Summer 2006

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If Your Patient is Non-Compliant, Depression Could Be The Problem

Depression is common among patients receiving home care services, but it is not usually considered as a possible barrier to a patient's compliance with his or her plan of treatment.

Feelings of sadness or a decreased interest or pleasure in activities are two primary symptoms for diagnosing depression. At least one of these symptoms must be present for a two-week time period for depression to be diagnosed. Other symptoms associated with depression include change in appetite or weight, difficulty sleeping, restlessness or sluggishness, loss of energy, lack of concentration, indecision, feeling of worthlessness, and recurrent thoughts of death or suicide.

When depression is left untreated, patients have problems completing daily activities and experience a loss in their functional ability. They may feel that nothing can be done to improve their health problems, and that can lead to non-compliance with the plan of care.

The OASIS comprehensive assessment includes two questions that can be used as an initial screening tool for depression, M0590 & M0610.

Fortunately, depression is a treatable illness. If you think your patient may be depressed, here are a few interventions that will assist in the assessment and treatment:

Very often, people who are exhibiting the symptoms of depression do not receive appropriate treatment. Don't let that happen to your patient.

Source: Raue, P. J., Brown, E. L., Murphy, C. F., Bruce, M. L. Assessing Behavioral Health Using OASIS Part 1: Depression and Suicidality. (2002) Home Healthcare Nurse, 20(3), 154-161.

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Resource Web Sites of Interest

This Web site is a valuable resource for promoting health education to patients with limited English skills.

The voluntary organizations that contribute to patientINFORM do so to promote patient understanding and attempt to prepare patients for productive dialogues with physicians.

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Outcome Based Quality Improvement (OBQI) vs. Home Health Compare

You have probably noticed that the rates for your publicly reported Home Health Compare outcomes differ from the rates in your OBQI report. The following overview provides an explanation as to why that occurs.

Background: Data for Home Health Compare and the OBQI outcome reports are from the same source: OASIS. As you know, home health agencies submit OASIS assessments to the State. The State then transmits the OASIS data to a National OASIS Repository that resides on a secure database maintained by the Centers for Medicare & Medicaid Services (CMS). The assessments are used to determine the start and end points of care for each patient so that a comparison can be made of the patient's health status at the beginning and end of the home health care episode. Each of the 41 OBQI outcome rates is calculated for all eligible patient episodes. OBQI reports are provided directly to agencies through the CASPER reporting system. The CASPER reporting system allows an agency to generate and download a variety of reports, from patient-level data to agency-level outcome reports.

In 2003, CMS established Home Health Compare, a Web site for the publicly reported outcome rates. Home Health Compare allows your agency to compare your rates with those of other agencies in New York State and the rest of the country.

Risk adjustment: The purpose of risk adjustment is to "level the playing field" for agencies whose patients are at higher risk or more frail when comparing outcome rates for two different patient populations. Risk adjustment allows valid comparisons to be made for your agency's rates over time, between your agency and another, and between your agency and the state and national rates.

Home Health Compare data is updated quarterly. Any improvement seen on the OBQI agency outcome reports will eventually be seen in the Home Health Compare agency reports, but it will take longer to see that improvement.

OBQI Report Home Health Compare
- Includes all episodes that have a SOC/ROC and a discharge within a 12 month period
  • Updated monthly and includes late OASIS submissions and/or corrections for the previous months
  • A patient may have multiple episodes within a 12 month period
  • Risk Adjusted Outcome Report: the "current rates" are NOT risk adjusted; the "adjusted prior" and "national" rates are risk-adjusted
  • Descriptive Outcome Report: the "current," "adjusted prior," and "national" rates are NOT risk adjusted
 - Includes all initially reported episodes in the OBQI reports for a given 12-month period
  • Updated quarterly and does not include late or corrected OASIS submissions
  • A patient may have multiple episodes
  • All "agency" and "statewide" rates are risk-adjusted
  • National rates are NOT risk adjusted
Home Health Compare rates can be interpreted as how your agency would have performed if your agency's patient population were similar to the national population. Large differences between the rates in the OBQI reports versus Home Health Compare can be attributed to a large difference between the agency's patient population and the national patient population.
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Physician Communication

SBAR: a Structured Communication Strategy

Communication with the patient's primary care physician is critical to effectively case-manage the patient's care to achieve an optimal health outcome. Home health agencies have identified a major barrier to reducing "avoidable" hospitalizations: communication with the physician when a change in the patient's condition occurs. "We never get a call back" and "We are told to send the patient to the ER" are typical comments shared by home health agencies.

A possible solution to this problem might be to adopt the SBAR approach to communication with a physician or physician's office when reporting a change in a patient's condition. Physicians need pertinent information about the patient, presented in a clear and concise manner. Developed by Dr. Michael Leonard and colleagues at Kaiser Permanente of Colorado, the SBAR (Situation, Background, Assessment, Recommendation) approach is a structured communication technique that provides the clinician with a framework for effective communication of critical patient information.

To employ the SBAR technique when a call to the physician is necessary:

You will find more information on the SBAR communication technique on the Institute for Healthcare Improvement's Web site at www.ihi.org.

Faxes are another way home health agencies have effectively reported changes in a patient's condition. The fax communication form provides an area for the physician's response. If the fax is a follow-up communication to a telephone call, identify the person in the physician's office the report was given to and the time.

An agency may also want to develop a "triage system" that provides the physician's office with an importance rating to the communication. Here is an example of a communication triage system:

Open and timely communication between the patient's Case Manager and the physician is critical to the provision of safe, effective, and quality patient care and can ultimately lead to reducing an agency's "avoidable" re-hospitalizations.

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Reducing Acute Care Hospitalizations: The ReACH Collaborative Experience

The ReACH Collaborative is a national project facilitated by the Center for Home Care Policy and Research of the Visiting Nurse Services of New York. The purpose of the collaborative is to reduce "avoidable" hospitalizations by implementing evidence-based strategies and actions. The collaborative builds on the accomplishments and lessons learned from the agencies and QIOs that participated in the acute care hospitalization national collaborative in early 2005, including IPRO and 15 New York State Home Health Agencies.

Fifteen agencies from around the state volunteered to participate in the current collaborative:

After several pre-work activities, these agencies were asked to develop a Plan of Action focused on identifying and managing patients at risk for hospitalization, strengthening care management, enhancing communication and coordination, and establishing processes for transition from hospital to home.

Collaborative information, educational material, measurement data management, and agency information sharing has occurred through a collaborative Web site and listserve. Distance-learning technology has been utilized for the collaborative learning sessions. The participating agencies have tracked and reported data monthly via the ReACH Web site. Measures and results table

At the second collaborative learning session, which occurred in Albany on June 22, agency team members found they could make a difference. Common themes from agency experiences during "Action Period 1" were:

IPRO will soon be recruiting agencies to take part in Wave II of the collaborative, which will begin in October 2006. Participants' responsibilities include:

For more information, please contact Christine Stegel at cstegel@nyqio.sdps.org.

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Systems Improvement / Organizational Culture Change Identified Participant Group (SIPG) Teleconferences

Agencies in the Systems Improvement/Organizational Culture Change Identified Participant Group (SIPG) have completed an initial survey measuring agency staff members' perception of how the agency leads care quality, how people work together within the agency and the agency's approach to delivering safe, quality care. Results of the survey have been shared with the managerial and direct care staff within the SIPG agencies that completed the survey.

The SIPG agencies have chosen an area of focus for organizational culture improvement and are developing and implementing Plans of Action. Areas of focus include teamwork, communication, care coordination, leadership, patient-centered care, organizational learning, and information management.

In the 8th Scope of Work that began August 1, 2005, the Centers for Medicare & Medicaid Services (CMS) mandated that home health agencies with a baseline acute care hospitalization rate below 23.9% were ineligible to participate as members of Identified Participant Groups (IPG).

These agencies, which have demonstrated a decrease in avoidable acute care hospitalizations, have been recruited by IPRO into a "Strategic Planning IPG" to share the lessons learned and agency interventions that led to their success.

The Strategic Planning IPG agencies, as well as several other agencies that have reduced their ACH rates through utilization of telehealth, have agreed to share the organizational practices that contributed to their success in a series of six teleconferences.

The first of these monthly, hour-long calls is scheduled for Wednesday, August 16, 2006 at 9:00 am. Registration instructions were sent to the HCQIP liaison in your agency in hard copy and email format.

The complete teleconference schedule is listed below.

Upcoming SIPG Teleconferences
Date Presenters Time
August 16, 2006 Winthrop University Hospital CHHAVNS of Western New York 9:00 AM - 10:00 AM
September 20, 2006 St Joseph's Certified Home Health AgencySouth Nassau Communities Hospital Home Care 9:00 AM - 10:00 AM
October 18, 2006 Eddy VNA - "Lean Thinking" 9:00 AM - 10:00 AM
November 15, 2006 Tompkins County Home Health CHHAVNA of Hudson Valley 9:00 AM - 10:00 AM
December 13, 2006 At Home Care, Inc.VNA of Rochester & Monroe County 9:00 AM - 10:00 AM
January 17, 2007 VNA of Albany Warren County Health Services CHHA 9:00 AM - 10:00 AM
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What is Rapid-Cycle Improvement?

Rapid-cycle improvement is a quality improvement technique that agencies can use to implement changes within their organization to boost their quality improvement efforts. The process, used by the Institute for Healthcare Improvement in their Breakthrough Series collaborative, employs a series of PDSA (Plan-Do-Study-Act) cycles to break down the proposed change into a series of smaller steps.

It is suggested that the organization pilot test with a small group to see if the change will result in improvement. The change is broken down into a series of smaller steps for "trial and error" testing. If the testing results in improvement, then the agency can spread the change to include larger groups within the home health agency.

The initial questions for the agency to ask are:

The PDSA cycle allows the agency to quickly test on a small scale (within one team or 1-2 clinicians), evaluate the response and revise based on the evaluation. Just enough data is collected and reviewed to be useful. The team may not need a month's worth of data; a week's worth may be adequate. The team meets frequently to monitor the testing process. Once the change has been tested and refined, and improvement is demonstrated, the team is ready to plan for spreading the change throughout the home care agency. The rapid-cycle improvement technique correlates with establishing Best Practices, planning the Intervention Actions, and monitoring steps of the OBQI process.

The best way to integrate the rapid-cycle improvement technique into your OBQI process is for the OBQI team to:

Rapid-Cycle Improvement Means:

Source: www.ihi.org

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Home Health STAR Web Site Launched

The Centers for Medicare & Medicaid Services (CMS) has launched the Home Health STAR (Setting Targets - Achieving Results) Web site, designed to assist home health agencies review OBQI and Home Health Compare data, determine target rates for their Plans of Action and measure improvement for the 11 publicly reported quality measures.

Setting targets to accelerate quality improvement is now a consistent 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 if 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 that you are working to improve.

Only your agency can determine a target that is meaningful to you. Your quality improvement team and agency 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, but targets can increase awareness about 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, this information should be communicated to 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 that access the STAR Web site at 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 STAR Web site is able to generate a Trend Graph that provides comparison of 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 to the MedQIC Web site in order to register on the Home Health STAR Web site.

Although it is easy to access Home Health STAR, you must follow the instructions for access carefully. Instructions for MedQIC registration and access to the Home Health STAR Web site have been forwarded to the IPRO Liaison in your agency and are also posted to the Home Health section of the IPRO Web site at www.ipro.org. Your IPRO Liaison also received a 1-page document containing your agency's Medicare Provider Number, MedQIC Web site Agency ID Number and your Home Health STAR Agency Security Key number. You will need this information in order to register to both Web sites. If you do not have this information please contact one of the IPRO Home Health Project team members and we will provide it to you.

The IPRO Home Health STAR Webex Training session for New York State home health agencies held on July 19, 2006 is available on the IPRO Web site at providers.ipro.org/index/homehealth. Instructions for access to the recorded session, presentation slides and instructions for registration to MedQIC & Home Health STAR are posted in this section and are available for download.

If you were not able to attend one of the live Webex sessions, we strongly encourage you to listen to the recorded event to gain a better understanding of the benefits of the Home Health STAR Web site.

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