Quality Rounds
Keeping Home Health Care Patients Home
Mary Wang, a registered nurse at North Country Home Care and Hospice in Bemidji, is happy to share the story of how prompt interventions kept one of her patients out of the hospital several times during the past year. While undergoing home care, the 74-year-old woman with heart failure experienced a massive build-up of fluid that brought her to the hospital in September 2007. After being placed on diuretics, she shed 30 pounds and was sent home. Wang outfitted the woman with a home telemonitoring system that could track her weight and alert her caregivers if she started retaining fluid. Since then, the woman has had eight episodes of fluid gain that were successfully treated with diuretics because she learned the importance of using the system to weigh herself daily. “Each time this happens, she catches it a little bit sooner,” Wang says of the fluid retention.
Keeping a patient healthy enough to avoid a hospitalization is exactly the kind of outcome Medicare has tried to achieve across the country with its most recent home health quality-improvement effort, the National Home Health Quality Improvement Campaign. The campaign focused on reducing the hospitalization rate among home health care patients. Figures from the federal government indicate that about 28 percent of the nearly 3 million Medicare home health care patients end up in the hospital while they’re receiving home care—a rate that has stayed high but that the Centers for Medicare and Medicaid Services (CMS) believes could be lowered given the right mix of interventions.
The 28 percent figure is only an average, however. Hospitalization rates not only differ among agencies but also swing wildly from state to state—from 18 percent in South Dakota to 41 percent in Louisiana, according to Medicare Home Health Compare data from April 2007 to March 2008.
“With the national rate of 28 percent and with a substantial number of home health agencies’ rates much lower than that, our hypothesis was that some home health agencies had room for improvement,” says Paul McGann, M.D., deputy chief medical officer of the CMS Office of Clinical Standards and Quality.
In 2002, CMS challenged its Quality Improvement Agencies to try to improve the quality of home health care. Quality Improvement Agencies such as Stratis Health in Minnesota work in each state to improve services delivered to Medicare beneficiaries. At that time, Stratis Health began helping about half of Minnesota’s Medicare-certified home health agencies learn and use quality-improvement methodologies.
Home Health Campaign Components
The following topics were covered in the 12 learning modules given to home health agencies taking part in the Centers for Medicare and Medicaid Services’ National Home Health Quality Improvement Campaign:
- Implementing hospitalization risk assessments
- Developing patient emergency plans
- Improving medication management
- Phone monitoring and front-loading visits
- Teletriage—responding to emergent patient problems over the phone
- Telemonitoring
- Immunizations
- Physician relationships
- Fall prevention
- Patient self-management
- Disease management
Source: www.homehealthquality.org/hh/
hha/interventionpackages/default.aspx
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In 2005, CMS decided to focus on the issue of hospitalization rates. That same year, Stratis Health launched the Minnesota Home Health Collaborative in order to give 62 participating home health agencies more intensive technical support and the opportunity to learn about best practices for helping patients avoid hospitalizations. After two years, CMS realized home health agencies were still far from achieving their goal of reducing the hospitalization rate to 23 percent. So to step up the effort, it launched the national campaign in January of 2007 at a summit in Baltimore, Maryland. About 5,600 home health care agencies from around the country signed up, including 124 in Minnesota, one of which was North Country Home Care and Hospice.
Minnesota’s Experience
Each month, the agencies participating in the campaign received a learning module on a specific topic (see “Home Health Campaign Components”). The modules included background information, best practice guidelines, forms, scripts, check lists, and examples of protocols the agency could use. They also included examples of how agencies reduced hospitalizations by implementing the guidelines and strategies. Stratis Health distributed monthly progress reports compiled by CMS to all the agencies working on improving their hospitalization rates.
Janelle Shearer, R.N., program manager for Stratis Health, says North Country Home Care and Hospice, which is affiliated with North Country Regional Hospital and serves about 80 patients in the Bemidji area, was one agency that successfully implemented strategies from both the campaign and the collaborative.
For instance, the agency increased the number of phone and in-person visits during patients’ first week of care. Previously, the agency distributed visits evenly over a nine-week period. North Country found that by doing more visits earlier providers could identify potential problems and prevent them from becoming serious and resulting in hospitalization. “We have found that if someone is discharged from the hospital, they will usually have their problems right away,” says Carrie Krump, R.N., clinical supervisor at North Country. She says seeing patients more often early on has been particularly helpful in identifying problems with medications. She tells of one patient, confused by the brand and generic names of her drugs, who was taking three beta blockers for her blood pressure instead of one. The nurse discovered the problem on a visit during the patient’s first week of care. Krump says the nurse might not have made the discovery as early under the old system in which visits were spread out.
North Country also standardized its approach to educating patients about the conditions that most commonly result in acute hospitalization—chronic obstructive pulmonary disease (COPD), emphysema, pneumonia, heart failure, and diabetes. Nurses started using a laptop with software provided by the campaign to educate patients. The program prompts the nurse to cover key points while reviewing written materials with the patient. It then automatically informs North Country’s electronic health record that the learning module has been completed. “This gave us something that was standardized and based on best practices, so we were all teaching and reinforcing the same thing,” Krump says.
The agency increased the frequency of phone checks and its use of telemonitoring for patients with heart failure and COPD. North Country also trained its nurses to use the Situation Background Assessment Recommendation (SBAR) technique, which standardizes the information they communicate to physicians and other caregivers. “Our physicians love it. We use it in a written format and fax it to the doctors and quite often we hear back from them in five minutes, since it is in a format that is easy for them to understand,” Krump says.
Back at the office, North Country held monthly staff meetings that included education about best practices, reviews of the CMS data reports, and discussion of what worked and what didn’t. The home health agency also took an aggressive approach to oversight and early on audited about half of its patients’ charts to ensure best practices were being used.
Because of these and other changes, North Country reduced its hospitalization rate from 24 percent in March 2007 to 20 percent in April 2008.
Medicare’s Next Step
The national results of the 2007 campaign were less impressive than North Country’s. The hospitalization rate among home health agencies around the country that took part decreased only 0.09 percent, on average. McGann points out, however, that agencies that did not participate saw a 1.1 percent increase in hospitalizations.
One of the lessons of the campaign was that many factors outside a home health agency’s control can determine whether a patient is hospitalized. Some of those include physician preference, hospital incentives to admit patients, and the local health care culture. For that reason, McGann says the second phase of the project will broaden its scope to include entire systems of care.
Despite meager gains nationally, McGann was glad to see so many agencies participate in the campaign and to hear success stories—stories that other agencies may one day be able to learn from. “The numbers aren’t dramatic, but we feel we’ve learned a lot and that we are in a very good position to do a much better job in the coming years,” he says. MM
Scott Smith is a staff writer for the MMA.