Home Care Case Management
Set up pilot program to test your care plans
Agency tackles high rehospitalization rates
So you've written your care plans and now you want to know how well they work.
Whether your goal is to reduce length of stay or clamp down on rehospitalization rates, starting a pilot program may be your best bet for testing your plans, says an Illinois quality manager.
Quality of Life Services in Carbondale, IL, has focused more intently on all quality issues, including reducing rehospitalization rates, since the agency became a part of the second phase of the Prospective Payment Demonstration project by the Health Care Financing Administration (HCFA) in Baltimore.
"Our utilization rehospitalization measure was significantly different and high compared with the other agencies in the demonstration project," says Debbie Newbolds, RN, clinical director of field operations for Quality of Life Services."So we focused on acute care hospitalization."
They collected information on each home care admission and each discharge to the hospital, with or without discharge from the agency. When patients came back out of the hospital, if they had not been discharged from the agency, nurses continued to collect data.
Then the agency, which has 80,000 visits a year, created care plans for use with patients who have had an exacerbation of some of the more prevalent chronic diseases, such as chronic obstructive pulmonary disease (COPD), diabetes, and congestive heart failure (CHF). These care plans also address another quality issue that has become important to the agency since it joined the demonstration project: reducing home care length of stay.
After creating care plans, the agency began a pilot program to see if the new care plans would have the desired effect of reducing rehospitalization rates.
So far, the outcomes on rehospitalization rates of patients are not in. However, the first pilot test of commercial and Medicaid patients has had some positive outcomes.
"We were able to reduce the amount of skilled nursing visits to the clients' homes, and yet still get the outcome of independent living and full understanding of their disease process," Newbolds says.
The first pilot is being followed up by a second one that involves Medicare patients, and this pilot program is expected to show whether rehospitalization rates improve.
Here's how Quality of Life Services set up the pilot program:
1. Select a population.
The agency wanted to focus on patients who had diagnoses that appeared more often and were more intensive in home care, so the diabetes, CHF, and COPD patients were chosen, Newbolds says.
During the first pilot, the staff focused on teaching clients everything about their disease process in fewer visits. The second pilot has focused on rehospitalization rates of Medicare patients.
The first phase didn't have a specific time frame, but the agency hoped to admit 30 patients into the pilot study. However, after eight months there were only four or five patients that could be used in the pilot program, so the first pilot study was dropped and the new one was begun.
For the second pilot, the agency randomly selected a particular branch office to pilot the three diagnoses. "We put names in a hat, and they drew them out," Newbolds says. "So it was random and we didn't influence the choice by what we know about the population in a certain area."
The pilot, which started in February, will last four months.
2. Educate staff.
Staff education included showing nurses how to conduct an assessment for patients with each of the three diagnoses.
"We showed them how to use those care plans, how to read them, how to set them up, and how to individualize them," Newbolds says.
"The staff didn't have to collect any additional information because it already was part of our regular assessment process, but it was maybe a little different format for them," she explains.
The agency previously had a narrative-style care plan for which nurses had to come up with their own nursing diagnoses. The new care plans gave them more direction based on a client's primary diagnosis.
For example, the new nursing care plan for COPD has five pages. The first three pages have categories for the nursing diagnosis and short-term and long-term goals.
The nursing diagnosis lists factors such as anxiety, respiratory distress, and threat of death. And below it are lists of client and family/caretaker interventions. One such intervention is:
· Perform actions to decrease feeling of suffocation:
- open curtains, doors;
- approach client from side rather than face on;
- limit visitors in room at one time.
The goals section includes categories for the approach, the discipline assigned, the date resolved, and the initial outcome.
An example of an approach is:
· Teach and instruct more effective breathing methods (first visit and ongoing).
The fourth page has categories for client and family/caretaker intervention and nursing interventions. And the last page is the interdisciplinary client case conference record, with space for signatures by participating individuals. It also leaves room for the nurse to write the previous goals and whether they were met, and to write a narrative.
3. Begin pilot process.
"We had all of the staff that completed initial assessments or evaluations begin the process," Newbolds says.
The assessing nurse would start the care plan, then the primary nurse would carry out the care plan.
Each office involved in the pilot program was given a copy of the care plan. Also, nurses were given handouts and written materials to use as a backup to what they taught that day.
The care plan gives detailed descriptions of what client and family interventions must be taught and how nurses should teach them. So as nurses begin the process, they will find most of their questions answered on the care plan forms.
Client and family interventions, for instance, include:
· Assess respiration for rate two times daily.
· Administer oxygen correctly, as ordered by physician.
Then the nursing interventions/instructions, for example, read:
· Teach and instruct client to assess respiratory status - rate, depth, ease, presence of dyspnea, use of accessory muscles, energy and fatigue level, breath sound or auscultation for abnormal breath sounds (first visit and ongoing).
· Instruct medication regimen including bronchodilators, nebulizers, and oxygen (first visit and ongoing).
4. Collect and store data.
The agency is tracking patients from the time they are admitted to the home care agency until they are discharged into self care, nursing home placement, or the hospital.
Then the agency will continue to collect data on their disposition after discharge for about one month, Newbolds says. Nurses will call the patient's home once every week or two to find out how the patient is doing.
Newbolds and another clinical director will gather the information, placing it in a computer program.
Their chief indicator will be whether the patient is admitted to a hospital, although other placements will be noted as well, she says. The goals are to reduce the rate of rehospitalization and to cut length of stay in home care.
"We have done some baseline data collection, but I don't have those numbers yet," Newbolds says.
Quality of Life Services will make sure its data collection is consistent by randomly selecting patient cases to review.
"Also, we'll do some client satisfaction surveys, and one of the questions in our survey is asking them how much they're involved in their care," Newbolds says. "We expect we will pull some information out of those surveys."
After the four-month pilot project is complete, the agency will extend its program to all branches and possibly begin to pilot some additional care plans.
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