Lower LOS of stroke patients through QI goals
Agency improves outcomes while volume increases
Milford (DE) Memorial Hospital Home Health got on the QI bandwagon to lower its length of stay for stroke patients because managed care has been pressuring the hospital to lower its LOS.
The home health agency, which has about 2,500 visits a month, took a look at its cardiovascular accident (CVA) cases and discovered two facts:
• The CVA diagnosis accounted for 25% of home care patients.
• The length of stay for CVA cases last year was three to six months.
"This was OK for right now, but with managed care dictating length of stays, our goal was to cut it down to three weeks of home care," says Barbara Peterson, RN, MSN, EdD, manager of home health for the full-service agency.
So the agency launched a QI program, picking up where the hospital’s QI program ended. Here are the program’s results after one year:
• The agency has reduced its average LOS for stroke patients to 22 days, with six weeks being the longest that patients stay in home care after a CVA.
• Patient satisfaction has remained high. In early 1997, 93% of the patients said the home care agency’s services were excellent; now, 95% give it an excellent rating.
• Fewer than 1% of all home care patients have returned to the hospital within 30 days.
Even better, the program has not reduced the agency’s overall visits because of another managed care trend that has routed more patients to Milford Home Health.
Shorter LOS facilitates increased volume
"Now we have physician practices saying, I have this patient I’d ordinarily send to the hospital, but do you think you could give them therapy and keep them out?’" Peterson says.
"They’re calling us first, and most of the time we can keep them out of the hospital, and they do get well," she adds.
So the agency has been able to handle the increased volume of new stroke patients because staff are no longer tied up on long-term CVA cases, Peterson explains.
Also, the agency has increased services for physical therapy, and more patients are being treated by LPN personal caregivers instead of certified nursing assistants, she adds.
"LPNs’ patient satisfaction is wonderful, and their assessment skills are better," Peterson says.
Here’s how the agency set up its QI program:
1. A QI committee set goals.
A home health QI committee decided the agency’s current LOS for stroke patients was too high at three to six months. The hospital LOS for stroke patients had been cut down to three days, and it appeared that the same managed care pressures soon would force the home care stay to be cut drastically as well.
First, the committee decided to shoot for a six-week LOS, but the agency soon determined it should be shorter than that.
The way the process worked was that the patient would be transferred to transitional care or rehabilitation after the brief hospital stay. Then the patient would be referred to home health care.
Occasionally, patients would be referred to home health immediately after the hospital stay, and the LOS for these patients might be a little higher, Peterson says.
"If they went to rehabilitation or transitional care, it worked a little easier because that gave them three weeks of post-CVA care before they were admitted to home health," she explains.
2. The committee researched CVA clinical pathways.
The hospital started using its CVA pathways in January 1997, and the home care pathways were in place six months later.
The QI committee members first built upon what the hospital had created. Their challenge was to take the hospital pathways a step further, says Cathy Schenker, RN, BSN, manager of home health for Milford Memorial Hospital Home Health. They did this by gathering information and guidelines from books written about CVA pathways and other research material.
"We had some nurses who had worked for other agencies outside of our area, and they got some information from those agencies for us," Peterson says.
Then committee members interviewed field nurses and therapists to find out exactly what they did and what they felt they could do for CVA patients during each visit.
Committee members asked nurses about specific skills and patient teaching goals, and how long these would take.
"We asked, Can this be done during one visit?’ and they would say, Yes, but not in 45 minutes,’" Peterson recalls.
The committee asked therapists and nurses some patient-oriented questions about what goals a patient might set for him- or herself.
For example, Peterson says, the nurse should find out from the patient and the family how independent the patient was prior to the stroke, and also how independent the patient wanted to be after therapy.
"And then we work with them to find alternative ways to do those kinds of things they wanted to do themselves," she adds. "So there’s a lot of time spent with the family discussing these things. It’s individualized." Each patient had his or her own individual care plan based on the pathways.
3. They wrote pathways for each discipline.
The committee wrote a goal for each discipline and listed details of what could be accomplished at each visit. (See story on CVA pathways for various disciplines, p. 49.)
The pathways include standards of care for CVA home care patients with goals for each visit. The standards listed for skilled nurses, for example, include the following:
Recommended visit frequency: Unless ordered differently, visit three times a week for two to three weeks, decreasing to two times a week as condition warrants.
Visit 1:
1. Assess condition.
2. Instruct patient:
patient rights and responsibilities
patient and home safety
expectations of home care
role of patient and expectations
role of significant other
role of home care staff
plan for care (discuss/collaborate)
visit schedule
medication regimen
pertinent telephone numbers
physician
agency
Department of Health hotline
pharmacy
durable medical equipment
Visit 2:
1. Assess condition.
2. Obtain recall from instruction completed during first visit.
3. Instruct regarding preventive maintenance.
4. Instruct regarding medication.
Visit 3:
1. Assess condition.
2. Obtain recall from instruction completed during previous visit.
3. Instruct regarding disease process:
definition of CVA
signs and symptoms of CVA
4. Instruct regarding medication.
Visit 4:
1. Assess condition.
2. Obtain recall from instruction completed during previous visits.
3. Instruct regarding causes of CVA.
4. Instruct regarding medication.
Visit 5:
1. Assess condition.
2. Obtain recall from former instruction.
3. Instruct regarding recovery and rehabilitation process.
4. Instruct regarding medication.
Visit 6:
1. Assess condition.
2. Obtain recall from former instruction.
3. Instruct regarding anticoagulation therapy.
4. Instruct regarding other medications.
Visit 7:
1. Assess condition.
2. Obtain recall from former instruction.
3. Instruct regarding medications.
Visit 8:
1. Assess condition.
2. Obtain recall from former instruction.
3. Instruct regarding medications.
Visit 9:
1. Assess condition.
2. Obtain recall from instruction completed during previous visits.
3. If patient is stable for 21 days, and meets goals, discontinue nursing care.
4. Put some flexibility in pathways.
Flexibility has been written into the pathway, with the nurse given discretion to extend visits if needed.
"The nurse knows the patient and the patient’s family, and she is the only one who is able to determine how fast anything is done," Peterson says.
The skilled nurse pathway, for instance, has a final category that reads:
Subsequent visits (if needed):
1. Assess condition.
2. Provide patient-specific teaching and elicit recall.
"If a nurse is able to accomplish all of the goals, fine," Peterson says. "But if she was only able to accomplish one goal during a visit, then she would chart it and say only one goal was met, and we’ll continue to work on goals at the next visit."
The agency has had occasions when managed care companies have declined to approve reimbursement for additional visits. But if the nurse case manager believes more visits are necessary, the agency will authorize the extra visits and consider it charitable work, Peterson says.
However, the Milford area only has about 20% managed care penetration. And while Medicaid clients are being handled by managed care companies, Medicare clients are not, Peterson says.
This has allowed the agency to be flexible in adhering to the pathways and still be reimbursed much of the time for visits beyond the three weeks.
"Now we have the luxury where if we see the Medicare patient has not met the goals in three weeks, then we can go to six weeks, and we still will be paid by Medicare," Peterson says.
Staff are reminded that the pathways are merely goals, and that nothing should be done to jeopardize a patient’s health and safety. "We don’t want a patient to feel that we’re rushing them to complete the visit," Peterson adds. "But we want them to get better as quickly as possible."
5. Educate staff.
Milford’s educational program was extensive, starting with inservices at the hospital. These inservices were held about eight times over a two-month period, and it was a requirement for both intermediate care staff and home health nurses, says Heidi LeGates, RN, MSN, clinical outcomes specialist for Bay Health Medical Center Milford Division. The hospital is a community hospital with 180 beds.
"They were required to do this, but we also had interest from med-surg nurses," LeGates says.
The main part of the inservices involved a review of the neurological system, and these were taught by the department heads of various specialty areas in the hospital. The instructors included the rehabilitation nurse who specialized in neurology, a stoma therapist, a physical therapist, and an occupational therapist. The inservices also covered the hospital’s clinical pathways for CVA patients.
After the hospital inservices, the home care nurses were given an additional four hours of inservices in the home care agency, Peterson says.
The home care inservices covered the home care pathways and discussed some specific issues related to caring for stroke patients in their homes.
Also, staff were given reading material about CVA that they could study on their own time, Peterson says.
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