Practicum-Home care hospitalizations

Practicum Report          Jessica Bertagnolli                  

Unplanned Hospitalizations, Re-hospitalizations and Emergent Care Visits

Home health care is an important part in the continuum of care that a patient receives during an episode of illness and recovery. Patients are referred to home health from various referral sources, including clinics, emergent care settings, hospitals, skilled nursing facilities and assisted living facilities. Home health care is a skilled service that is paid for by Medicare and Medicaid. The Centers for Medicare & Medicaid Services (CMS) is moving to implement Pay for Performance. This is an initiative that encourages home care to utilize valid quality measures of patient improvement data (Crossen-Sills, Toomey & Doherty, 2006). Acute care hospitalization rates is a utilization outcome that is mentioned by CMS in this initiative and an outcome measure that is now being reported and monitored via the OASIS (a mandatory reporting tool required of home care agencies by CMS to receive payment for services). Hospitalizations are stressful on the patient and family and have a significant financial impact on the health care system.

Unplanned hospitalizations and re-admissions have become more of an issue, because patients are being discharged sooner from the hospital following an acute episode, therefore are sicker and more complex. This has been driven by payer practices and the need for organizations to be profitable. Home health care can help to keep these patients out of the hospital following discharge, but need to implement strategies to reduce unplanned hospitalizations in their practices. Some strategies are front loading visits within the first 2 weeks of home care services, creating a standard of care for specific populations (i.e. disease management programs) and daily monitoring via telehealth. The identification of at risk patients is key to early intervention and care planning (Crossen-Sills, Toomey & Doherty, 2006).

Crossen-Sills, Toomey & Doherty (2006), of the Norwell Visiting Nurse Association, report their outcomes from implementation of a three-step unplanned hospitalization intervention process. The three-steps involved changing the service delivery model by standardizing visit frequencies, implementing an education and training program for staff and implementing early home telemonitoring. These efforts resulted in a 2.6% decrease in hospitalization rate in a 6 month period. Evaluating current practices and outcomes can help to identify areas of opportunity to help reduce unplanned and avoidable hospitalizations in the home care patient population.

Anderson, Hanson, DeVilder and Helms (1996) identified the need to look further into hospital readmissions of patients receiving home care services. It was identified that there was much literature and focus on hospital readmissions from the medical standpoint and acute-care perspective, but minimal information available about acute-care readmissions for home care patients. They developed the Hospital Readmission Inventory (HRI), an audit tool to gather data about the characteristics of those patients on home care services that are readmitted to the acute care setting within the first 31 days of home care service delivery.

In the pilot study, Anderson, Hanson, DeVilder and Helms (1996) audited 68 medical records from 8 home care agencies in the Midwest. They specifically looked at those referred to home care at time of discharge from a facility (acute care hospital, rehabilitation or skilled care), patients 65 years or older, had at least one skilled home care service discipline and had been readmitted to the hospital during the first 31 days of home care service. It was found that those re-hospitalized were mostly elderly females, required help to care for self, referred to home care by the hospital, average length of stay on home care services was 14 days, primary diagnosis at home health admission and hospital readmission was COPD or CHF.

Following the pilot study, Anderson, Helms, Hanson and DeVilder (1999) again looked at unplanned hospital readmissions utilizing the HRI tool. During the study, they evaluated 916 medical records from 11 Midwestern home care agencies. This time the inclusion criteria was that the patient was referred to home care from a facility (same as the pilot study from 1996), at least one home care discipline ordered and was re-hopitalized within 100 days of start of home care service. Again, they found that the patients typically readmitted were elderly females and were readmitted after an average of 18 days on home care services.

            For my leadership practicum, I evaluated 20 medical records from one home care agency. The inclusion criteria was that the patient was on home care services at some time during the month to August, 2011, had at least one emergent care visit or hospitalization during the current home care episode and had an OASIS (Outcome and Assessment Information Set, CMS) completed at the start of home care services. The patients were pulled from a report made available from SHP (Strategic Healthcare Programs, LLC). This is a real time OASIS-C data scrubbing and benchmarking software (See www.shpdata.com/products/home-health-agencies/overview.aspx for more information about the program). It was found that most of the patients utilizing emergent care were elderly females, being hospitalized within the first 2 weeks of home care services and failing to utilized the home care triage system prior to emergent care (See attached Data Summary document).

Change and Effective Leadership

Effective leaders must involve those whose practice and work outcomes are being evaluated early in the change process. There are various studies that have shown management style and organizational characteristics have an effect staff satisfaction, as described by Stordeur & D’Hoore (2007). Factors which can affect nurse satisfaction are compensation and recognition, shared decision making, staff empowerment and leaderships’ communication practice.

Shared decision making practices and leaderships ability to effectively listen are important factors when considering retention and staff satisfaction (Stordeur & D’Hoore, 2007). It is important that staff perceive that management listens and responds to their concerns, contributions and needs.  According to Porter-O’Grady and Malloch (2011), there are three important elements to accountability; the right, power, and competence to decide and act. This requires the leader to provide forums for shared decision making and engaging staff to “own” their practice

Nurses want to be involved in the decision making process. One way this is achieved is through shared governance practices, where nurses can discuss issues that affect their work environment and ways to address the issues at hand. This way, those who are delivering the care, who have insight and experience about the practice, are the ones who are the change agents and have accountability for the desired action.

Havelock’s theory on change describes six parts  to the change process; building a relationship, diagnosing the problem, acquiring the relevant resources, choosing the solution, gaining acceptance and stabilization and self-renewal (Roussel, 2006). It is important to involve staff at the point of care in the beginning of this process. It is much more effective for a leader to present the problem, not the solution. In order to allow for accountability at the point of care, the staff must be able to realize the problem and have ownership in identification of the solution.

After gathering the preliminary data about emergent care visits and hospitalizations for patients on home care (HC) services, I went to the home care Nursing Practice Council. It was here that I presented the problem of hospitalizations and more importantly, avoidable hospitalizations. I spoke of the health system as a whole and how home care fits in when addressing the problem of avoidable hospitalizations as a system. I then presented some of the HC data for the month of August 2011. I offered information on trends that I found and information on specific diagnoses.

After discussing the preliminary data, I asked the council members if they saw anything that is of concern that they may be able to address in their practice. Members pointed out the data on the use of home care triage prior to emergent care (EC) visits and hospitalizations. They felt that there may be a way to better educate the patients on when and how to utilize their triage prior to going to EC. Another topic that was brought up by council members was that of identification of high risk patients for hospitalization and how to address it in the plan of care. They discussed the idea of more standardized practices of the number of visits for identified patients.

In Havelock’s change theory, the meeting with the home care practice council included the steps of building a relationship and diagnosing the problem. In presenting the data and allowing the nurses to diagnose the problem allowed me to acquire relevant resources and pursue possible solutions. In collaborating with the nurse educator, manager and director of home care I was able to identify current practices and align with the goals and vision of the department. The nurses on the practice council and the management team, all felt that better identification of high risk patients and better patient education about triage throughout the plan of care would be appropriate solutions to focus on.

Based on these meetings and information, I pursued further data collection and looked at other research that was in the literature on the topic. I gathered more data and analyzed further. I then put the information in a report and noted significant trends found.

The next steps in the change process will be to gain acceptance and stabilization, then self-renewal. My plan is to meet with the nurse educator and practice council chairperson to solidify a practice proposal to the nurses in early January. This proposal will include standardizing verbiage and consistency of education at every visit about the use of HC triage and avoidable hospitalizations. It was identified that the only hospitalized patients that utilized HC triage were those who were opened to services within two weeks of EC, which may reflect the need to re-educate throughout the HC episode. The reminding and re-educating of patients at certain intervals throughout their care may help to increase the involvement that HC can have in addressing use of EC and avoidable/unplanned hospitalization with early interventions and communication with the physician.

I think that having the nurses on the practice council take the practice change forward to the rest of the staff will help to gain acceptance and stabilization of the practice. The hospitalization and EC visit data for the month following the practice change should be analyzed utilizing the same data collection tool, to assess the impact of the effort. This will allow evaluation of the change and provide positive feedback to the nurses to help stabilize the change or will help to identify a different process to address the problem, if found that no impact was made. Feedback to those at the point of care will be important in stabilizing the change that is made and recognizing them for the work they do. 

References

Anderson, M., Hanson, K., DeVilder, N. & Helms, L. (1996). Hospital readmissions during   home care: a pilot study. Journal of Community Health Nursing, 13(1), 1-12.

Anderson, M., Helms, L., Hanson, K. & DeVilder, N. (1999). Unplanned hospital readmissions: A home care perspective. Nursing Research, 48(6), 299-307.

Crossen-Sills, J., Toomey, I. & Doherty, M. (2006). Strategies to reduce unplanned hospitalizations of home healthcare patients: A step by step approach. Home Healthcare Nurse, 24(6), 369-376.

Porter-O’Grady, T.  & Malloch, k. (2011). Quantum Leadership: Advancing Innovation, Transforming Health Care (3rd ed.). Jones & Bartlett Learning, LLC.

Roussel, L. (2006). Management and Leadership for Nurse Administrators (4^th ed.). Jones & Bartlett Publishers, Inc.

Stordeur S. & D’Hoore W. (2007). Organizational configuration of hospitals succeeding in attracting and retaining nurses. Journal of Advanced Nursing, 57(1), 45-58.