HIV home care operation cuts monthly stays
Quality indicators, communication are keys
The shift to ambulatory clinics and home care operations has undoubtedly enabled hospitals to reduce patient length of stay, and in many cases, dollars spent treating patients. But consumers are increasingly leery that these shifts represent a decrease in the quality of care given, while recent headlines about fraud in the medicare system, especially ambulatory and home care, seem to support those suspicions. If providers are to reassure the public and win good managed care contracts, they have to be able to point to quality outcomes and processes.
That’s exactly the approach one Rochester, NY-based ambulatory clinic and home care operation has taken, using quality indicators and other continuous quality improvement strategies to ensure good outcomes.
The facility is Community Health Network (CHN), a state-licensed, not-for-profit interventional treatment center for AIDS and HIV patients. More than 680 patients, ranging from the affluent to the homeless, visit the center for infusion therapy, infection monitoring, counseling, and follow-up planning. About 95% of those individuals then enter the clinic’s home care program.
What CHN has learned working with AIDS and HIV-positive patients applies to most outpatient settings. In fact, some health care professionals argue that if these programs can succeed with this often very ill population, they should work equally well for other chronically ill populations.
"Because of the nature of our patient population, we’re really trying to focus more on ambulatory care and patient education instead of having them always wind up in the hospital and emergency room," says Bill Valenti, MD, a physician with CHN. "But that doesn’t mean their care has to suffer either."
Measure carefully for best feedback
CHN measures those outcomes that give it the best feedback on the program’s efforts. That has meant that if often exceeds the outcomes measurements required by Medicare, while simultaneously investing a proportionately greater share of resources in patient and staff education.
"We look at emergency room utilization in home care patients and the number of readmissions to the hospital within 30 days of discharge, for example," explains Valenti. "We also monitor blood stream infections in patients with long-term catheters and the number of admits resulting from the infection. This is a great indicator of how our discharge planning and home care program are working. If a patient ends up back in the hospital, we try to find out what went wrong so we can avoid similar [admissions] in the future." (See complete list of CHN’s quality indicators, p. 156.)
Communication + coordination = quality care
But the clinic does not achieve quality improvement entirely on its own. In-house coordinators from three outside agencies two home health and one infusion therapy provider work directly with the clinic to coordinate home care regimens and ensure nursing staff competency for dealing with HIV and AIDS therapy. These outside case managers meet weekly also with the clinic’s physicians, nurses, and agency staff to ease a patient’s transition from the hospital to a home care environment.
Depending on the patient situation, family members also participate in case management meetings. The care coordinators educate them in a number of areas, including the presence of infection, infusion therapy, nutrition, and medication regimens.
"We like to include everyone who is a caregiver because we want everyone on the same page. Working with information is a great thing, especially when you’re talking about discharge instructions which can get very confusing if you’re not properly educated," Valenti adds.
In addition to its connection with the outside agencies, the clinic also has a close working relationship with Highland Hospital, a facility about two blocks away that treats the clinic’s sicker patients. When a patient is admitted into the hospital, the discharge planning process begins immediately. The clinic follows the individual throughout his or her stay, monitors progress, and collaborates with hospital staff for discharge plans.
"The real key here is communication . . . an element frequently missing in home care settings. Our physicians are never out of the loop. We work right along with the social worker and discharge planner at Highland. Communication and coordination can make the difference between good care and excellent care."
The quality improvement efforts spurred many positive changes, primarily in regards to hospital visits, which Valenti says are "relatively few and far between."
In 1989, prior to the implementation of any notable quality improvement initiatives, patient hospital days totaled 600 per month. The clinic introduced in-house coordinators in 1994, and by 1995, hospital days fell to about 360 per month. Those days currently total only 45 per month. (See chart, p. 155.)
A push for improved performance
Quality consultant Pat Peters, RN, BSN, MBA agrees that it is a good idea to go beyond Medicare requirements. In the not too distant future, home health agencies will be required to do so in any case, she says.
"It’s not enough to just meet Medicare’s quality assurance standards," warns Peters, vice president for Deerfield, IL-based Risk Management Resources Inc. "The Joint Commission [for Accreditation of Healthcare Organizations] and the National League of Nursing, both of which have deemed status with Medicare, are really moving more toward performance improvement and team initiatives. Sooner or later, home care [agencies] are really going to be held more accountable for their outcomes. They have to get on the ball."
[Contact information: Bill Valenti, MD, Community Health Network in Rochester, NY. Telephone: (716) 544-1566. Or contact Pat Peters, RN, BAN, MBA, vice president of clinical services, Risk Management Resources Inc. in Deerfield, IL. Telephone: (800) 222-4774.]
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