How to integrate acute and home care
Paths can make a difference
The key to seamless and successful transitions of patients from acute care to home health lies in critical pathways that outline treatments and interventions -- and which care site is responsible.
Patients may experience better outcomes and quicker recoveries when such documentation tools integrate easily, say case managers who have worked with their home care agencies to improve patient flow between the two care settings.
Advocate HealthCare, formerly Lutheran General Hospital, in conjunction with Health Connections Home Care, both in Park Ridge, IL, have used continuing care pathways for two years. This collaborative effort has produced continuing care pathways for eight of the hospital's most common home health referrals:
* cerebrovascular accident (CVA);
* dementia;
* depression;
* hip fracture;
* hip replacement;
* knee replacement;
* generic path for frail, elderly adults;
* congestive heart failure.
The pathways have enabled the hospital case managers, or care coordinators, to provide more appropriate referrals and have reduced home health visits overall by an average of five per patient, explains Uta Tichawa, RN, MSN, project director for Advocate's Pathway Project. Tichawa oversees each pathway patient across the continuum.
Interventions are site-specific
Because all interventions are site-specific, a new pathway is initiated when the patient is discharged to home care. Inpatient paths, however, include a transition phase that ensures all necessary documentation is in place from the acute care nursing staff. Prior to the home care visits, Tichawa sends the following documentation to the home care coordinators:
* assessment form, which includes medical history and medication documentation as well as notes from the hospital care coordinator;
* primary care pathway;
* inpatient pathway.
Additional tools help Tichawa keep a handle on the patient's progress through the system, as well as how the communication is flowing between the hospital and home care providers. Variances are tracked by both hospital and home care coordinators on an Interdisciplinary Care Plan/Variance Record, on which the nurses document the cause of the variance, the intervention taken, and the outcome of that intervention. (To see how variances are tracked, see the Interdisciplinary Care Plan/Variance Record, below.)
Staff across the continuum use uniform variance codes to standardize and expedite documentation. The variances are categorized into four main groups: clinician, patient/family, hospital/site, and community. Common variances are categorized accordingly and coded. (To see how Advocate lists common variances, see the Variance Codes Chart, p. 101.)
Tichawa and another pathway project manager review the data monthly with the home care representative on the pathway project team to discuss changes and strategies to make the pathways more effective.
Hospital, agencies team up
Catholic Medical Center in Rego Park, NY, is taking a similar approach to streamlining the acute care to home care transition. Catholic Medical also teamed up with its home health agency to create cross-continuum pathways almost three years ago. Although the organization has not conducted statistical studies on the results of the program, the integrated pathways appear to expedite healing and rehabilitation based on observation, says Anita Payne, MA, RN, director of organization and staff development for Catholic Medical Center Home Health Agency, which is owned by the hospital. The integrated pathways are improving the care patients receive, she adds.
The integrated pathways, called Multidiscipli-nary Care Plans (MCPs), include the following conditions, surgeries, treatments, and procedures:
* geriatric care;
* pneumonia;
* total hip replacement;
* cerebral vascular accident;
* pediatric specialty care.
The MCPs list specific interventions and treatments and identify the multidisciplinary team members responsible for completing them.
The documentation initiated in the hospital and then forwarded to the home care coordinators is similar to what Advocate requires and includes the following:
* patient assessment form;
* patient education plan;
* discharge plan;
* variance management form.
More specifically, per the MCP, the hospital case managers collect a myriad of information that is transferred to the home care coordinators, including: date of acute admission; current/previous medical history; medication history; advance directives; substance abuse history; mobility; sensory skills assessment; nutrition/eating; nutritional services; elimination/toileting; discharge planning needs; pressure ulcer; potential score; falls risk score; tests; treatments; outcomes; IV therapy; consults; pastoral care; respiratory services; physical/ occupational therapy; social service; interventions for nourishment, hygiene, activity, safety and vital signs; nursing assessment for neurology, respiratory, cardiovascular, gastrointestinal, skin, mobility, pain control, psychosocial, and dietary.
Paths outline process
Tichawa and Payne agree that cross-continuum pathways are perhaps the best method to ensure proper, smooth acute care to home care transitions because care processes are outlined for both settings. They also suggest the following tips to further enhance the use of those pathways:
* Develop an open line of communication with referral sources.
"The hospital case managers need to have an open line of communication with their referral sources, whether it is home care or a skilled nursing facility. They need to be able to feel free to call them and give them an update about what is occurring with their patient," says Tichawa.
This open line of communication also keeps the case manager aware of any changes in services or staff that the agency may be undergoing, which could impact their patient's care, Tichawa also points out. "Case managers should be aware that there could be either limitations to what a particular site might be able to provide or there may be more advanced services for that patient because the agency has increased its staffing, acuity, or skills."
* Visit home care sites regularly.
Tichawa encourages case managers to "broaden their horizons by going out to see the home care sites and meet the people who will be caring for their patients after they leave the hospital. This step is crucial," says Tichawa.
"I know from our experience that there are several case managers and discharge planners who are just becoming aware of what a subacute unit can provide. It also helps when you can identify a name with a face. You will often be able to provide more information meeting face-to-face than over the telephone," Tichawa adds.
* Provide up-to-the minute assessments.
A lack of current assessment information from the hospital to home care was a problem Tichawa had noted prior to implementing the cross- continuum pathways. Home care nurses need to know "how the patient is today, not when he was admitted," she says. Home care nurses often do not receive patient information until hours before their visit, therefore, "they need to know what is going on with that patient when they walk in his [or her] door." The most important information includes patient status, assessment, medication, nutrition, psychosocial support, and treatments.
Getting to know each other
"The case managers need to have that [information] at their fingertips when they are making the referral, or communicating to the next health care provider," Tichawa stresses.
* Use consistent patient education materials.
Payne recommends that hospital case managers and their corresponding home care coordinators use the same teaching materials. This step will give the patient consistent instruction, which in turn, will encourage compliance, she notes.
* Visit the patient prior to making the referral.
Despite the typical modern conveniences of telephones, fax machines, and e:mail systems, information still gets lost, says Tichawa, especially during this time of integration and mergers. "Within our organization, because we recently merged, it is bringing two systems together that were completely different."
The ideal system would include a liaison "who can go see the patient, and then make referrals to whatever side of care is needed." Yet, today's health care environment is focused on cost savings and having a liaison person just to make visits isn't feasible, she continues. Therefore, "it is up to the discharge planner or the case manager to provide that information. With their busy schedules, especially if they are doing utilization management on top of case management, it is very difficult to do it all and do it effectively." *
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