits data entry of self-reported information from the patient.

The tool also captures agency-specific information related to cost, staff training and type of equipment (video, non-video and/or telephone monitoring) and peripherals used for care management.

The Telehealth Data Collection Tool was pilot tested by ten New York State home health providers from June through September 2006. It in now in the final stages of completion, incorporating recommendations offered by the pilot agencies, and will be distributed to all of the New York State Medicare-certified home health providers in March 2007. IPRO will send notification of distribution and provide an opportunity for agencies to attend a Webex demonstration of tool applications.

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New Addition to the IPRO Home Health Project Team

IPRO welcomes Victoria Agramonte RN, MSN, our new Home Health Performance Improvement Coordinator. Vicky brings to this position expertise from her twelve years in the home care provider setting, including experience in performance improvement and involvement in CMS initiatives at the provider level. Vicky joined IPRO in December 2006 and is a welcomed addition to our project team!

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Strategies to Improve Care Transitions Across Provider Settings

Many home care providers have shared concerns about a barrier they encounter in their efforts to reduce avoidable acute care hospitalizations: receiving home care referrals from acute care providers for patients who are inappropriate for home care services. These patients are usually inappropriate due for safety reasons. The safety concerns most commonly relate to social/environmental factors in the patient's home, clinically complex or fragile medical conditions or behavioral issues that result in the patient not following or making appropriate decisions related to their medical plan of care. Agency staff members devote a lot of time and energy to these referrals, which often result in readmission of the patient to the hospital.

Because these patients have very complex needs, the referral source may be reluctant to share this patient information at the time of referral, perhaps assuming that agencies may not partner with them in planning for a safe hospital discharge to home care services for these patients.

Home care agencies may find the following strategies helpful when partnering with referral sources to safely plan for hospital discharge and communicate care transition information about these challenging, clinically complex patients:

  1. Contact the manager of the discharge planning department at your most frequent referral sources. Set up a process to review any patient referrals you received that involved safety issues requiring readmission of the patient to the hospital. Request a meeting to discuss the safety issues that affected the patient's ability to receive home care services and make recommendations on how the home care agency can work with the hospital discharge planner to plan a safe discharge.
  2. Establish a list of patient-related information that must be present for a referral to be accepted by your home care agency. Communicate that list to the agency's referral sources and be strict about its enforcement.
  3. When a high-risk patient is admitted to the hospital, call the hospital discharge planner and request a pre-discharge visit while the patient is still in the hospital. During that visit, review the patient's status with the discharge planner and discuss the specifics of the discharge plan.
  4. Prior to the patient's discharge, as part of the follow-up referral process, notify the patient's primary physician(s) and send them a copy of the discharge orders (referral) for home care services.
  5. If the patient is being sent to the Emergency Department (ED) by the home care clinician, call the ED and report the reason the patient is being sent to the ED and a list of their current medications. Follow-up with the ED to inquire about the findings and disposition of the patient.
  6. For high-risk patients, have the Case Manager serve as the discharge liaison nurse for that patient and plan that patient's discharge to home.

The MEDQIC Web site contains an excellent teleconference that describes how one Virginia home health agency worked collaboratively with a local hospital to reduce the agency's acute care hospitalization rate and keep patients at home. "Culture, Creativity, and Collaboration! Hear How One Home Care Agency Worked With A Local Hospital to Reduce Acute Care Hospitalization" can be accessed on the Home Health section of MedQIC at www.medqic.org. Click on the "Acute Care Hospitalization" area in the left-hand menu and then on the "Presentation" section in the right-hand menu.

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New Best Practice Resource: The Chronic Care Clearinghouse

Until now, there has been no single or comprehensive source of information about Best Practices in Home Care. The Visiting Nurse Association of America (VNAA), with funding from the U.S. Department of Health and Human Services Centers for Disease Control and Prevention, spearheaded the development of The VNAA Chronic Care Clearinghouse. Their goal was to develop a single "Go To" resource of evidence-based best practices related to caring for individuals and families experiencing chronic illness.

With assistance from an Expert Panel, disease-related information was researched, collected, and reviewed for inclusion into the Web site. Diabetes is the first chronic disease that has evidenced-based practice material posted to the Web site; there are plans to add congestive heart failure and chronic lung disease, as well as material in additional languages, to the site.

The Best Practices include guidelines, recommendations, resources, tools and ideas home care clinicians can use when working with patients and families as they learn how to better manage their chronic illness. Best Practices are grouped into seven focus areas: nutrition, exercise, monitoring, medications, problem solving, coping, and risk reduction. Best practice guidelines for the home care setting appear at the beginning of each focus area. The seven focus areas are categorized according to the four elements of the nursing process: assess, plan, implement, and evaluate. Available materials are at the eighth-grade literacy level or lower. They can be freely distributed and used as any copyright issues have been resolved.

Clinicians will find educational materials they can use to improve their own skills, as well as some designed to help patients improve their self-management skills. The site is easy to navigate and, because it is Internet-based, can be accessed whenever time is available.

Access the site via the VNAA Web site at www.vnaa.org or directly at www.chronicconditions.org.

And add this information to your orientation program for new clinicians and your next staff meeting agenda!

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Updated OBQI & OBQM Reports & Case Mix Analysis Reports

The OBQI & OBQM Reports are now available by Branch ID!

Beginning December 18, 2006, the HHA OBQI and HHA OBQM reports will allow the user to request that the report be displayed by branch for all OBQI and OBQM reports. Two new columns have been added to the OBQI

Outcome Tally, OBQI Case Mix Tally, and the OBQM Patient Listing reports to display the value of M0016 (Branch ID) recorded in the Start of Care assessment and the End of Care assessment for the identified Episode of Care.

Use the following directions to request reports by branch:
  1. Once logged into CASPER, select the desired arguments (agency and time period)
  2. Check the box next to 'Report By Branch'
  3. Select 'Submit'

When branch information is requested all reports except for the OBQI Outcome and Case Mix Tally Reports and the reports will display in the following manner:

  1. Agency as a whole
  2. Data for patients served by the parent agency
  3. Data for patients served by a branch, in numerical order

Note: If the Start of Care and End of Care assessments display different Branch IDs, the data associated with this episode of care will only be reported on the overall branch report.

The following reports will display by branch:

HHA OBQI Reports:

You can also use the OBQI Report 2 Col Package or the OBQI Report 3 Col Package to request these reports by branch.

HHA OBQM Reports:

You can also use the OBQM Report 2 Col Package or the OBQM Report 3 Col Package to request these reports by branch.

Case Mix Analysis Reports for ALL of the 41 outcome measures are now available on the same site where the OBQI reports are available. As a reminder, the Case Mix Analysis Report is the report we forward to you on a quarterly basis for the ACH quality measure for use in identifying case mix factors for the hospitalized and non-hospitalized patients within your agency.

Now agencies will be able to identify patients who are at a higher risk of not achieving Improvement in Management of Oral Medications, also!

For the Case Mix Analysis Summary Report, the user can select one or more of the 41 outcomes from the OBQI Outcome Tally Report. The Case Mix Analysis Summary will display the average value for the case mix measure for patients who have and have not achieved the outcome, as well as the difference between the two calculations. Multiple outcomes requested at the same time will be available for viewing under one link in 'My Inbox' under Folders.

Directions to request the Case Mix Analysis Summary Reports:

  1. Once logged into CASPER, select Reports, then HHA OBQI Reports
  2. Select 'Case Mix Analysis Summary Report'
  3. Select desired Outcomes by placing a check in the box to the left of the title.
  4. Select desired arguments (Agency and time period)
  5. Select 'Submit'

It is recommended that users select no more than five outcomes at one time.

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