DVT treatment opens new niche of patients for home health agencies
Wisconsin home health agency develops DVT pathway
Deep-vein thrombosis (DVT) patients typically have been treated in a hospital for five to six days with an intravenous infusion of heparin and concurrent oral anticoagulant therapy. Recent medical advances now make it possible for some of these patients to be treated safely in their homes by home health nurses. This possibility opens up a potential new market niche for home health services, particularly among patients covered by commercial insurers.
A Milwaukee home health agency has developed a clinical pathway for DVT treatment in the home as a way to ensure quality care. The pathway also makes it easier for the agency to market the program to insurers and referral sources.
"A DVT program probably isn’t going to be a huge moneymaker; however, in home care we’re going to see these referrals and we should know how to have a good quality approach to providing DVT care," says Lisa A. Gorski, RN, MS, CS, CRNI, a clinical nurse specialist with Covenant Home Health and Hospice in Milwaukee. Covenant serves six counties and the Greater Milwaukee area in southeastern Wisconsin. Gorski spoke about DVT home care at the National Association for Home Care’s 19th Annual Meeting & HOMECARExpo, held in New Orleans in September.
Promising outcomes noted
The agency’s outcomes have been promising. Of 62 DVT patients treated in the home, 61 were discharged to self-care and had follow-ups with their physicians. Only one patient had to be rehospitalized for excessive bleeding. The patient later went home without complications.
"About 2½ years ago, we put together a pathway on how to treat these patients at home in a straightforward, simple program that provides continuity of treatment," Gorski says. "There’s a significant amount of nursing education that goes along with this." Here’s how Covenant developed its DVT program:
1. Assess need. Low-molecular-weight heparin has been used since 1993 for the prevention of DVT in high-risk patients after surgery. More recently, the Washington, DC-based U.S. Food and Drug Administration (FDA) approved the use of a specific low-molecular-weight heparin, Lovenox, for treating DVT.
Clinical trials have assessed the safety and efficacy of using Lovenox in an outpatient setting for treating DVT, and the research has shown that its safety is comparable to heparin use in the hospital for most patients.
About four in five patients are good candidates clinically for treatment in the home setting, Gorski says. Since Lovenox is considerably more expensive than heparin, and Medicare does not cover medications, most Medicare patients will opt to be treated in a hospital setting where the care will cost them less out-of-pocket. However, this still leaves a younger population of DVT patients whose private insurance will cover the drug costs because of the less expensive medical care in the home setting vs. the hospital setting.
The cost savings and the desire of some patients to be treated at home have made Lovenox treatment for DVT a viable alternative to the traditional treatment in a hospital setting.
2. Educate staff. Home health nurses may be familiar with low-molecular-weight heparin, but they likely have been using it in different doses than what is required for treating DVT. So education is extremely important.
Covenant Home Health trains all staff nurses to treat DVT patients because it would be difficult to provide consistent coverage for all potential patients if this diagnosis was handled strictly by a team of specially trained nurses. "A number of patients will go see their doctor on Friday; their doctor sees the problem, and on Friday night they are started on DVT treatment," Gorski explains.
The nurse education included teaching them how to use the DVT treatment pathway. Gorski provided some education at staff meetings and also developed a self-study packet and a competency test.
DVT training now is included in the home care agency’s orientation for nurses, and nurses are observed performing the skills involved, Gorski says. "It’s important that nurses understand what the treatment doses are, so we teach them about the disease and how to minimize the risk at home."
Gorski gives nurses an overview of DVT that includes the following:
— DVT and pulmonary embolism are venous thromboembolism diseases.
— Lower extremity thrombosis may include superficial leg veins, deep veins of the calf, and proximal veins.
— Thrombosis in other veins is less common, although the frequency of upper extremity venous thrombosis is increasing due to use of long-term venous access devices.
— DVT development may be caused by venous stasis, hypercoagulability, and vein wall trauma.
— Patient risk factors include being over age 40, having surgery, previous DVT diagnosis, pregnancy, cardiac disease, malignancy, and obesity.
— DVT can become a chronic disease, especially in patients with ongoing risk factors.
— Valve damage can lead to venous hypertension that causes recurrent leg swelling and pain.
— Pulmonary embolism is the occlusion of a portion of the pulmonary blood vessels by an embolus.
— Minor pulmonary embolism is subacute and has insidious onset, whereas major pulmonary embolism may be identified with symptoms of syncope and low blood pressure.
— Nurses need to learn how to monitor the patient’s therapy and their bleeding. They need to set treatment goals focusing on preventing local extension of the clot and preventing the thrombus from embolization.
— Patients need concurrent oral anticoagulation therapy to prevent the formation of fibrin, the component that holds a clot together.
Develop useful pathways
3. Establish clinical pathway. Covenant Home Health developed an extensive treatment pathway for treating DVT with low-molecular-weight heparin. It covers three days with categories of outcomes, focused assessment, treatments, activity, medications, and tests.
"The pathway’s key pieces are to look at outcomes, which includes the goal of having patients do injections independently," Gorski says.
The pathway’s assessment includes having nurses check patients for pain and discomfort. They also check the patient’s lower extremity for circulation/sensation problems, inflammation, swelling, and skin integrity.
Nurses look for signs and symptoms of bleeding or pulmonary embolism. And they assess the patient’s readiness and ability to learn how to do their injections and whether the patient has caregiver support.
The low-molecular-weight heparin injection is given in a 1 mg/kg dose of Lovenox every 12 hours. (See American Academy of Home Care Physicians’ treatment protocol insert.)
4. Educate patients. It’s crucial that nurses teach patients how to monitor their own care after the home care visits end.
"Patients who learn how to do these injections very quickly are discharged quickly, too," Gorski says. "A couple of days after a patient is discharged from home care, the nurse needs to call them and make sure they are taking their injections on time."
Nurses remind patients of scheduled lab work and ask if they have had any problems with bleeding. Patients also must understand the signs and symptoms of pulmonary embolism.
When patients are willing, nurses will teach them how to inject the medication following safety precautions, such as never administering Lovenox intramuscularly.
Patients learn prevention strategies such as wearing elastic stockings, walking more frequently, and sitting with uncrossed legs. Also, nurses teach them the various risk factors including recent surgery and obesity.
5. Monitor outcomes. Covenant Home Health has kept data on 62 patients ages 15 to 92. Thirty-eight or 61% of the patients were admitted after a hospitalization in which they had a mean length of stay of three days.
Another 24 patients were directly admitted to home care without having any acute-care days.
Of all of the cases, the number of home care visits ranged from one to 30 visits with a mean of 7.1 visits. Of the 38 patients who became independent in self-injection technique, the number of home care visits ranged from one to 12, and the mean number of visits was 3.2.
Most of the 24 patients who did not learn how to self-inject failed to do so because they were unwilling to give themselves the injections. Three had a fear of needles; three had functional limitations and no caregiver, and four had their therapy discontinued early. Of all 62 patients, only one patient had to be rehospitalized due to bleeding.
6. Market program to payers and referral sources. "We let payers know about our program, and we did one formal presentation for an HMO," Gorski says.
The agency also worked with physicians, showing them how patients who met certain criteria could be treated with DVT in home care as safely as they could be treated in the hospital.
Not surprisingly, a majority of the patients (61%) were covered by managed care companies. Only 8% of the referrals were Medicare patients. Other reimbursement sources were Medicare plus a secondary payer and Medicare HMOs.
The pathway, staff training, and informal marketing have been successful. The agency rarely was referred a DVT patient previously, and now it’s a much more common referral, Gorski says.
"This program helps us pick up a new group of patients who were historically managed in the hospital," Gorski says. "The program is reaching out and providing quality and cost-effective care to a particular population with a well-validated treatment."
• Lisa A. Gorski, RN, MS, CS, CRNI, Clinical Nurse Specialist, Covenant Home Health and Hospice, 9688 W. Appleton Ave., Milwaukee, WI 53225. Telephone: (414) 535-6922.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content