www.ohiokepro.com
Vol. 2 No. 3
Fall 2004
Collaborative Home Care Research:
Does this Ever Work? Yes!
Does this Ever Work? Yes!
By Elizabeth A. Madigan, PhD, RN
Exploring Rehospitalization
he Home Group of the Greater Cleveland Nursing Research
Consor tium represents 8 to 10 agencies and several researchers
from the Frances Payne Bolton School of Nursing, Case Western
Reser ve University. The group has been in existence since 1996.
The impetus for the rehospitalization study, which took place prior to
the initiation of PPS (1997-98), was to determine if it was possible to
predict on home health care admission which patients would need
to be rehospitalized during the course of home health care. In par t,
this was due to the explosion of managed care at the time, but also
because of concern about the numbers of patients who were being
rehospitalized and the primar y drivers of the rehospitalization.
Consor tium represents 8 to 10 agencies and several researchers
from the Frances Payne Bolton School of Nursing, Case Western
Reser ve University. The group has been in existence since 1996.
The impetus for the rehospitalization study, which took place prior to
the initiation of PPS (1997-98), was to determine if it was possible to
predict on home health care admission which patients would need
to be rehospitalized during the course of home health care. In par t,
this was due to the explosion of managed care at the time, but also
because of concern about the numbers of patients who were being
rehospitalized and the primar y drivers of the rehospitalization.
T
Wound Care Issues and Dilemmas
Three home health care agencies agreed to collect data on 40
patients, age 65 or older, with hear t failure as a primar y or secondar y
diagnosis. Patients were tracked as they were admitted and followed
for 12 weeks. If there was a hospitalization, the agency representatives
asked the nurses and/or therapists to complete the Home Care
Re-admission Inventor y or HCRI (Anderson et al., 1997) and several
OASIS items (this was prior to mandated use of OASIS). Almost
one-four th of the patients (22 percent) were re-admitted within the
12-week period. To our surprise, we could not predict on admission
which patients would be rehospitalized. However, when we looked at
the HCRI, we found that, for the most par t (48 percent of the time),
patients developed a new problem, rather than being rehospitalized
for an existing problem. The home health care agency staff identified
that the rehospitalizations were not preventable (71 percent of the
time) and were necessar y (87 percent of the time).
patients, age 65 or older, with hear t failure as a primar y or secondar y
diagnosis. Patients were tracked as they were admitted and followed
for 12 weeks. If there was a hospitalization, the agency representatives
asked the nurses and/or therapists to complete the Home Care
Re-admission Inventor y or HCRI (Anderson et al., 1997) and several
OASIS items (this was prior to mandated use of OASIS). Almost
one-four th of the patients (22 percent) were re-admitted within the
12-week period. To our surprise, we could not predict on admission
which patients would be rehospitalized. However, when we looked at
the HCRI, we found that, for the most par t (48 percent of the time),
patients developed a new problem, rather than being rehospitalized
for an existing problem. The home health care agency staff identified
that the rehospitalizations were not preventable (71 percent of the
time) and were necessar y (87 percent of the time).
Lessons learned
We learned a number of lessons from this study. First, this study
was done on a small budget--$3,500. The university and agency
investigators donated their time. Second, research rarely goes as
one expects. We were relatively cer tain we would find the predictive
factors for rehospitalization in this study. When we did not, it took
group discussion to sor t out why. What this led us to conclude is
that ever y good study raises at least as many new questions as it
answers. The third lesson was how to collaborate on disseminating
the findings--the study was published in the journal Home
Healthcare Nurse in 2001 (Madigan, Schott and Matthews) and was
presented several times including at the National Association for
Home Care Annual meeting.
We learned a number of lessons from this study. First, this study
was done on a small budget--$3,500. The university and agency
investigators donated their time. Second, research rarely goes as
one expects. We were relatively cer tain we would find the predictive
factors for rehospitalization in this study. When we did not, it took
group discussion to sor t out why. What this led us to conclude is
that ever y good study raises at least as many new questions as it
answers. The third lesson was how to collaborate on disseminating
the findings--the study was published in the journal Home
Healthcare Nurse in 2001 (Madigan, Schott and Matthews) and was
presented several times including at the National Association for
Home Care Annual meeting.
Home health care agency staff have long been recognized as having
exper tise in wound care, primarily because of the types and numbers
of wounds they see on a regular basis. Despite this exper tise, one
of the challenges in practice is changing to a standard of care that
moist wound healing is the appropriate approach.
exper tise in wound care, primarily because of the types and numbers
of wounds they see on a regular basis. Despite this exper tise, one
of the challenges in practice is changing to a standard of care that
moist wound healing is the appropriate approach.
The first research-based recommendation for moist wound healing was
published in the 1960s. As in other areas of health care, however,
research has not translated into practice. In part, this reflects physicians
not being up-to-date on the latest practice standards for wound care.
However, there also are agency staff who are either not aware of or
not advocating on behalf of moist wound care approaches. With this
as a foundation, the Home Care Group of the Greater Cleveland
Nursing Research Consor tium decided to study several aspects of the
issue. First, how prevalent was the use of wet-to-dr y dressings? And
second, were there differences in wound care outcomes and numbers
of visits for patients receiving moist versus wet-to-dr y dressings?
Funding for the study came from Case Western Reser ve University;
the funding was primarily used to suppor t the research assistants
with agency par ticipants opting whether they wanted to be reim-
bursed for copies and/or paper. All the investigators--university and
agency--contributed their time "in-kind" or without salar y suppor t.
published in the 1960s. As in other areas of health care, however,
research has not translated into practice. In part, this reflects physicians
not being up-to-date on the latest practice standards for wound care.
However, there also are agency staff who are either not aware of or
not advocating on behalf of moist wound care approaches. With this
as a foundation, the Home Care Group of the Greater Cleveland
Nursing Research Consor tium decided to study several aspects of the
issue. First, how prevalent was the use of wet-to-dr y dressings? And
second, were there differences in wound care outcomes and numbers
of visits for patients receiving moist versus wet-to-dr y dressings?
Funding for the study came from Case Western Reser ve University;
the funding was primarily used to suppor t the research assistants
with agency par ticipants opting whether they wanted to be reim-
bursed for copies and/or paper. All the investigators--university and
agency--contributed their time "in-kind" or without salar y suppor t.
More wounds than expected
For one month, October 2001, the agency par ticipants identified ever y
patient who came into the agency ser vices as a new admission.
Following Institutional Review Board approval (IRB), the agencies then
provided the researchers with data records, primarily OASIS data, but
also medications and demographic information. Research assistants
then visited the agencies to collect data on the wound care techniques
used. To the surprise of all par ticipants, there were many more
patients classified as having wounds than expected--550 from 5
For one month, October 2001, the agency par ticipants identified ever y
patient who came into the agency ser vices as a new admission.
Following Institutional Review Board approval (IRB), the agencies then
provided the researchers with data records, primarily OASIS data, but
also medications and demographic information. Research assistants
then visited the agencies to collect data on the wound care techniques
used. To the surprise of all par ticipants, there were many more
patients classified as having wounds than expected--550 from 5
Continued
Collaborative Home Care Research (cont.)
agencies. This was due, in par t, to the OASIS definitions for what
constitutes a wound, but also because of the number of wounds
that do not require dressings. Of those that required dressings,
there were three primar y patient groups--those with pressure ulcers
(n = 63), those with stasis ulcers (n = 25), and those with surgical
wounds (n = 225). Preliminar y conclusions are that a persistent use
of wet-to-dr y dressings continues with up to 25 percent of patients
receiving this kind of care. Data analysis is underway with
publication of the findings expected within a year.
constitutes a wound, but also because of the number of wounds
that do not require dressings. Of those that required dressings,
there were three primar y patient groups--those with pressure ulcers
(n = 63), those with stasis ulcers (n = 25), and those with surgical
wounds (n = 225). Preliminar y conclusions are that a persistent use
of wet-to-dr y dressings continues with up to 25 percent of patients
receiving this kind of care. Data analysis is underway with
publication of the findings expected within a year.
There were a number of valuable lessons learned from this study.
First of all, there are many more patients with wounds than any of
us expected! Second, the number of wound care products compli-
cates this kind of research because it is not easy to classify the
products into the various types, even with char ts and materials
provided by manufacturers. Third, it is possible to under take a large
study on a shoestring budget. The budget for this study was
approximately $6,000, almost all of which went for research
assistant time. Four th, any size agency can par ticipate in this kind
First of all, there are many more patients with wounds than any of
us expected! Second, the number of wound care products compli-
cates this kind of research because it is not easy to classify the
products into the various types, even with char ts and materials
provided by manufacturers. Third, it is possible to under take a large
study on a shoestring budget. The budget for this study was
approximately $6,000, almost all of which went for research
assistant time. Four th, any size agency can par ticipate in this kind
of study. While there were several ver y large agencies, there were
also ver y small agencies whose caseload provided as few as nine
patients for the study.
also ver y small agencies whose caseload provided as few as nine
patients for the study.
Biggest factors in success
There is strength in numbers--university-based investigators need
access to patients while agency investigators may benefit from
collaborating with university investigators. Although large grant
funding is available, the process of obtaining the funding is long
and ver y competitive. In some cases, strong results that have direct
clinical application can be obtained from smaller-scale funding. The
biggest factors in our success were that these investigations are
collaborative projects and we should discuss, from the outset, what
is involved. Although the studies never go as first planned, the
results speak for the benefits of the collaborations.
There is strength in numbers--university-based investigators need
access to patients while agency investigators may benefit from
collaborating with university investigators. Although large grant
funding is available, the process of obtaining the funding is long
and ver y competitive. In some cases, strong results that have direct
clinical application can be obtained from smaller-scale funding. The
biggest factors in our success were that these investigations are
collaborative projects and we should discuss, from the outset, what
is involved. Although the studies never go as first planned, the
results speak for the benefits of the collaborations.
Dr. Elizabeth A. Madigan is Associate Dean/Associate Professor,
Frances Payne Bolton School of Nursing, Case Western Reser ve
University, Cleveland. I
Frances Payne Bolton School of Nursing, Case Western Reser ve
University, Cleveland. I
Ohio KePRO Home Health Team
Alice Stollenwerk Petrulis, MD, FACP
Betty Pilous, RN, MHSA, CPHQ
Linda Day, RN, BSN, MBA
Cindy O'Connell, RN, BSN
Eileen Wallenhorst, RN, BSPA
John Dooley, MBA
Kerri Gilligan, RN
Donna Maynard
Rosalie McGinnis, RN, MS
Ramona Pennell, RN, BA
Marla Rawson, BA
Robin Reitzel, BS
Chris Titus, MCSE, CNA, MCP
Betty Pilous, RN, MHSA, CPHQ
Linda Day, RN, BSN, MBA
Cindy O'Connell, RN, BSN
Eileen Wallenhorst, RN, BSPA
John Dooley, MBA
Kerri Gilligan, RN
Donna Maynard
Rosalie McGinnis, RN, MS
Ramona Pennell, RN, BA
Marla Rawson, BA
Robin Reitzel, BS
Chris Titus, MCSE, CNA, MCP
Publication No. 4011-OH-032-9/2004. This
material was prepared by Ohio KePRO, the
Medicare Quality Improvement Organization
for Ohio, under contract with the Center s for
Medicare & Medicaid Ser vices (CMS), an
agency of the U.S. Depar tment of Health and
Human Ser vices. The contents presented do
not necessarily reflect CMS policy.
material was prepared by Ohio KePRO, the
Medicare Quality Improvement Organization
for Ohio, under contract with the Center s for
Medicare & Medicaid Ser vices (CMS), an
agency of the U.S. Depar tment of Health and
Human Ser vices. The contents presented do
not necessarily reflect CMS policy.
Register online at www.ohioke-
pro.com/providers/home-
health/events.asp or by fax at
216-654-1510
pro.com/providers/home-
health/events.asp or by fax at
216-654-1510
Save the dates!
September 30, 2004
"The Leadership Script"
Teleconference
10:00 a.m11:00 a.m.
Speaker: Tammera Caine, MS,
CPHQ, QI Project Coordinator,
Ohio KePRO
1.2 CE credits for nurses awarded
for 100% completion of program.
Register online at www.ohioke-
pro.com/providers/home-
health/events.asp
"The Leadership Script"
Teleconference
10:00 a.m11:00 a.m.
Speaker: Tammera Caine, MS,
CPHQ, QI Project Coordinator,
Ohio KePRO
1.2 CE credits for nurses awarded
for 100% completion of program.
Register online at www.ohioke-
pro.com/providers/home-
health/events.asp
CALENDAR OF EVENTS
November 2, 2004
Community of Practices Group
Session: "Recr uitment,
Retention, and Super vision"
9:00 a.m.12:30 p.m.
Hampton Inn
Tiedeman Road
Brooklyn, Ohio
3.3 CE credits are pending
for this of fering.
Community of Practices Group
Session: "Recr uitment,
Retention, and Super vision"
9:00 a.m.12:30 p.m.
Hampton Inn
Tiedeman Road
Brooklyn, Ohio
3.3 CE credits are pending
for this of fering.
October 13, 2004
"Outcome-Based Quality
Improvement (OBQI) Training"
8:15 a.m.4:30 p.m.
Embassy Suites Hotel
Corporate Exchange Drive
Columbus, Ohio
9 CE credits are approved for
nurses attending 100% of
this program.
"Outcome-Based Quality
Improvement (OBQI) Training"
8:15 a.m.4:30 p.m.
Embassy Suites Hotel
Corporate Exchange Drive
Columbus, Ohio
9 CE credits are approved for
nurses attending 100% of
this program.
November 4, 2004
Community of Practices Group
Session: "Recr uitment,
Retention, and Super vision"
9:00 a.m.12:30 p.m.
Columbus Mar riott Nor th
Columbus, Ohio
3.3 CE credits are pending
for this of fering.
Community of Practices Group
Session: "Recr uitment,
Retention, and Super vision"
9:00 a.m.12:30 p.m.
Columbus Mar riott Nor th
Columbus, Ohio
3.3 CE credits are pending
for this of fering.
Executive Editor: Suzana C. Iveljic, MBA Editor: Robert A. Feigenbaum, MS
November 11, 2004
Regional Seminar on Chronic
Disease Management
8:30 a.m.3:30 p.m.
Holiday Inn Richfield
Richfield, Ohio
CE credits are pending for
this of fering.
Regional Seminar on Chronic
Disease Management
8:30 a.m.3:30 p.m.
Holiday Inn Richfield
Richfield, Ohio
CE credits are pending for
this of fering.
November 17, 2004
Regional Seminar on Chronic
Disease Management
8:30 a.m.3:30 p.m.
Quest Business Centers
8405 Pulsar Place
Columbus, Ohio
CE credits are pending for
this of fering
Regional Seminar on Chronic
Disease Management
8:30 a.m.3:30 p.m.
Quest Business Centers
8405 Pulsar Place
Columbus, Ohio
CE credits are pending for
this of fering
For more infor mation on the
above events, please contact
the Home Health Team at
1-800-385-5080, or via e-mail
at homehealth@ohqio.sdps.or g.
above events, please contact
the Home Health Team at
1-800-385-5080, or via e-mail
at homehealth@ohqio.sdps.or g.
T H E FA L L 2 0 0 4 I S S U E O F Q U A L I T Y O U T C O M E S H A S A R R I V E D !
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THE NEWSLETTER OF THE HOME HEALTH OUTCOME-BASED QUALITY IMPROVEMENT INITIATIVE
Ohio KePRO Provider QIC Line--Your Quality Improvement Connection: 1-800-385-5080 · Medicare Help Line: 1-800-MEDICARE (1-800-633-4227)
Home Health Team e-mail: homehealth@ohqio.sdps.org
Home Health Team e-mail: homehealth@ohqio.sdps.org