Focus on process rather than outcomes will improve patient care
New quality measures designed to empower patients
Although the 20 new measures endorsed by the National Quality Forum (NQF) will improve both the quality and the patient experience in home health care, the most noticeable difference from previous measures is the focus on behavior, rather than strictly outcomes.
The previous set of measures focused on outcomes, but this focus hasn't helped save money in home health expenditures at the rate that the Centers for Medicare & Medicaid Services had hoped, says Charlotte Weaver, RN, PhD, senior vice president and chief clinical officer for Gentiva Health Services in Atlanta. "We saw a major shift in focus with OASIS-C [Outcome and Assessment Information Set] in which nurses are directed to get more involved with patient teaching and empowering patients to be more involved in managing their own care," she says. The new set of measures includes some process-driven measures, in addition to outcome measures. (See measures.)
Communicating the value of process measures to the general public is more difficult than simply communicating outcomes, but they are an important part of improving the quality of care, points out Carol Spence, RN, PhD, director of research at the National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, and co-chair of NQF's steering Committee on home health care.
"We were also careful to be sure that providers are held accountable for things that they can influence and not held accountable for things they cannot control," says Spence. For example, when looking at wound care and reducing the number of emergency visits related to wounds, home health nurses can make sure that diabetic patients receive proper training on foot care and that nurses check regularly for lesions. Home health nurses also can tell patients to call the home health nurse about changes in wounds and control the type of care given when the patient calls the agency. "Nurses cannot influence the situation when the patient calls the primary care physicians and is told to go to the emergency room," she adds.
"We tried to keep all of the measures fair and focused," says Spence. "In fact, most of the measures fall within the scope of what most home health agencies are already doing," she adds. Agencies may have to find or develop tools for some of the measures, including screening patients for depression or evaluating pain levels in patients, she says.
Although home health agencies are already performing the tasks included in the quality measures, there are challenges, says Weaver. "Medication reconciliation and monitoring is the biggest challenge with the number of elderly patients in our home health population," she explains. "We don't have continuity of care or good community between different physicians, hospitals, and other referral sources, so patients are receiving multiple medications without anyone checking to see how these medications might interact," she says. Home health nurses can take steps to reduce the risk to patients by evaluating all medications to identify potential interactions, potential overdoses due to multiple prescriptions for the same medication, and potential adverse reactions. "Many of our patients are taking 7 to 9 medications a day without knowing what they are taking or why," she adds.
Education emphasized
Two of the patient/caregiver education measures look at the percentage of patients and caregivers who received thorough instruction on how to take medications correctly and how to identify potential adverse reactions, says Weaver.
Being able to thoroughly educate patients means that home health nurses need tools to help them identify medication risks, says Spence. "The ideal situation is a drug database that the nurse can access remotely, while still in the patient's home," she says. Nurses should check for potential allergic reactions, therapy overlaps, incorrect dosage, potential adverse interactions, and duplicate medications, she says. Different agencies are at different stages of electronic capabilities, so not all home health nurses have this type of database at their fingertips, she admits.
"There are subscription services that enable nurses to put in clinical information and have the medications checked against a pharmaceutical database, and consulting pharmacists can also help in complex cases," says Spence.
At Gentiva, the nurses do have a clinical information system and work processes that help them maneuver the medication maze, says Spence. "We also have clinical supervisors who help field clinicians, and we work closely with primary care physicians," she adds. Educational sessions on the importance of medication management and monitoring are held for all staff members, and proper documentation of the education is emphasized, she adds.
The one thing that Spence would like to see to improve monitoring of patients' medications is a standing order for blood levels. "Now, nurses have to call physicians for an order if they believe the patient needs to be monitored at this level," she says. "This requires a lot of time for nurses and physicians to call each other back and forth to ask for, give, and receive the order," she explains.
Change in processes to improve care, such as demonstrating the need for a standing order, is the ultimate goal of any performance improvement initiative, says Spence. "Looking at quality measures as industry standards benefits everyone," she says. Patients, home health agencies, and payers can expect improved care, more efficient processes, and lower costs, she explains. "Standardized measures facilitate studies that compare apples to apples, because we are all collecting data in the same manner."
Sources
For more information about quality measures, contact:
Carol Spence, RN, PhD, Director of Research, National Hospice and Palliative Care Organization, 1731 King Street, Suite 100, Alexandria, VA 22314. Telephone: (703) 837-3137. E-mail: [email protected].
Charlotte Weaver, RN, PhD, Senior Vice President and Chief Clinical Officer for Gentiva Health Services, 3350 Riverwood Parkway, Suite 1400, Atlanta, GA, 30339. Telephone: (770) 951-6450. E-mail: [email protected].
q Although the 20 new measures endorsed by the National Quality Forum (NQF) will improve both the quality and the patient experience in home health care, the most noticeable difference from previous measures is the focus on behavior, rather than strictly outcomes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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