[Success Stories]
Robinson Visiting Nurse & Hospice Takes Three-Phase Approach to Acute Care Hospitalization
By Linda Day, RN, BSN, MBA, Quality Improvement Project Supervisor
In 2002, Robinson Visiting Nurse & Hospice, a medium-sized home health agency (HHA) located in Ravenna and servicing Portage County and surrounding areas, found out its Risk Adjusted Outcome Report Score was 37 for acute care hospitalization (ACH). Understanding the importance of reducing this rate, Robinson began an ambitious three-phase ACH improvement program.
During Phase I, Robinson’s first decision was to embrace Outcome-Based Quality Improvement (OBQI). Following attendance at an Ohio KePRO sponsored OBQI training session, the QI Team developed their first Plan of Action (POA.) Agency commitment was total with administration and management willing to commit the resources required to develop a plan. Robinson established a multi-level team including managers, QI staff, and clinicians committed to reducing ACH rates and sharing that commitment with other agency staff. The Team’s most time consuming task at the onset was completing the Process of Care Investigation.
“After auditing 30 hospitalized patient charts we discovered that we were not doing clinical assessments for patients at risk for ACH as well as we should,” said Gayle Bentley, RN, BSN, Home Care Manager. This prompted Robinson to incorporate the following into its POA:
- Clinicians will perform diagnosis/condition related assessments and document findings in the clinical record
- Clinicians will report significant changes from baseline assessment to physicians on the same day with documentation in the clinical record
- Patient education to be initiated, including disease management, signs and symptoms of disease to report to nurses/physicians, medication management, and response to that education over the course of care.
By the end of July 2004, Robinson’s ACH score dropped to 30.39. However, the agency believed it could do much better and therefore, began Phase II of its ACH improvement plan. Further analysis of hospitalized patient information revealed two patient conditions—congestive heart failure (CHF) and falls—accounted for the largest number of ACHs. Robinson decided to focus on CHF. Robinson had already purchased laptop computers for nurses in the field to perform clinical assessments and to document findings. “Our use of laptops improved compliance with best practices for CHF patients as identified by the American Heart Association and Robinson’s own internal organization,” said Bentley.
The Ohio KePRO tools that proved particularly helpful were the OBQI Training Manual, Clinician Pocket Guides, and the Tip of the Week. Vicki Brosius, RN, HCS-D, PI/Intake Coordinator and Marian Pillar, RN, CNP, RN Home Care Case Manager, also found Ohio KePRO’s disease management seminar and materials extremely helpful when addressing their CHF patient population. To launch the CHF initiative, Robinson held in-service educational sessions with clinical staff. Using their Certified Nurse Practitioner, current material obtained from Ohio KePRO’s Home Health Team was presented on the treatment and management of CHF.
The CHF initiative was reviewed and approved by Robinson’s Professional Advisory Committee, which includes physicians, RNs, a pharmacist, a respiratory therapist, and social worker.
Modified POA
The POA now had a new focus – CHF—and a new QI Team was established. To reflect these changes, the following new best practices were established:
- Intake RN will initiate and complete if possible the agency’s re-hospitalization risk assessment (RRA) tool on all patients with a primary and secondary diagnosis of CHF and provide the tool to the admitting clinician and case manager
- Field staff RN will complete the tool for Start of Care/Resumption of Care (SOC/ROC) assessments
- Field staff RN will initiate CHF visit frequency protocol–visit three times a week for the first two weeks, with phone monitoring scheduled two times a week between visits
- For physical therapy (PT) only patients, physical therapist will report observed and patient/caregiver reported symptoms of CHF to RN case manager and obtain a physician order for a skilled nursing (SN) visit on the same day of observation.
During Phase II, Robinson took advantage of Ohio KePRO-sponsored Communities of Practice, agency on-site visits, telephone consultations, resource materials, regional seminars, and teleconferences to stay focused on implementing the agency’s best practices and executing the POA.
Looking at falls
In Phase III Robinson is addressing the issue of falls and how it affects transfer.
“We did not have a good risk assessment tool and good process for addressing fall risk,” said Brosius. Consequently, Robinson did a failure mode effect analysis (FMEA) to identify the factors involved in patient falls. Once again they have established a new team to study ways to reduce falls through best practices. As a proximal measure, Robinson selected improvement in transferring as the focus for the new POA. Clinicians now:
- Complete the agency’s fall risk assessment on SOC/ROC and recertification
- Initiate the fall risk protocol for patients scoring 10 or higher on the tool or perceived as high risk by the clinician
- Provide and review “Check for Safety” booklet, identify areas for patient teaching, and document in plan for next visit
- Communicate in writing or verbally the patient’s fall risk status to other disciplines involved.
Keys to success
“Getting clinical staff involved is crucial to gaining their buy-in for improving care and outcomes,” said Brosius. “Selecting team members who are affected by the changes and who can act as ambassadors for the change make it real for staff.”
Robinson has also been fortunate to have the backing of its hospital system. “Our hospital system has been very supportive of our efforts to improve care,” said Bill Kahl, Director. “Evidence-based practice shows us that Senior Leadership support is critical to the success of any Quality Initiative.”
Perseverance has enabled the agency to achieve its current ACH rate of 29%. There is a willingness to peel back the layers to find the answers to new questions.
HM Home Care Making Significant Strides on Quality Measures
By Linda Day, RN, BSN, MBA, Quality Improvement Project Supervisor
Outcome-Based Quality Improvement (OBQI) is yielding significant results for HM Home Care in Girard, Ohio. The large-sized home health agency (HHA), which is affiliated with St. Elizabeth Health Center and St. Joseph Hospital, primarily serves Trumbull, Mahoning, and Columbiana counties.
A system-wide initiative on Congestive Heart Failure (CHF) was the impetus for HM Home Care’s strategy for reducing acute care hospitalizations (ACH). While HM’s ACH outcome scores approach the CMS national target goal of 23%, HM Home Care wants to do better and believes it can.
“OBQI has had a big impact on the way we approach health care delivery,” said Claudia Axelson, RN, Quality Improvement Manager. “It gave us the structure necessary to look at the problem, do an audit, and study data to give us direction on ways to proceed.”
The first step was to establish a QI Team comprising a multi-disciplinary approach to address acute care hospitalization. HM management then did something unusual. They asked the Team to complete a survey developed by the British National Health System. Based on the findings, management and the Team would be able to predict the Team’s ability to sustain the changes they wanted to institute as reflected in improved outcome scores. The team received high marks to support this new quality initiative.
The second step was to implement the Plan of Action (POA) for acute care hospitalization. Actions taken included:
- Development of CHF Home Care Steps
- Development of a clinical guideline for CHF Home Care Steps
- Development of a measurement method to audit for CHF steps and telephone visits
- Communication of the Process-of-Care-Investigation results and best practices
A critical third step was monitoring and evaluation. HM’s QI staff and agency clinicians are diligent about completing quarterly audits and sharing the results. Careful attention is given to the results to determine if the issues identified on audit are clinician problems or process issues. If the issue is clinician compliance, the information is referred to the Assistant Director to be addressed with the staff member. The message is loud and clear– quality is everyone’s business at HM Home Care.
Staff buy-in
It is understood that improved results do not happen without staff buy-in. A conscientious effort is made to communicate information in the following ways:
- Display initiative information on a bulletin board
- Share audit results regularly to keep staff updated
- Send out e-mail messages
- Execute a new initiative in intra-disciplinary communication
- Provide positive feedback to clinicians using CHF Steps and telephone visits
Modifications were made to the POA when the Team identified a need in the following ways:
- Monitoring of use of Case Communication Note and treating education as a competency
- Implementation of Patient Problem Solving Guide–a triaging tool for HC/ED decision
- Trial phase of a Telephone On-Call Log– the log reinforces scheduling of telephone and follow-up visits and communication with disciplines
- Establishment of Best Practices using CHF Steps for any CHF patient.
Looking forward is a “built-in” in the agency’s standard operating process. HM is now:
- Considering implementing “lessons learned” for other disease processes beyond CHF
- Initiating discussions with Leadership for system collaboration, specifically involvement in a medication reconciliation task force
- Exploring expanding telehealth from phone monitoring to telemedicine.
“We have a multidisciplinary team for each diagnosis and condition,” said Axelson. “The teams review best practices before they are rolled out to the staff.” Teams typically meet every other week to discuss patients’ progress in quality and utilization outcomes.
Tools prove helpful
HM Home Care considers Ohio KePRO a partner in quality. Clinician Pocket Guides continue to be a valuable quick reference resource for field staff. The Weekly Home Health Tip of the Week has provided a constant reminder to stay focused on quality. Accessing Ohio KePRO’s Web site at www.ohiokepro.com offers an opportunity to obtain needed information day or night. Site visits and telephone consultation also provide individuals and the Team with access to customized focused discussion—and it is all free of charge.
Proven results
HM Home Care has seen marked improvement in its ACH. In 2003 its score was 31%; in July 2004, 23.52%; in July 2005, 21.69%; and in September 2005, 20.70%. However, HM Home Care is not content to rest on its laurels. The agency is doing preparatory work on a telemonitoring system and has a program in place to reduce falls and improve transfers.
“Our initiatives have had a big impact on what we are doing,” said Axelson. “They’re so relevant to the improvements we are seeing.”
Ohio KePRO offers a variety of free tools and interventions on health literacy and pneumococcal vaccination, the Physician Office Toolkit, mammography postcards, brochures, booklets, and more. View Shopping Bag>>
QUALITY OUTCOMES FEEDBACK SURVEY
Ohio KePRO is continuously working to improve the quality of care delivered to Medicare beneficiaries. We offer innovative products and services and educational resource materials to encourage and support continuous quality improvement.
In an effort to improve the effectiveness of Quality Outcomes, we would like you to take three to five minutes to complete the following survey. Participation is voluntary and all answers are confidential. Please fill out this survey at your convenience and click on the submit button to e-mail it back to Ohio KePRO. We appreciate your feedback.
Newsletter: Quality Outcomes (Winter 2005-2006)
Ohio KePRO Home Health Team
Betty Pilous, RN, MHSA, CPHQ
Linda Day, RN, BSN, MBA
Cindy O’Connell, RN, BSN
Eileen Wallenhorst, RN, BSPA
Tracy Hammer, LPN
Rosalie McGinnis, RN, MS
Robin Reitzel, BS
Donna Maynard
Chris Titus, MCSE, CNA, MCP
Editor: Robert A. Feigenbaum, MS
If you have a disability and need a document on this Web site to be provided to you in another format, please contact the Webmaster.