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Vaccinate to Reduce Avoidable Acute Care Hospitalizations
By Linda Day, RN, BSN, MBA, Quality Improvement Project Supervisor, and Robert A. Feigenbaum, MS, Communications Writer/Editor
We’re in the heart of the flu season and the good news is that unlike previous years, there is plenty of vaccine available. However, the availability of vaccine doesn’t solely guarantee that this flu season will be a mild one. Patients must be vaccinated. Home health agencies (HHAs) can play a major role in ensuring that patients are vaccinated.
A recent 11-state pilot study of acute care hospitalization (ACH) revealed that 33 percent of HHAs did not assess the immunization status of patients. The study also determined that pneumonia was among the top 10 principal diagnoses for a hospital stay, accounting for nine percent of admissions.
The failure to vaccinate for both flu and pneumonia not only increases healthcare costs through re-hospitalizations and visits to physicians, but also puts patients at risk. The Centers for Disease Control and Prevention (CDC) estimates that flu and its complications cause 36,000 deaths and 200,000 hospitalizations each year. In Ohio, pneumococcal pneumonia causes more than 3,000 deaths annually, placing flu and pneumonia among the top 10 causes of death in the state.
How to reduce ACH
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A recent 11-state pilot study of acute care hospitalization (ACH) revealed that 33 percent of home health agencies (HHAs) did not assess the immunization status of patients. |
For the 2006-2007 flu season, review your processes/procedures to be sure that your agency is consistently assessing the immunization status of patients.
- Do your comprehensive assessment forms include screening for both influenza and pneumonia?
- Are you performing the immunization screening on SOC, ROC, and Recertification?
- You need to assess your existing patients who are not having a ROC
- Does your agency have a system in place to screen your health care workers (HCWs) for influenza immunization status?
- Some of your HCWs may have been immunized at a physician’s office, clinic, etc. Determine and implement a process to track their immunization status. You will also be able to use this to calculate the percentage of your HCWs who have been immunized. Studies have found that HCW immunization reduces mortality in patients by 40 percent. In addition, one study found that HCWs who were vaccinated had 28 percent fewer documented lost work days attributable to respiratory infection and 28 percent fewer days on which they felt they were unable to work compared with those who were not vaccinated. Another study found that HCWs receiving the influenza vaccine had a 41 percent reduction in days lost from their work compared with controls.
- Do you have a standing orders policy for immunization?
- Read all about the standing order provisions and see examples of standing orders on pages 28-35 of the Immunization Toolkit 2006, which was mailed to your Quality Improvement Coordinators last September.
- Check your assessment forms and/or computer program to make sure that both influenza and pneumonia immunizations are included.
- Does your process include referrals to local vaccination resources if your agency does not provide the vaccine?
- Does your process include follow-up to ensure the patient received the vaccine?
- Educate your staff on the purpose of screening, how to screen, and how to document their findings.
- Place immunization stickers on patients’ charts to signify their immunization status or recertification.
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Telehealth Promises a Better Way to Treat Chronic Conditions
By Pat Emmerson, MS, Communications Specialist, Oregon’s Medicare Quality Improvement Organization (OMPRO)
If you or someone you know has heart failure, Mr. Smith’s story will sound familiar. Mr. Smith is not real, but his story is. Joe DaFoe, RN, a home care nurse manager with Salem Hospital Home Care Services, Salem, Oregon, has heard this story many times.
Mr. Smith, age 76, arrives at the emergency department (ED) gasping for breath. His ankles are swollen; his blood pressure is high. He is diagnosed with heart failure and admitted to the hospital.
After five days of inpatient treatment, he is discharged and sent home with a prescription for diuretics, a set of dietary guidelines, and a packet of instructions for self-care. Two weeks later, Mr. Smith’s condition exacerbates, so he returns to the ED. He is stabilized in the ED and sent home with a set of self-care instructions.
Another two weeks pass. Mr. Smith once again appears in the ED, is stabilized, and again sent home. Within a week Mr. Smith is back, this time needing inpatient hospitalization. And so it goes until Mr. Smith needs palliative care.
What went wrong?
“Nothing,” says DaFoe, a member of Salem Hospital’s heart failure committee. “The system worked perfectly for what it was designed to do—treat acute conditions—and, hopefully, cure them. But chronic conditions such as heart failure aren’t generally curable, although they can be managed. If we don’t find better ways of managing chronic conditions, patients will continue to cycle in and out of the ED with frequent hospitalizations until they pass on.”
Growing ranks of the chronically ill
Chronic conditions currently affect one in four persons over age 65 and consume three out of every four Medicare dollars. The most common chronic conditions include diabetes, chronic obstructive pulmonary disease, arthritis, and heart failure.
Of these conditions, heart failure has been singled out as disproportionately expensive. About 14 percent of people over 65 have heart failure, but they account for 43 percent of Medicare spending. According to the report “High Cost Medicare Beneficiaries,” published by the Congressional Budget Office in May 2005, heart failure is the most common diagnosis among those over 65 who are hospitalized, and makes up half of the diagnoses among those who are readmitted to a hospital within six months.
Numerous studies reveal that better outcomes for heart failure patients depend on what happens in the first two or three weeks after hospital discharge. “If we can watch those patients every day for the first two or three weeks after they go home,” DaFoe says, “we can spot trouble early and intervene before they end up in the ED or the hospital. Heart failure patients aren’t fine one day and in crisis the next—they accumulate fluid gradually—over four or five days. We have ample warning.”
The challenge for home care agencies in providing this level of service, explains Joan English, RN, Director of Salem Home Care, has been how to meet a growing demand from an increasing number of chronically ill patients, with a shrinking pool of home care nurses and declining reimbursements. Salem Home Care recognized the challenge several years ago when they began searching for a way to preserve quality outcomes while extending the reach of their existing staff.
Enter telemonitoring
Published reports on successful applications of telehealth in other states convinced English that the technology held the solution. The Department of Veterans Affairs (VA), an early explorer in the field of telemedicine, began studying the potential of technology in 1997 with a small telemental health project in Lincoln, Nebraska. Positive results from this and other studies over the years had led the VA to formally implement large telemedicine systems.
The State of Hawaii Access Telehealth Network (STAN), which went live in July 1998, links hospitals and providers in several islands of the South Pacific. STAN provides an array of telemedical, educational, and conferencing services beyond home health monitoring, reaching patients and providers in remote communities. Savings in travel costs total hundreds of thousands of dollars.
After researching different systems on the market, Salem Hospital Home Care settled on the telemonitoring system that includes a central station for receiving data, software for organizing and presenting the data, and portable monitoring units to send to patients’ homes. The monitoring units come with attachments and peripherals that transmit vitals such as weight, oxygen saturation, blood pressure, and blood sugar level over an ordinary telephone line. Salem purchased 150 units.
This particular system is a Federal Drug Administration Class II medical device, which requires a doctor’s prescription. Because few Oregon doctors had previous experience with telemonitoring, Salem Home Care had to convince them to give the monitors a try.
Home care nurses, too, were initially cautious about using the new technology. But as of fall 2005, most of the agency’s nurses had one-third of their patients on home monitors. Cherry Currin, RN, BSN, a management evaluation nurse, became an early adopter and champion of the technology. Nearly half of her patients are on telemonitors.
Currin treats some of the agency’s sickest patients. With telemonitoring she can carry a weekly patient load of 30 while working only 30 hours a week. Despite the large patient load of very sick people and her short work week, Currin has the lowest hospitalization rate in the agency. In November 2005 she had no adverse events, and only one patient who needed to be hospitalized.
“Think of the impact if all our nurses had nearly half of their patients on monitors. What if we could take Cherry’s record and repeat it across the nation? We could save millions of healthcare dollars and prevent untold suffering,” says English.
How telemonitors work
If Mr. Smith had been prescribed a telemonitor when he left the hospital the first time, things would likely have turned out much different for him.
Within a day of discharge, a Salem Home Care nurse delivers a portable monitoring unit to Mr. Smith and teaches him how to use it. The unit is about the size of a clock radio and fits easily on the kitchen table.
The unit alerts Mr. Smith in a clear computer-simulated voice that it’s time to take his vitals. The voice, which can be programmed to speak in nine languages, guides Mr. Smith through weighing himself, taking his blood pressure, and measuring his blood-oxygen saturation. The voice asks him a few key questions: Is he feeling well? Is he in pain? Has he fallen? Has he had trouble taking his medicine? Mr. Smith answers by pushing a yes or no button, and then pushes a button to transmit the data.
Each day for the next 48 days that Mr. Smith has home care, his vitals are displayed on the central station monitor, where a specially trained nurse checks them. At the first sign of an exacerbation, the nurse notifies Mr. Smith’s doctor and his regular home care nurse. When Mr. Smith is discharged from home care, he is referred to the hospital’s outpatient clinic for heart failure patients, where he continues to manage his condition outside the ED or hospital.
According to DaFoe, most people are good candidates for telemonitoring. Only a few may not be—for example, people who have significant cognitive impairment and no one at home to help them, or people with certain psychiatric challenges who might be too easily startled by the unit’s computer voice or transmission sounds. “We don’t place units with people who won’t benefit from them,” he says.
Improved outcomes, increased productivity
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Numerous studies reveal that better outcomes for heart failure patients depend on what happens in the first two or three weeks after hospital discharge. |
Data collected by Outcome and Assessment Information Set (OASIS) and analyzed by Outcome Concept Systems shows that between October 2004 and September 2005, Salem Home Care’s heart failure patients with telemonitors had a hospital admission rate of 6.3 percent compared with 28 percent for those without telemonitors.
“I’m working on a process that incorporates telemonitoring into best practices, just like wound management,” says DaFoe. “The benefit has been demonstrated beyond a doubt.”
Connecting across the continuum of care
“We see home care applications for heart failure patients as just the first phase,” says English. “Where settings of care now sometimes operate in silos, we see the potential for telehealth along the continuum of care to improve communication and break down those silos. Telemonitors can be used by any healthcare service.”
Medicare and other insurers do not yet pay for telemonitoring visits. Until they do, small independent agencies may not see an immediate financial benefit. However, English points out, telemonitoring can help all agencies extend nursing services and save labor costs.
Another telehealth option for small agencies—which Salem Home Care also uses—involves a plain old telephone answered by a nurse trained in urgency response protocols.
Interest from CMS
To address mounting Medicare costs, in August 2005 the Centers for Medicare & Medicaid Services (CMS) initiated an investigation into the potential of telehealth for reducing acute hospitalizations among home health patients. CMS, an agency of the Department of Health and Human Services, contracted with state-based Quality Improvement Organizations (QIOs) across the country to work with home health agencies over the next three years on telehealth processes and systems.
As the Medicare QIO for Oregon, OMPRO recruited a small, select group of home health agencies interested in telehealth, among them, Salem Hospital Home Care Services—Oregon’s telehealth pioneer. Salem Hospital Home Care, which has worked with OMPRO on other quality improvement efforts since 2002, eagerly signed up.
“We are thrilled that Salem will be available as a resource for other home health agencies in our group. We know of two or three agencies that are looking to implement similar systems soon,” says Priscilla Swanson, RN, quality improvement specialist with the OMPRO home health project.
“I am also thrilled that these systems are coming to Oregon, especially because so much of our state is rural. My own father lives in rural South Dakota. He has heart failure and a home monitor. He’s happy because he feels someone cares. He knows someone is paying attention because he gets phone calls on his readings. Having a monitor has also prompted him to take more responsibility himself. He started keeping his own log, and now he knows a lot about how his numbers correspond to how he feels.
His doctor is also happy, because when my dad goes in with a complaint, he now has a complete record to help him figure out what’s going on. Before my dad got his monitor, he was in the hospital two times in the space of four months. In the two years that he’s had his monitor, he hasn’t been in the hospital at all.”
English anticipates that Salem Home Care’s telehealth services will soon include patients with other chronic conditions. She also sees the potential stretching far beyond home health. “We see enormous potential for telehealth in disaster planning,” English says. “With an in-home monitor, a nurse can visit patients who have been quarantined with contagious diseases or who are isolated by weather or road conditions. We found that out during the 2004 ice storm. We didn’t have a single patient needing to go to the hospital during that time. I think a lot of it had to do with reducing our patients’ anxiety. They knew we were still checking on them.”
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Teletriage: Are You Prepared?
Teletriage is a vital component of telehealth. It is the unscheduled, appropriate handling of health-related problems by skilled clinicians via telephone or electronic information technologies. Unlike phone monitoring and telemonitoring, which is initiated by the home health provider, teletriage is set in motion by the patient or caregiver.
The home health agency (HHA) staff triages the patient information over the phone to determine the best course of action. Teletriage is not optional and occurs as a daily part of normal HHA operations. The process begins in one of four ways:
- A patient or caregiver contacts the HHA with a clinical problem or question
- Telemonitoring data is received
- An incoming patient call occurs
- Telemonitoring data falls out of pre-established parameters
Value of teletriage
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Teletriage promotes the appropriate use of healthcare services and resources and in so doing reduces avoidable hospitalizations. |
Teletriage imparts advantages to both the HHA and patient. It is a mechanism by which HHAs can increase the value of their services to patients, caregivers and referral sources. Patients have improved access to skilled and empathetic healthcare professionals. In addition, teletriage promotes the appropriate use of healthcare services and resources and in so doing reduces avoidable hospitalizations.
Prior to teletriage
HHAs can maximize the effectiveness of teletriage by establishing home care goals with patients and their families early on. The patient’s physician should be brought into the process and should sign off in advance on potential interventions. HHAs should be proactive in efforts to decrease the risk of an urgent teletriage encounter. To prepare for teletriage encounters, HHAs should have patients’ past medical histories, current medications and allergy information readily assessable.
For detailed information about telehealth, including teletriage, please refer to the Telehealth Reference 2006/2007. It is available at www.medqic.org.
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National Campaign Seeks to Reduce Avoidable Acute Care Hospitalizations
A two-year campaign to reinvigorate efforts to improve the quality of care and quality of life for Americans receiving home care is planned for launch early next year.
The campaign is designed to inspire transformational change in healthcare delivery around the nation and complement the work of existing quality initiatives including the Home Health Quality Initiative (HHQI).
How your HHA can get involved
Home health agencies (HHAs) that agree to commit to working on the goals outlined by the campaign will be considered participating providers, and their aggregate process toward meeting the campaign goals will be monitored on a regular basis. Participating providers will receive assistance and guidance from a local campaign leader.
Acute care hospitalizations
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The campaign is designed to inspire transformational change in healthcare delivery. |
A major focus of the campaign will be on reducing the number of avoidable acute care hospitalizations (ACH). The Centers for Medicare & Medicaid Services (CMS) has identified the following four strategies as effective in reducing ACH:
- Hospital risk assessment. This strategy is most often identified in HHAs’ plans of action. Of importance in risk assessment is the need to first identify the agency’s high-risk population if possible and then select an appropriate risk assessment tool. Once patients at risk have been identified care plans tailored to meet their individual care needs are a must.
- Emergency care planning. Key factors of this strategy include: the agency’s 24-hour availability/ response system, reminder tools like magnets and whiteboards with numbers and signs and symptoms to look for, and an individual patient’s response plan that identifies those symptoms that are the patient’s triggers.
- Patient self-management. A major component of chronic disease management is patient self-management. Patient self-management begins with an assessment of the patient’s ability to engage in shared decision-making and the establishment of patient and caregiver goals and expectations.
- Transitions of care. This strategy requires a HHA to collaborate with other stakeholders in the patients care. Consider the factors that are integral to discharging the patient from hospital to home. Factors include medication reconciliation and connecting with the patient’s primary care physician for new orders. The latter is especially important if during the patient’s inpatient stay a hospitalist provided medical care. Identify key criteria for safe and appropriate discharge. Share them with your inpatient referral sources. Develop a process to ensure timely initiation of services, problem identification and care planning. Give some thought to readmitting patients. Ask yourself has anything changed with this hospitalization? How did the patient’s behavior in the past affect his condition/disease? Is there anything the agency could do that is new and will make a difference? Treat each referral as though it was for a new patient. Recognize that there is more and more evidence-based practice to guide clinicians in providing exceptional patient care.
More information about this campaign is forthcoming. To stay connected, please sign up for Ohio KePRO’s home health e-newsletters:
- Go to www.ohiokepro.com
- Enter your e-mail address and click “Go” under Newsletter Subscription
- Select Home Health Tip of the Week and Quality Outcomes. Enter the rest of your information and click Subscribe/Unsubscribe.
Order Free Materials
Ohio KePRO offers a variety of free CD-ROMs, brochures, booklets, and clinical pocket guides to help your home health agency provide quality care to patients. View Shopping Bag>>
We encourage you to share the newsletter with others at your home health agency. Those who wish to receive their own issues of Quality Outcomes can subscribe free of charge to the newsletter by visiting www.ohiokepro.com >Publications >Newsletters >Subscribe Online.
Ohio KePRO Home Health Team
Ronald A. Savrin, MD, MBA
Betty Pilous, RN, MHSA, CPHQ
Linda Day, RN, BSN, MBA
Carolynn Guelker, RN, CCM
Tracy Hammar, LPN, MBA
Donna Maynard
Rosalie McGinnis, RN, MS
Jennifer Rako, BS
Robin Reitzel, BS
Chris Titus, MCSE, CNA, MCP
Shandra Tucke, MA
Eileen Wallenhorst, RN, BSPA
Communications Writer/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.
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