Agency works to improve outcomes with new teams
Goal is also to increase home health referrals
A West Virginia home care agency has begun a project that is expected to improve patient outcomes in cardiac care and other areas, as well as increase referrals to home health services.
Plus, since the agency is hospital-based, its new program may help the hospital prevent readmissions and emergency room visits by providing patients with home-based support. Although the results aren’t in yet, managers are optimistic that the new program and its performance improvement teams will meet all of these objectives, says Terrye O’Sullivan, RN, assistant director of the Visiting Nurse Association of Medical Park in Wheeling, WV. The agency is a department of Wheeling Hospital.
"We formed a huge hospital discharge team, looking at the discharge process from beginning to end, including continuous care and home care," O’Sullivan says.
The hospital’s focus on discharge strategies has an added benefit of encouraging more referrals to home health. Since the Wheeling area’s managed care penetration is growing, home health services are looking more attractive to physicians who now must be cost conscious, O’Sullivan adds.
For instance, 45% of the overall home care population is covered by managed care companies, and soon that number will grow as Medicare patients switch to managed care products, she says.
This has shifted how and when patients are admitted to the hospital, as well as how long they are permitted to stay for observation. "Say a patient comes into the hospital emergency room last night, and the ER doctor thought they needed to be admitted into the hospital," O’Sullivan says. "The managed care case manager nurse can come in and say, This patient doesn’t need to be admitted, and I’m putting this person on a 24-hour observation.’"
Or the managed care company may limit a patient’s stay to three days, when previously the patient would be there twice as long. When this happens, it is in the physicians’ best interest to write a home care referral prior to the patient’s discharge. This way if the patient has a relapse of symptoms, a nurse will be able to provide assistance and contact the physician, perhaps preventing an emergency room visit.
The agency recently began working on convincing doctors to write referrals to home health while the patient still is in the hospital, and this way, it gives the patient enough time to choose a home health provider. Plus, the home care agency can begin treatment immediately after discharge, O’Sullivan says.
Agency lobbies for referrals with hospital booth
The VNA of Medical Park’s lobbying efforts include setting up a table display in the hospital with patient educational material and other information about home health care. The table was set where both patients and hospital staff could see it.
O’Sullivan also gave an inservice on home health for every department in the hospital. She brought attendees pencils and pens with the agency’s name imprinted on them.
"Hospital employees didn’t know everything we did in home care," O’Sullivan says. "They thought we only treated patients with wounds and intravenous lines, and they didn’t realize we could take care of patients just for teaching."
So far, it appears physicians are responding and increasing home health referrals, she adds. The agency is now receiving referrals from the emergency room (ER) department. Some of these referrals involve patients with Foley catheters who are at risk of forgetting their instructions about how to take care of the catheter — ending up back in the ER with an infection or another problem. Now, a home health nurse visits the patient after the patient leaves the ER simply to teach the patient how to take care of the catheter.
The agency also receives referrals from the recovery room and from other hospital departments. While the referrals were a little slow at the start, O’Sullivan says she’s encouraged that doctors are beginning to understand the importance of home care.
"It’s new to doctors; they don’t like insurance companies telling them what to do," O’Sullivan says. "But they also recognize the need to identify these [potential home care] patients earlier because of managed care pressures."
The performance improvement teams — called design teams — first began to focus on treatment of congestive heart failure patients. The 250-bed hospital had a high readmission rate with these patients, and hospital officials didn’t want the rate exacerbated by the trend of payers pushing for lower hospital lengths of stay.
Also, when hospital officials looked at what type of education was given to CHF patients, they found that it wasn’t consistent from nurse to nurse, says Marsha Buterbaugh, RN, clinical supervisor at the VNA of Medical Park, and a member of the design team.
Patient education lacked consistency
"Some patients were given a higher quality of education about how to take care of themselves, prior to discharge, and some were not," Buterbaugh says. "I was interested in the topic, because my background is in cardiac care and I wanted a continuation of patient education in the home care arena."
Buterbaugh and other members of the design team worked on a plan that would make patient education consistent and seamless as the patient went from the hospital into home care.
The hospital recently has begun to measure cardiac outcomes, looking at various indicators, including:
— Was the patient started on an ACE inhibitor at discharge?
— Was the patient instructed on a low-sodium diet?
— Is there documentation of patient education?
— Is there an order for home health follow-up visits?
"We want to keep patients from being readmitted; we feel that home health is a key component to reduce admissions," says Tish Thoburn, RN, BSN, case coordinator for care management at Wheeling Hospital.
The hospital is tracking the outcomes by calling patients. "We make follow-up phone calls, asking patients whether they understand the importance of a low-sodium diet and going over their medications with them," Thoburn adds. "And we’re looking at all readmissions within 15 days."
Whether an agency is hospital-based or freestanding, it probably will help improve patient care and increase the agency’s referrals if the agency aligns itself with a local hospital to provide consistent education and follow-up care to patients. Here’s how the VNA of Medical Park and Wheeling Hospital did exactly that:
• Design team members researched CHF treatment.
The multidisciplinary team, consisting of a cardiologist, care management staff, respiratory therapy, pharmacy, and hospital and home health nursing staff, reviewed current medical literature about cardiac treatment. For example, they researched the use of pulse oximetry, which is a way of measuring oxygen in blood for CHF and other cardiac patients.
• They created standards for CHF care.
The design team drew up a plan for routine admission orders for CHF patients, and these orders would have to be signed by physicians, Buterbaugh says.
Then the team created a patient-care map that begins with admission and continues through discharge. The map lists exactly what patients are taught during each day of their hospital stay. So if a home care nurse begins to see a CHF patient after the patient leaves the hospital, the nurse will know where to begin with education and which areas to focus on, Buterbaugh explains.
"We review the education the patient received in the hospital and go on from there," she explains. "That way, we’re not duplicating and know what is expected to have been done in the hospital so we can evaluate what the patient has retained."
• The hospital and home health share educational materials.
The design team decided that patient education needs to be consistent. The hospital nurses couldn’t start teaching some things, and then home health nurses would teach something else. Now, the hospital and home health share educational materials.
This consistency also makes it easier for the home health staff to assess which information the patient has learned and which needs to be reinforced. For example, Buterbaugh says, it’s quite common for CHF patients to be given new medications while in the hospital. The hospital nurses will teach them about their medication change, but when the patients return home, they become confused and often revert back to using their old medications.
As a result, the home health nurses will have information about exactly which medications the patient should be taking, plus documentation of how the patient was taught about these prescriptions. And when home health nurses report to physicians that the patient is taking they wrong medication, they also can give details about how the patient didn’t retain this part of the hospital education. Therefore, it needs to be reinforced for X number of home care visits.
"That problem is one reason the hospital started the program for cardiac patients because doctors weren’t aware of this issue," Buterbaugh says. "Now, home care nurses go out to visit a patient the day after hospital discharge and first check the patient’s medications."
Sources
• Marsha Buterbaugh, RN, Clinical Supervisor, VNA of Medical Park, 58 16th St., Wheeling, WV 26003. Telephone: (304) 243-2929.
• Terrye O’Sullivan, RN, Assistant Director, VNA of Medical Park, 58 16th St., Wheeling, WV 26003. Telephone: (304) 243-2929.
• Tish Thoburn, RN, BSN, Case Coordinator for Care Management, Wheeling Hospital, One Medical Park, Wheeling, WV 26003. Telephone: (304) 243-3204.
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