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Home Nursing Service and Hospice Achieves Success with Oral Medication Management

 

By Linda Day, RN, BSN, MBA, Quality Improvement Project Supervisor, and Robert A. Feigenbaum, MS, Editor

 

A patient tells her home care nurse that because of her arthritis she is unable to take her pills. Another patient when asked by his home care nurse what medications he is taking replies that he is unsure. Situations like these and others confront home health agencies (HHAs) throughout Ohio every day. The Home Nursing Service and Hospice in Marietta is no exception. That is why this HHA decided once again in 2005 to select Oral Medication Management as one of its quality measures for the 8th Statement Of Work.

 

Home Nursing Service and Hospice is a medium-sized agency that serves counties in the Marietta area. Its service area extends from Ohio into West Virginia. Services that are available include skilled nursing care; physical, occupational, and speech therapy; and emergency response units.

 

“Shortly after going through Ohio KePRO’s Outcomes-based Quality Improvement (OBQI) training in 2003, we selected Oral Medication Management as one of our quality measures,” said Joni Arnold, RN, Quality Improvement Coordinator.

 

After selecting the Oral Medications Management as the agency’s focus, Home Nursing Service and Hospice developed a team consisting of members from management and nursing to explore ways to improve patient management of oral medications.

 

Best practices

 

“We followed the OBQI model supplied to us by Ohio KePRO,” said Arnold. This consisted of implementing a number of best practices.First, Home Nursing Service and Hospice performs a Medication Management risk assessment on patients at admission. Factors assessed include: need for assistance (MO780); vision impairment (MO390); cognitive impairment (MO560); literacy level; ability to open medication bottles; compliance; and ability to obtain refills and new medications. The risk assessment is performed every 60 days. At every skilled nursing visit, the nurse reviews with the patient the medications he or she is taking and checks the patient’s compliance. At discharge, a nurse reviews each medication with the patient and reinforces why the medication is being given, possible side effects, and the importance of compliance.

 

A “yes” to any of the risk assessment factors identifies the patient as “at risk.” At a minimum during each visit, patient education on medication purpose, side effects, and administration times is provided, and medication compliance and changes in medication are assessed.

 

At SOC/ROC conferences, with the case manager or team leader are held to share risk factors and planned interventions.

 

Additional interventions

 

“Based on assessment findings, we provide other additional interventions as needed,” said Arnold. She explained, for example, that a patient with arthritis who complains that her stiff fingers are preventing her from taking pills might be referred to occupational therapy. Or, if money or transportation issues are compliance barriers, the patient might receive a referral to social service.

 

The agency is also addressing polypharmacy among its home health patients. On a patient’s admission, the agency contacts his or her physician to review the appropriateness of any and all medications. Nurses at each visit provide the patient with a computerized list of his or her medications. The patient is taught how to update the list so that various healthcare providers will have an accurate list of the patient’s medications.

 

Home Nursing Service and Hospice’s efforts resulted in substantial improvements in its Oral Medication Quality Measure score. When it began working on the measure in 2003, its score was 25. By 2005, the score increased to 48.

 

“At the beginning of the 8th Scope of Work in August 2005, we wanted to make sure we would hold our gains,” said Cindy Carpenter, RN, Director. Consequently, the agency took several key steps. The admissions packet was modified to include reminders to nurses to address oral medication issues. Monthly audits were continued and in-service sessions with staff were held. In addition, staff members were recognized for their success with rewards such as complimentary breakfasts and lunches.

 

“We also found the resources provided by Ohio KePRO in the Quality Measure Resource Binders to be extremely helpful with the Oral Medication and other quality measures,” said Arnold. She added that Ohio KePRO’s Tip of the Week contains important information and is shared regularly with the staff.

 

 

Appalachian Community VNA Uses OBQI, OASIS to Improve on Pain Interfering with Activity

 

By Linda Day, RN, BSN, MBA, Quality Improvement Project Supervisor, and Robert A. Feigenbaum, MS, Editor

 

Appalachian Community VNA (ACVNA), which is a medium sized, full service home health agency (HHA) in Athens that serves a predominantly rural population, combines a number of strategies to realize positive results on the quality measure for pain interfering with activity, according to Deb Sechkar, RN, Vice President.

 

Utilizing Ohio KePRO’s pain resource manual along with materials from the Ohio Pain Initiative the agency has developed a comprehensive pain program. “With a focus on OASIS integrity, our scores have improved over the last six months,” said Sechkar.

 

Comprehensive pain assessments

 

ACVNA’s pain assessment is extremely comprehensive, notes Linda Mitchell, RN, Clinical Information Systems Director. The assessments cover numerous areas including who reported the pain, the type of pain scale being used, severity, if the pain radiates, pain onset, associated symptoms, and response to treatment. “If a nurse feels pain is a problem she will address the problem that day,” said Mitchell. “If a nurse finds the patient’s pain is not controlled, she will call the physician.”

 

Mitchell also notes that the agency is fully computerized. This is invaluable in doing the comprehensive pain assessments. There are triggers built into the system that must be addressed at each visit.

 

Another key pain management strategy for ACVNA staff is education. All nursing staff are required to complete the end-of-life education nine-module series. Also, its nurses are cross-trained in palliative care, and there is an emphasis on pain and symptom management. At ACVNA pain is everybody’s business.

 

Communication

 

ACVNA makes use of a public display board to track its Home Health Compare scores and those of other agencies. This not only informs the staff where the agency is on a particular measure, but also reinforces the progress it is making over time. It helps keep focus on the agency’s quality initiative.

 

Other tools that have proven to be helpful to the agency in its pain management efforts include the OASIS 2005 Answer Book, which nurses take with them in the field, and Ohio KePRO’s teleconferences and programs.

 

Moving forward an emphasis will be placed on improved monitoring and comparing outcome report and Home Health Compare scores to the degree of compliance with best practices.

 

“Despite major changes in the organization including downsizing, we’ve come a long way in the last three to four years,” concluded Sechkar. “Starting with a July 2004 baseline, our Improvement in Pain Interfering with Activity score was 42 percent a year. In July 2005, the agency had achieved a score of 55 percent. Our most current score reflecting February 2006 achievement is 62 percent.”

 

 

Community Health Professionals Marks Solid Progress on Improvement in Transferring

 

By Tracy Hammar, LPN, MBA, Quality Improvement Project Leader, and Robert A. Feigenbaum, MS, Editor

 

Community Health Professionals, a full service home health agency with nine offices covering 15 counties in Northwest Ohio is using a variety of approaches to fuel its ongoing progress on improvement in transferring.

 

The agency started with a baseline measurement score of 46.85 percent (12-month period from August 2003 through July 2004) and progressed to 51.80 percent at the last reporting period (from March 2005 through February 2006). In a group of similar sized agencies with 500 to 700 episodes of care within a 12-month period, the agency has made more progress than its peers, one-half of which have had a decrease in the reported transfer outcome.

 

OASIS and transferring

 

“In 2005, we wanted to focus and identify for our nurses what OASIS meant and the importance of recognizing what they were observing in patients with respect to transferring,” said Kathy Ulm, RN, Staff Development Coordinator. The agency mandated an “Oasis Island: Can You Survive It” program, which supplied to nurses information on how to properly answer OASIS questions. Nurses were instructed to watch clients perform a transfer using the “show me rather than tell me” approach. Those patients that scored a “2,” “3,” or “4” or “5” at a start of care or resumption of care on MO690 had a Physical Therapy referral.

 

“A new fax/coversheet was developed to accompany patient information for referral to Physical Therapy,” said Jeanie Saum, RN, Hospice Supervisor. It also identifies the nursing goals for the client, indicating appropriate diagnosis and targeting what the therapist should focus on. The fax/coversheet clearly indicated that improvement in transferring was one of Community Health Professionals’ target outcomes.

 

Ulm adds that a lot of instruction was directed at answering the “690” question on OASIS. “When you read an OASIS question, you can come up with different interpretations,” she said.

 

Beginning in 2004 the agency developed a video in conjunction with Physical Therapy and Occupational Therapy. This video focused on several transfer techniques and how to properly answer MO690.

 

Get up and go

 

In 2006, Community Health Professionals initiated a series of steps to further enhance their success with improvement in transferring. This included a program titled “Tips to OASIS Survival.” It was offered at branch offices and was attended by nurses and clinical supervisors; attendance was mandatory.

 

“Last February we began doing a timed ‘get up and go’ test,” said Saum. “This test has been determined to be a reliable screening tool by the Physical Therapy Department of the University of Alabama. In this assessment, a resident was asked to get up from a chair, walk 10 steps, and return to the chair. The result was documented. If a patient took more than 30 seconds to accomplish the task, he or she received a Physical Therapy referral.”

 

From these assessments, the agency was able to evaluate a resident’s risk of falling. “If a patient is at risk of falling it definitely changes the way we treat him or her,” said Ulm. This fall the agency plans education initiatives on fall prevention

 

The agency also makes use of interventions and tools supplied by Ohio KePRO including the e-mailed Tip of the Week, periodic teleconferences, and information during site visits.

 

Help from Ohio KePRO

 

Ulm notes that Ohio KePRO has also been extremely helpful to the agency in monitoring its progress on the various quality measures including transferring. Ohio KePRO helps the agency to brainstorm new creative ideas that makes staff involvement more enjoyable. Interventions have included three onsite visits by Ohio KePRO’s quality improvement project leaders and ongoing assistance with the development and implementation of the agency’s plan of action (POA). Ohio KePRO also supplied to the agency in February 2006 its Transferring Change Packet. Community Health Professionals also uses a subsidiary company (Strategic Health Partners) to flag outcomes and adverse events.

 

“We also update our staff on how we’re doing,” said Ulm. “For example, we include information on our progress with paychecks.”

 

Both Ulm and Saum are coordinators of the agency’s Quality Improvement Team. The team consists of social workers, supervisors, human resources staff, the vice-president of clinical services, rehabilitation company representatives, and nurses. It monitors the agency’s progress on improvement in transferring and other quality measures.

 

By brainstorming, the Quality Improvement Team comes up with new and creative ideas to continue the agency’s progress.

 

 

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Ohio KePRO Home Health Team

Betty Pilous, RN, MHSA, CPHQ

Linda Day, RN, BSN, MBA

Eileen Wallenhorst, RN, BSPA

Tracy Hammer, LPN

Rosalie McGinnis, RN, MS

Miriam Rose, MEd

Robin Reitzel, BS

Donna Maynard

Chris Titus, MCSE, CNA, MCP

 

Editor: Robert A. Feigenbaum, MS

 

 

 

 

 

To Contact Us
E-Mail: homehealth@ohqio.sdps.org
Provider QIC Line: 1.800.385.5080

 

Rock Run Center, Suite 100 · 5700 Lombardo Center Drive · Seven Hills, OH 44131 · www.ohiokepro.com

 

Ohio KePRO, the Medicare Quality Improvement Organization (QIO) for Ohio, is working with committed hospitals, nursing homes, home health agencies, and physicians throughout the state who are dedicated to the common goal of Continuous Quality Improvement for Medicare beneficiaries.