This was the prevailing thought in one home health agency (HHA) as rehospitalization rates often exceeded the 30th percentile in Outcome-Based Quality Improvement (OBQI) scores. OBQI scores are calculated by the Centers for Medicare and Medicaid (CMS) to compare achievement of patient outcomes among HHAs. These scores also allow agencies to compare their scores with the national average (benchmarking). Decisions made by physicians, patients, and their families appeared to be a determining factor in most HHA patients' emergency room usage and rehospitalization, with the HHA only hearing about the admission afterwards. This prevented the HHA from providing any intervention to possibly prevent the rehospitalization. Yet, we and other HHAs are being held responsible. In "Pay for Performance" or "value-based purchasing" being developed by CMS, HHA reimbursement rates will be determined in part by these rehospitalization rates. As CMS also began to pilot bundling, HHAs will need to work with other providers along the patient's care continuum (MedPAC, 2010, March). This was a call to action for our HHA.
The Role of HHAs in Preventing Rehospitalizations
Hospital readmissions from home health and long-term care among Medicare beneficiaries remained frozen at 28% from 2003 to 2006 and actually increased to 29% in 2007, despite concerted efforts by providers and insurers to decrease these rates (MedPAC, 2010, June, p. 207). Rehospitalizations create a significant strain on the federal Medicare budget and were estimated at $12 billion in 2005 at an average cost of $7500 per admission (MedPAC, 2007). Jencks et al. (2009) reported findings with an estimated cost for unavoidable rehospitalizations in 2004 at $17.4 billion. Surprisingly, there are no more recent findings available from MedPAC on cost of rehospitalization as of September 2010.
This organization is a small, municipal-based Medicare-certified HHA/public health nursing agency and provides service to five area towns, providing a public health nurse to two of the participating towns. The HHA budget is approximately $800K with a patient census of 40 to 50. There are 14 other certified agencies, providing significant competition, including the local hospital having its own HHA. Remaining competitive in this environment requires being competitive in Home Health Compare with OBQI rates. Home Health Compare is a CMS Web site providing a detailed comparison of individual agencies services and risk-adjusted outcomes available for public review to aid in their decision making when selecting an agency (CMS, 2010).
The literature was reviewed and several trends were found to be instrumental in preventing unnecessary rehospitalization. These include care transitions, chronic disease management, and coaching.
Care transitions are defined by the American Geriatrics Society as "a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location" (Coleman & Boult, 2003, p. 556). Care transitions are identified as a time of increased vulnerability for patients, particularly those with complex care needs (Coleman, 2003). The transition between healthcare facility and home creates a shift in emphasis of care delivery with a decrease in the role of the professional and additional responsibility for family members or other "care partners" to implement follow-up plans of care, adhere to complex medication regimens and other therapies, as well as assure follow-up with primary care provider (PCP)'s and specialists. A focus on involving the patient and care partner in the plan of care (POC) at this juncture in the patient's movement along the healthcare continuum from hospital to home is essential, knowing the increased vulnerability of patients and the increased responsibility of the patient and care partners (Parry et al., 2006).
Care transition is a complex phenomenon created in part by the introduction of diagnostic-related groupings (DRGs) as a determinant of hospital reimbursement in 1983 (Naylor, 2000). Earlier discharges place additional pressure on families and post acute healthcare providers such as home health agencies to provide additional care due to the increased acuity of the needs of the discharged patient (Shaughnessy et al, 2002; Levine et al, 2010). The occurrence of increased rehospitalizations led to the recognition of the need to focus on the "transitions" as a time of increased vulnerability to patients resulting in poor outcomes (Naylor et al., 2004).
Chronic illnesses are often described as "lifestyle" diseases, meaning their management depends as much on the patient's lifestyle decisions as on medical management. Four in five healthcare dollars (78%) are spent on behalf of people with chronic conditions. Ninety percent of seniors have at least one chronic disease, and 77% have two or more chronic diseases (Anderson & Horvath, 2004).
MedPAC (2009, June, p. 12) reports: "the most costly beneficiaries tend to be those with multiple chronic conditions, those using in-hospital services and those who are in the last year of life." Of the top 10 hospital DRGs accounting for the greatest share of total Medicare expenditures, seven are chronic illnesses. Of these DRGs, all are included in the top 10 home care diagnoses (USDHHS, 2007). Thus, the most costly Medicare beneficiaries are the typical home care/hospice patients: several comorbidities, recent hospitalization, and often in the last year of their life.
Fortunately, with the plethora of information available on the Web and an increasingly computer-savvy population, there is an increased demand by patients for input into their healthcare decisions. Also, with the increasing percentage of the population 65+ and the decreasing numbers of primary care providers, access may also become more difficult, placing a greater responsibility for healthcare on the patient.
Encouraging patients to identify their own health goals and then developing the POC around those goals is critical to increasing a patient's self-management skills with chronic illness. Health coaching has been described as an "approach of partnering with patients to enhance self-management strategies for the purpose of preventing exacerbations of chronic illness and supporting lifestyle change" (Huffman, 2007, p. 271). Coaching differs from health education as the coach is seen as a facilitator to assist the patient in establishing goals and time lines. When acting as a health educator, the goals are identified by the clinician and the interventions established. This has been shown to be less effective when the desired outcomes require long-term behavioral changes. The emphasis in coaching is on a partnership between patient and clinician, and the clinician provides expertise to support patient-identified goals. When coaching, clinicians ascertain the patient's goals by asking questions such as "What is the most important part of your recovery to you?" and it may elicit a response of "playing a round of golf" or "sitting on the floor to play with my grandchild". The clinician then develops the POC to support attainment of these patient-identified goals and link teaching and interventions to goal attainment. The POC, developed with input from the patient and care partners, helps to determine realistic goals of what may and may not be accomplished during a home care admission. Coaching or motivational interviewing has been identified as a more effective method of assisting patients with chronic illnesses in learning to develop the lifestyle changes necessary to cope with a chronic illness on a daily basis.
A Call to Action
As part of a program to introduce evidence-based practice into the HHA, a review of current recommended interventions to prevent rehospitalization from the home health setting was initiated. Although there are other models, the HHA focused on two. These were the Quality Cost Model of Advanced Practice Nurse Transitional Care developed by Naylor (Naylor, 2000) and the Care Transitions Model developed by Coleman (Coleman et al., 2006).
The research has focused on interventions using acute care–based nurses, both general and advanced practice nurses, following the patient from the hospital to the home (Coleman, et al., 2006; Naylor, 2000). Although these approaches are effective in our situation, there are several reasons why using advanced practice/acute care nurses may not be the best model:
- Increased implementation costs
- Duplication of services concurrently being provided by certified home care agency
- Lack of reimbursement under Medicare
- Lack of recognition of the specialized skills of the home care clinician
- Inefficient use of Advanced Practice Nurses, needed in primary care due to the projected shortage of primary care providers with the aging population (Naylor & Kurtzman, 2010).
In later research utilizing Coleman's Care Transitions InterventionSM, the use of various levels of clinicians was examined, including nurses, social workers, and community workers, although no rehospitalization rates were reported in the study (Parrish et al., 2009).
Home care nurses are well positioned to lead an intervention directed at patient self-management, as home care nurses have established an ongoing care management relationship with the patient and care partners in the home setting, are knowledgeable about the availability and access to community resources, and have knowledge regarding use of adult learning principles, goal setting, and patient education materials. These activities are an essential part of the role of the home care nurse (ANA, 2008). In addition, the experience of working with elders in their homes immediately after a hospitalization provides the home care nurse with a realistic view of the challenges these patients and their families face.
Using this information, the organization began to examine the Four Pillars of the Coleman Care Transitions InterventionSM.
Coleman interviewed patients and their families after a recent hospital discharge to better understand the challenges faced by older adults after an acute care hospitalization. The issues identified by participants included lack of (a) information transfer, (b) patient/caregiver preparation, (c) support for self-management, and (d) empowerment skills to assert preferences. Findings of this study led to the development of four pillars or interventions to resolve these issues identified as creating the most difficulty and turmoil to patients and their care partners following discharge from the hospital (Coleman, 2003; Coleman et al., 2002).
Coleman and colleagues identified these Four Pillars (Table 1) to provide tools to the clinician and the patient for preventing the most common adverse events from occurring after discharge from the hospital (Coleman et al., 2006). The domains or pillars identified to prevent these issues from occurring included (a) assistance with medication self-management; (b) use of a patient-centered health record; (c) early, consistent communication/follow-up with primary care providers and/or the medical specialist; and (d) a list of personalized "red flags" indicative of a deteriorating condition.
Coleman identified the need to focus on coaching or motivational interviewing to assist patients and their care partners in becoming more able to "self-manage" their chronic illnesses (Coleman et al., 2006).
Implementing the Plan
Staff, including nursing and therapists, were included in the discussions regarding interventions to decrease rehospitalizations. Rehospitalization-focused staff meetings were utilized as the time and venue to develop the intervention. At the end of our every other week case conferences time was also carved out to plan the interventions. This multidisciplinary approach was necessary to develop an effective intervention. Buy-in from all members was key to a consistent intervention that would continue over time. The initial literature review was conducted by the administrator of the HHA as part of a doctoral program of research. The staff was presented with the current available research. Once the Four Pillars of Coleman's Care Transitions InterventionSM was selected, staff began discussion on how to implement or operationalize the selected intervention. Ideas were generated; the administrator developed samples and policies incorporating the suggestions and then presented them to the staff for their review and feedback. Topics of the meetings included:
- What is a Care Transition?
- Elements of Coleman's Care Transition InterventionSM with the Four Pillars
- Samples from other care transition programs
- What do we want for our patients?
- Review of each of the Four Pillars
- How does this apply to HHA patients?
- How can we incorporate the information into the HHA admission process?
- What additional information would staff need?
- How do we assure consistency/continuity with this intervention?
There were forms and other tools that needed to be created. Development of the various forms, including the Personal Health Record (PHR), took approximately 3 months, with an additional pilot testing of the various forms over the next month. All of the above were considered as the PHR was being developed. The PHR was considered the cornerstone of the intervention. The final plan was then presented to the Group of Professional Persons (GPPs) for their suggestions and approval. At this HHA, the GPP comprises community members representing the various professionals active in the agency, such as nursing, physical, occupational, and speech therapists, and a social worker as well as a physician, a pharmacist, and a public health nurse and a consumer. The function of the GPP, as outlined in the Home Health Agency Conditions of Participation, is to provide community input into policies related to admission and discharge criteria, medical supervision and plans of care, emergency care, clinical records, personnel qualifications, and program evaluation (CMS, 2005). The initial version was finalized and implemented.
A revision of the forms was conducted after approximately 18 months of usage based on comments by clinicians and patients. These included a greater emphasis on goal setting, additional specific records to provide data to PCP, and the addition of a Fall Prevention Teaching Guide.
Creating a Tool Kit for Clinicians and Patients
Creating a tool kit for clinicians and patients began with an introduction to the staff of the Coleman Care Transitions InterventionSM. We then examined each "pillar" and identified what would be needed for clinicians and patients to utilize these pillars (Table 1). The contents of the initial PHR (Table 2) utilized in the quality improvement project described in this article were then expanded to include examination of additional tools listed in the "tool kit" below. The additional tools are available to clinicians for patients as they deem appropriate.
Medication reconciliation is a requirement of the home care admission visit, in order to respond to the often-conflicting information between the medication list accompanying the patient home from the hospital or physician's office and what the patient reports they actually take at home. This information is also required to enable completion of the OASIS-C document.
Tools for the patient may include paper or electronic forms depending on the preference of the patient. Ability to update the list is the primary goal of form selection. In addition, appropriate supports to assure medication compliance such as pillboxes, prepackaged medications, and/or reminder systems may be needed. Of primary importance is assessing the patient's ability and/or willingness to comply with the medication regimen (Table 3).
Along with a current medication list, the clinician also needs access to information on medication use and side effects, a list of high-risk medications such as Beers Criteria (Fick et al., 2003; Beers, 1997) or Institute of Safe Medication Practice (ISMP, 2008), and agency policies regarding interventions related to these high-risk medications. In addition, a helpful document to assist in identifying the medication reconciliation process is the Medication Reconciliation Tool (Coleman et al., 2005) to identify common medication discrepancies and how they are resolved (Figure 1).
Personal Health Record
Use of the PHR assists the patient in communicating with the various medical providers involved in their care. Table 4 lists tools for the clinician and the patient to utilize the PHR.
The updated medication record, along with the goal identification sheets for the patient, and a form to list questions to ask at the PCP visit all serve to increase collaboration between patient, care partners, and clinicians. It is also important to have the patient identify their "care partner" as the person they perceive as being the most supportive in meeting their healthcare goals. This may be a family member, friend, significant other, healthcare proxy, or even a neighbor. Having another person who is knowledgeable of their healthcare needs can assist them as the role of the home care nurse, therapist, and home health aide decreases. Also, encouraging the patient to take the PHR to the PCP/specialist visit provides an opportunity for dialogue and to update the PHR. Table 2 includes the contents of the PHR.
Having the ability to visit the patient more frequently early in the episode (front-loading visits) is encouraged, as this is when the patient is most vulnerable to rehospitalization (Rogers et al., 2007).
Communication among care providers and patient, family, and other care partners is a necessity in decreasing rehospitalization (Tanner, 2010). The increase in use of hospitalists has further fragmented the communication, as the PCP is often neither aware of the patient's hospital stay nor knowledgeable regarding the new diagnoses and treatments resulting from the hospitalization. Facilitating an appointment with the PCP and/or specialists within 2 weeks of hospital discharge has been shown to decrease hospital readmissions (Jencks et al, 2009). Assuring the patient has transportation to the appointments is often a critical issue the clinician may be involved in solving. Encouraging the patient to write down questions in the PHR prior to the appointment and encouraging the patient to also take the PHR to the appointment to ask the listed questions further enhances communication.
Communication tools for the patient and clinician are listed in Table 5. The clinician must have current information regarding the patient's various physicians. Policies for formalizing communication lines between clinician, patient, and PCP/specialists are critical. As more medical practices implement email as a communication tool, the ability to have rapid information exchange is possible. Providing tips to the family on preferable times to contact the PCP (avoid lunch time, after 4 PM, or Monday mornings, as these are high-volume call times). Because there is often a delay in the PCP receiving hospital discharge information, faxing critical information to the PCP may also facilitate more timely communication of patient condition.
Use of SBAR
In addition to assuring early face-to-face contact with the PCPs, educating the patient regarding when to contact the PCP and what information is needed is critical for supporting patient self-management.
SBAR (Situation, Background, Assessment, Request) has been utilized by clinicians to support clear communication across disciplines (Figure 2). In addition to professional clinical staff, inclusion of home health aides in learning SBAR is essential. Providing them with a pocket card can assist them in communicating their observations to other care providers. SBAR may also be utilized by patients and their care partners to organize the information prior to contacting the physician. (Denham, 2009). A sample guideline for patients and care partners can be provided in the PHR (Figure 3).
Identification of personalized "red flags" enables the patient and/or care partner to recognize a change in condition prompting notification of nurse (Table 6 and Figure 4). The list should be personalized to the individual patient, with an area for specific recommendations to be added. General areas that may be included are signs of heart failure, wound infection, urinary tract infection, anticoagulant toxicity, and changes in mental status. In addition, when to call 911 immediately should be listed, along with specific emergency planning information such as what to do if electricity goes off and there is oxygen or IV equipment in the home. Specific parameters of when to seek assistance should also be noted, such as "weight gain greater than 3 pounds in a week" or "pulse above 110." Use care in using medical jargon or abbreviations such as "hold", systolic blood pressure or SBP < 60. Teaching guides appropriate to patient diagnosis and literacy level should also be placed in PHR. Recognition of the need to be cognizant of vision needs and health literacy principles led to the development of a document with numerous pictures and diagrams (Figure 4). Numerous teaching tools are available on the Web to meet health literacy needs (AHRQ, 2010) (Box 1).
Impact of Intervention on Patient Outcomes
Implementation of the Four Pillars of the Coleman Care Transition's Model resulted in a 12 percentage point decrease in rehospitalization among Medicare beneficiaries (Table 7). This statistically significant finding (P = <.05) brought the HHA well below the national case-mix adjusted average of 23% to 24%. The HHA also experienced a 6% decrease in emergent care visits, but were unable to achieve the national benchmark of 18% to 19% (Table 8). One possible explanation for this continued use of emergent care may be that patient's deteriorating condition was being identified earlier, and stabilized in the emergency room, thereby possibly avoiding hospitalization. Also, culturally, the community takes pride in its local hospital and it has been suggested that some see emergency room visits as "supporting the hospital." This belief system presents a challenge to the HHA clinicians who encourage the patient to "call us first."
Six Lessons Learned
Implementation of this intervention provided many lessons for our agency:
- Identifying "champions" in the agency whose actions supported the project through the challenges that occur during implementation.
- Staff buy-in was critical: inclusion of multidisciplinary staff in planning and implementing the project helped guarantee success. Participation and success created a feeling of teamwork and pride in the project and organization.
- There was a cultural shift within the agency as staff and patients alike were empowered to prevent rehospitalization with the provision of the various tools and planned interventions.
- Incorporating the project into current procedures, such as the admission visit, created ease of use and less of an impact on productivity.
- Marketing tools came from our successes: referral sources such as hospitals and physician groups are also concerned with decreasing rehospitalization rates and so we had something they wanted and understood—the perfect marketing tool!
- Additional in-service education in coaching provided by the agency via online courses, instructional manuals, and role-playing within agency can provide additional knowledge and support to staff as they develop in the coaching role (Box 1).
Decreasing rehospitalization is a challenge for all sites along the healthcare continuum, but in home healthcare there is often a feeling among staff that the decision to rehospitalize a patient is made by others, without their input. These interventions may prevent the patient and physician from reaching the point of needing to make a decision regarding rehospitalization by teaching the patient how to prevent serious exacerbations and when to intervene earlier in the illness trajectory to prevent the need for rehospitalization by providing treatments available in the outpatient setting. The application of the Four Pillars of Coleman's Care Transition InterventionSM and the special skills of home healthcare clinician can aid in avoiding rehospitalization by teaching the patient appropriate self-management skills.
The author thanks the staff of Acton Public Health Nursing Service for their support of this project.
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