Winter 2005/06

Acute Care Hospitalization Initiative: Plan of Action Due
Plan of Action Monitoring
Multidisciplinary Approaches for Improvement in Oral Medication Management
Acute Care Hospitalization: The Transition Period
Spanish Version of Red-Yellow-Green Zone Self-Management Tools
Telehealth: It's not just about technology; It's about the patient
OBQI -- Plan of Action Tips
Oral Medication Management: Medication Reconciliation
Improving Adult Immunizations Rates in the Home Health Setting
Home Health Compare Update
Educate and Empower Patients and Caregivers!
New Home Health Tools Posted to JENY

Acute Care Hospitalization Initiative: Plan of Action Due

The IPRO Home Health Project Team continues to collaborate with New York State home health agencies to develop and implement their Acute Care Hospitalization (ACH) Plans of Action. IPRO has asked each Medicare-certified home health agency in New York State to support this initiative through use of the OBQI process, targeting reduction of avoidable acute care hospitalizations.

The national acute care hospitalization quality measure rate has remained at 28% since the launch of the Home Health Compare Web site in November 2003. Similarly, the statewide average in New York has remained at 31% for the same time period. The Centers for Medicare & Medicaid Services (CMS) has selected this quality measure for focus by the home health community of practice nationally, establishing a national target goal of 23% by 2007.

In October 2005, IPRO sent an ACH Planning Packet to the IPRO Health Care Quality Improvement Program liaison in your agency. The ACH Planning Packet, designed to provide all of the initial components to support the initial steps of Plan of Action development, included the following materials:

Hard copy of the Risk-Adjusted and Descriptive Outcome Reports and corresponding Case Mix Report for your agency.
A CD-ROM containing a Patient Tally Workbook that combines your agency Outcome Tally Report and Case Mix Tally Report into a workbook intended to assist you in selecting records for a Process of Care Investigation of patients hospitalized during the report period.
Instructions for navigation through the Patient Tally Workbook.
A chart audit tool to utilize for the Process of Care Investigation.
A Case Mix Analysis Tool that identifies the risk factors associated with hospitalized and non-hospitalized patients for your agency.
A sample Risk Assessment Tool that can be utilized at Start of Care/Resumption of Care to identify patients at high risk for re-hospitalization. This enables earlier implementation of interventions which may prevent an avoidable hospitalization.
A CD-ROM containing the Acute Care Hospitalization Improvement Matrix and corresponding tools and resources. These provide evidence-based strategies that can be incorporated into your Plan of Action.
The Plan of Action template, which provides all of the important components that need to be incorporated into the development of your plan to address this quality measure.

The ACH Plan of Action was due to IPRO by 12/30/05 for review and formal feedback. If you have not yet started developing your ACH Plan of Action, please contact one of the IPRO Home Health Project Team members as soon as possible for assistance with this process.

Plan of Action Monitoring

Monitoring and evaluating the Plan of Action are extremely important activities once your agency's Plan of Action (Plan) has been implemented. The monitoring results inform the team that the intervention actions have been completed and the Plan has been fully implemented. The team assesses whether the Best Practices have been incorporated into the clinician's patient care delivery by performing evaluation activities. The most common evaluation activity is clinical record audit. Other methods to measure whether the clinician is utilizing the best practices include performing supervisory visits with the clinicians and interviewing individual clinicians during case conferences.

There are two types of measures that are tracked during the evaluation of the agency's Plan. They are outcome measures and process measures. An outcome measure informs the team whether the target outcome addressed by the Plan is improving. For example, the Plan related to acute care hospitalization is improving if the rate or number of re-hospitalizations within your agency is decreasing. To measure the outcome rate, discharged patient records are reviewed. A process measure informs the team whether the clinicians consistently perform the Best Practices. To measure the processes, concurrent or open client records are reviewed.

We emphasize the importance of monitoring and evaluation because the agency is unlikely to reach the goal of sustained improvement in the target outcome if the clinicians do not consistently perform the best practices. The agency may not be aware that the best practices are not being consistently performed if the intervention actions are not monitored for compliance.

A single, "right" schedule for monitoring does not exist. Generally, the team begins monitoring activities soon after the Plan has been implemented, within the first month, and then monthly until the team feels comfortable about the Best Practices being consistently followed by the clinicians.

Remember:

If the agency is pilot testing, then review only the active patient records that are within the pilot.
If the agency is implementing the Plan for a specific patient population, then only review active patient records within that specific patient population.

IPRO has tools available that will assist agencies in monitoring their outcome and process measures. They are available electronically at www.ipro.org; click "Browse by Provider"; click "Home Health Agency"; click "Home Health Quality Initiative"; click "Resources." The tools are named the "Best Practice Tracker Tool" and the "Outcome Tracker Tool." The first time an agency uses either of these tools, the IPRO Home Health Team can take you through them step by step. Results of the monitoring activities can be easily displayed in a trend report generated from these electronic tools. There are also paper tools available in the Acute Care Hospitalization CD sent to all home health agencies in October 2005 in the ACH Planning Packet.

Tracking and communicating your agency's progress and the Plan's impact on the targeted outcome is extremely important to achieve buy-in for direct care staff to change their care behavior and incorporate the Best Practices consistently into patient care. The results of your monitoring activity can be posted as a trend report. The graphical display allows direct care staff to easily understand how changes in their patient care delivery are impacting the agency's patient outcomes. On www.medqic.org there is a "Storyboard" format that illustrates how to display outcome and process measure results to present to staff. Using a "Storyboard" approach may decrease staff's defensiveness and enhance discussion. The Storyboard approach can also be used to create an educational program for ancillary staff, including home health aides.

Remember:

If the Plan has been fully implemented and the clinicians are consistently utilizing the Best Practices, but the outcome rate is not improving, then your OBQI Team will need to modify the Plan. Another Process of Care investigation may need to be performed to reassess the clinician's care behaviors that are impacting the target outcome results. This is the time when the team may decide to pilot test or consider "small tests of change" that will allow an agency to test the change on a small scale before implementing it agency-wide.

If direct care staff members are not following the Best Practices, then the team will need to investigate why and may need to add to the Intervention Actions to facilitate the desired care behavior change.

In summary, the monitoring steps to follow are:

Review the monitoring activities on your Plan and check that the Intervention Actions have been completed.
Identify the outcome and process measures that will be tracked.
Establish the data management system for tracking.
Begin collecting and compiling your data results.
Review the results with the agency's OBQI team and direct care staff.

IPRO's Home Health Project Team is available to assist you in all the above monitoring activities.

Multidisciplinary Approaches for Improvement in Oral Medication Management

Agencies involved in the design and development of a Plan of Action addressing the Improvement in Oral Medication Management quality measure should consider adopting a multidisciplinary approach.

Here are some suggestions for the various disciplines that are often overlooked.

Physical Therapy

Therapy-only patients need to have the therapist's eyes and ears assessing for medication side effects and compliance issues.
Are the therapists equipped with tools and education on commonly prescribed medications and their side effects? Do the therapists know what questions to ask the patient or caregiver to determine compliance and whether side effects have occurred?
Does the agency have processes in place for therapists to report possible side effects or compliance issues?

Occupational Therapy

Are appropriate referrals concerning medication management issues, such as difficulty with opening containers, alternative pillboxes or reminder systems, being made to Occupational Therapy?
When hand strength is weak, Occupational Therapy can have an impact on the patient's medication independence by implementing an exercise program to increase hand strength.
Do staff members know to make referrals to Occupational Therapy for cognitive issues, and that the therapist may be able to provide more cognitively appropriate materials?
Use of simplification in processing, i.e., color-coded simple systems.

Speech Therapy

Memory sequencing issues affect medication management; this is an area that Speech Therapy can address.
Cognitive and visual issues are other areas in which Speech Therapy can assist the patient.

Social Workers

Financial assistance to pay for medications.
Find volunteers to help with medication management, i.e., pre-fill the patient's pillboxes.
Address anxiety or other psychosocial issues that may have an impact on medication compliance.

Home Health Aide:

Remind patients to take their medications.
Assist patients with opening their medication bottles or pillboxes.

Pharmacists

Partner with local pharmacies for help in determining potential adverse effects and possible medication reduction suggestions to submit to the physician.

Acute Care Hospitalization: The Transition Period

The "transition period" is defined as the time when a patient moves between different service providers or levels of care. The transition period between discharge from a hospital or nursing home to admission by a home care agency is a very difficult time for patients and their caregivers. A great deal of information is communicated to the patient and caregiver, requiring coordination and continuity. For example, there are instructions related to medications, discharge instructions, and follow-up care by their physician. Patients with multiple chronic illnesses have even greater difficulty transitioning between settings because they are frail, usually have several physicians involved in their care, and take several medications. The complexity of their care requires a great deal of coordination. Home care agencies have been frustrated with the amount of patient-related information that is communicated during the referral process for these complex patients. All of these factors can lead to medication errors, gaps in communication and service, and reduced quality of care.

Two health care professionals have been conducting research to improve care for patients during their transition period across health care settings. Dr. Eric Coleman and Dr. Mary Naylor have identified two programs that, when implemented, improve communication during the transition period. Dr. Coleman, a geriatrician at the University of Colorado, has developed a "Care Transitions Intervention Design Model" and Dr. Naylor, Professor of Gerontology at the University of Pennsylvania School of Nursing, has designed a "Cost Quality Model of Advanced Practice Nurse (APN) Transitional Care."

The "Care Transitions Intervention Design Model," a multidisciplinary team model, utilizes a "Nurse Transition Coach" (Coach) to facilitate communication and care coordination during the transition period. It was developed for use in the hospital setting, but it can be adapted for application in home care. The Coach works jointly with the patients and their caregivers in four major areas: medication management; primary physician follow-up; patient's ability to identify symptoms that indicate deterioration in condition; and use of a personal health record (PHR).

The Coach's role is to provide information and support to the patient so the patient can communicate to the health care professional any concerns and/or problems. Each visit and follow-up telephone call is designed to empower the patient to adopt a more active role in his or her care by expanding knowledge that is provided during encounters and assuring that care needs and questions are answered during the transition period. The important difference between the Coach and the traditional nurse role is that the Coach guides patients to address their problems and promotes self-management activities rather than providing direct care.

The Personal Health Record is the tool that facilitates communication and ensures continuity of the patient's care plan between health care settings and providers. It is updated as changes occur in the patient's care. The PHR, initiated by the Coach, includes information related to the patient's demographics, medical history, primary care physician, caregiver contact information, advance directives, medications, allergies, a list of warning signs, and a structured list of activities that should assist the patient in communicating information between settings. The PHR enhances the efforts of the Coach because it incorporates standardized follow-up visits and telephone calls as the keys to the smooth transition between care settings. It is kept and maintained by the patient. More information on the entire model can be found at www.caretransitions.org.

Spanish Version of Red-Yellow-Green Zone Self-Management Tools

The Red-Yellow-Green Zone Self-Management Tools for Asthma, CHF and Diabetes are now available in both English and Spanish and may be downloaded from the IPRO Web site for agency use. To access these tools, log on to http://providers.ipro.org/index/homehealth, go to the menu on the right-hand side of the screen, and click "Resources." In the "Resources" section, please note the Red-Yellow-Green Zone Self-Management Tools on the list of available tools.

Many agencies have successfully implemented the Zone tools to assist patients in self-management of their disease processes. The Zone tools have been used to teach the patient and/or caregiver to call the home health agency as soon as there is a deterioration in the patient's condition. This creates an opportunity for the clinician to intervene and potentially prevent an avoidable acute care hospitalization.

Telehealth: It's not just about technology; It's about the patient

Recent discussion and review of the literature identify common barriers experienced by home health agencies when they try to enlist physician support for telehealth technology. Some of these barriers include limited knowledge regarding effective use of home telehealth and lack of understanding related to reimbursement for home telehealth.

In the spirit of sharing lessons learned, agencies nationally have shared the following strategies that have proved successful in overcoming physician resistance.

Strategies to Improve Physician Buy-in:

Invite the office staff and/or nurse to the agency to demonstrate how the telemonitoring system works and how it can assist the physician in care management of patients. The physician's staff member or nurse may influence the physician's opinion, which may lead to identification of physician champions for home telehealth that can be used to gain other physicians' buy-in.
Demonstrate to physicians that telemonitoring data is real-time and can be compiled for the physician in graphs, if desired.
Aggregate the data to show how the telemonitoring program has had a positive impact on patient care, and share evidence-based results rather than anecdotal information with as many physicians as are interested.
Provide physician offices with home telehealth articles from journals.

These strategies may result in positive responses from physicians leading to patient referrals for home telehealth programs and "physician approved" agency protocols for early treatment of patient symptoms, thus potentially reducing avoidable hospitalizations.

OBQI -- Plan of Action Tips

Here are some useful suggestions that the Home Health QIOSC has distributed nationally to assist home health agencies in the OBQI process and Plan of Action development:

Reducing acute care hospitalization rates definitely will take Teamwork to be successful. By creating a multidisciplinary team, including home health aide and clerical staff representation, the agency has the opportunity to have full participation of all staff members.
In response to the agency nurses' protest of another piece of paper to complete on admission when an agency implemented the "High-Risk Assessment" form, the QI Coordinator emphasized that the form was not as much work as completing a Resumption of Care OASIS. Reducing an agency's hospitalization rate can improve nurses' satisfaction with reduced paperwork and recognition for a job well done.
Staff education can be frustrating at times, especially if the agency is large and has multiple offices. How do you reach everyone? The keys to Success are Diversity and Creativity. Offering the education program in a variety of formats for staff will improve your success. Face-to-face educational sessions are the most effective method, but they are not always possible or cost-effective. A Pennsylvania agency has successfully employed a "train-the-trainer" approach. A staff member from each branch is trained and the session is videotaped. The Branch Trainer is then responsible for training in the branches and the videotape is available for agency staff members who are unable to attend. E-mail is an excellent way to ensure all staff members receive new information. All staff members, including contracted staff (therapists), are responsible and accountable to read all e-mail notifications. Creative and unique ways to educate staff include games, tapes, health education fairs, puzzles, scavenger hunts -- the methods are endless!
Are transition issues involving Hospitalists a problem for your agency? The home health agency can enhance communication with the patient's primary physician and smooth the patient's transition from hospital to home by calling the primary care physician to inform him or her of the patient's discharge from the hospital, and faxing the discharge orders and list of medications to the physician. During the first week of service, make sure the patient schedules an appointment with his or her primary care physician. Make sure your referral process includes getting the primary care physician's name.

During the ACH Workshops, some agencies found out that their on-call nurses were routinely sending patients to the ED. To assist agencies in evaluating their own internal systems and processes related to this issue, the "Emergent Care Flow Diagram" was provided for review and reference. The diagram provides guidance to an agency for establishing situations that require an after-hours nursing visit. The diagram is located on IPRO's JENY Web site, at http://jeny.ipro.org/attachment.php?attachmentid=1059&d=1135018349.

Oral Medication Management: Medication Reconciliation

The Institute for Healthcare Improvement defines medication reconciliation as "creating the most accurate list possible of all medications a patient is taking ç including name, dosage, frequency, and route -- and comparing that list against the physician's orders, with the goal of providing correct medications to the patient at all transition points within the hospital" or between health care settings. Medication reconciliation occurs at the time of start of care or resumption of care when a patient is discharged from another health care facility and referred for home care services. This practice has become more challenging for home care clinicians with the introduction of "hospitalists" into the hospital setting. Hospitalists are physicians who care for patients while they are in the hospital, but provide no, or very little, follow-up medical care once the patient is discharged from the hospital. Often, the home care clinician's call to the patient's primary physician to initiate home care services is the first time the primary physician is notified of the patient's discharge from the hospital.

Medication reconciliation is time consuming and should occur within 24 hours of admission to service. Barriers to medication reconciliation include:

Incomplete medication list on referral.
Gaps of communication between health care settings.
Patient or caregiver is a poor historian or is confused.
Many physicians caring for the patient.
Staff not familiar with medications.

Tips that may assist an agency in medication reconciliation:

Organize an interdisciplinary team to develop and review policies for medication reconciliation.
Ensure a list of the patient's current medications is received at time of referral.
Develop a standardized trigger tool (such as an interview guide) to assist staff in obtaining all medication information.
Provide education to therapists and nurses in medication reconciliation.
Thoroughly assess medication history by examining all medication vials in the home and over-the-counter medication containers.
Reconcile medications at all transition points during the patient's episode (post-ER visits, recertification, post-physician appointments).

Adverse events related to medication discrepancies may cause an avoidable hospitalization and can be prevented by implementing a medication reconciliation system.

Sources: Ketchum, K., Grass, C. A., Padwojski, A. (2005). Medication reconciliation. American Journal of Nursing, 105(11), 78-85. www.ihi.org

Improving Adult Immunizations Rates in the Home Health Setting

Did you know?

Pneumococcal disease and influenza, combined, are the fifth leading cause of death in the United States among persons aged 65 and older.
Influenza was responsible for approximately 36,000 deaths each year from 1990 to1999, with 90% of deaths occurring among those aged 65 and older.
Pneumococcal infection causes an estimated 125,000 hospitalizations for pneumonia annually in the U.S.
Influenza-related deaths usually resulted from pneumonia or from worsening of existing cardiopulmonary conditions and other chronic diseases.
It was estimated that in 2002, medical expenditures for treatment of pneumonia among the Medicare population was approximately $1.8 billion.

In response to financial and other burdens of influenza and pneumonia, the Centers for Medicare & Medicaid Services (CMS) has initiated a comprehensive effort across all settings of care (hospitals, nursing homes, home health agencies, and physician offices) to improve the immunization rates of Medicare beneficiaries. CMS has asked Quality Improvement Organizations, including IPRO, to work with home health agencies (HHAs) to ensure that an assessment of influenza and pneumococcal immunizations is included in the comprehensive patient assessment to work towards the first step in achieving this goal.

Recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), outlined in the Morbidity and Mortality Weekly Report (MMWR) of July 29, 2005, state "Beginning in September, nursing-care plans should identify patients for whom vaccination is recommended, and vaccine should be administered in the home, if necessary. Caregivers and other persons in the household (including children) should be referred for vaccination." Although CMS chose not to incorporate all of these recommendations in the 8th Scope of Work, it is clear that there are "missed opportunities" to vaccinate individuals that should be addressed.

In 2004, the national rate for influenza vaccination was reported to be below 75%; for pneumococcal vaccination, the rate was reported to be below 68%. In light of these low rates, CMS is encouraging progression to the next step of this initiative: referral of eligible patients to vaccine sources and implementation of follow-up activities to verify that eligible patients actually receive the vaccinations. These efforts are in alignment with the national goal of Healthy People 2010 (U.S. Department of Health and Human Services), to achieve a 90% immunization rate for individuals 65 years of age and older.

Home Health Compare Update

In September 2005 update to Home Health Compare, CMS added the availability of a Spanish language version of Home Health Compare. With this new tool, Spanish-speaking Medicare beneficiaries now have additional information to help make decisions about nearly 7,000 Medicare-certified home health agencies across the country.

The information in Spanish can be accessed by visiting www.medicare.gov, clicking on "Espanol" in the upper right-hand corner and scrolling down to select "Compare Home Health Agencies in your Area," or by calling 1-800-MEDICARE (1-800-633-4227).

The next quarterly update of data to Home Health Compare is scheduled to occur on March 16, 2006, covering the data-reporting period of December 2004 - November 2005.

Future quarterly updates to Home Health Compare in 2006 will be made between the 1st and 3rd days of the month in the months of June, September and December.

Educate and Empower Patients and Caregivers!

Self-Management is the collaboration between the clinician and the patient to manage his or her health status. This does not mean the patient adheres to the clinician's plan. Instead, effective self-management results from the patient adapting his or her behavior based on changes in environment and physical status. The patient, with assistance from the clinician, establishes reasonable goals that will improve self-efficacy and disease management.

For this to occur, staff members must be encouraged to talk with and listen to their patients about activities that they are unable to perform but would like to do again. Listening and observing body language, along with the interpretation of clinical signs and symptoms to determine response to treatment, will result in positive behavioral changes that have a long-term impact on the patient's health status. Patients and caregivers require a lot of teaching and coaching to ensure their desire to achieve improved disease management and ADL function is met.

New Home Health Tools Posted to JENY

Joint Effort New York (JENY) is an online forum, administered by IPRO, that encourages open sharing of best practices in order to stimulate health care quality improvement in New York State.

Visitors to the site, at http://jeny.ipro.org, can participate in a range of interactive areas:

The Main Conference Hall houses the general work and knowledge of the community. Features include an information booth and help desk, conference call schedule, archives and a general discussion area on quality improvement.
Breakout Rooms go in-depth on specific topics as part of structured collaboratives run by IPRO. These include such topics home health and nursing home quality, cardiac care, infectious disease, health information technology, and more.
Cafe Melior provides an informal area for community members to share ideas, chat off-topic and get to know one another.

The site also includes a Member List, Calendar and FAQ.

Recent postings in the Home Health/Plan of Action Tools section of JENY include:

Emergent Flow Diagram for on-call nurse and agency processes.
Case Conference Note (used when supervisor is reviewing Start of Care/Resumption of Care with the clinician who performed visit).
Risk Factor Hospitalization Tool.
Acute Care Hospitalization Record Review Tool.
Case Report (for communication to physicians via fax).