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 (4th 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.
