Shooting for the top 10%? Monitor results, implement best practices

(Editor's note: This is the second part of a two-part series that addresses reduction of hospitalization and strategies to improve performance in Home Health Compare measures. This month, strategies that help successful home health agencies reach the top 10% of Home Health Compare categories will be discussed. Last month, findings of the National Home Health Hospitalization Reduction Study were discussed, with tips from best performers.)

While the parameters for pay for performance are not yet set, experts agree that monitoring and improving your performance in Home Health Compare will get you ready for the changes in the payment process.

Just looking at your numbers isn't enough for an agency to succeed. You must have a process in place and you must be willing to adopt best practices to make changes, says Robert Fazzi, Ed.D, president and CEO of Fazzi Associates, a benchmarking and consulting company in Northampton, MA. "The National Home Health Hospitalization Reduction Study identifies best practices to reduce hospitalization, but how do we accelerate adoption of best practices to affect the national home health hospitalization rate of 28%?" he asks.

There are home health agencies that are addressing different Home Health Compare items and doing well, Fazzi says. There are more than 2,400 agencies in the top 10% for at least one Home Health Compare measure; but the numbers drop to only nine agencies in the top 10% for nine out of 10 measures, and there are no agencies that are in the top 10% for all measures, he says. (See chart below)

While reaching the top 10% for all measures might not be practical for all agencies based upon services they provide and populations they serve, the identification of areas in which best practices can create improvement is important, says Lazelle E. Benefield, PhD, RN, professor in gerontological nursing at the University of Oklahoma Health Sciences Center in Oklahoma City.

"The benefit of implementation of best practices is improved patient outcomes," she says. When outcomes are improved, the agency's fiscal management improves because staff members are providing the most effective care, she adds. "Also, staff satisfaction may improve because an environment in which best practices can be implemented will further the professional role of the staff."

Addressing all Home Health Compare measurements is overwhelming, so the staff members at VNA of Rhode Island in Lincoln choose two outcomes to focus upon each year, says Patricia Fleming, RN, chief clinical officer for the agency.

"We don't just focus upon Home Health Compare; we look at all outcomes measured by OBQI," she says. The outcomes chosen for performance improvement efforts are not necessarily the outcomes that represent the lowest scores; instead they represent areas in which real improvements can be made that will affect a large group of patients, she says.

She reviews agency outcome data on a regular basis, and produces reports that show trends and comparisons of her agency to national averages, enabling staff members to identify areas for improvement. Improvement areas are chosen in June, then staff members on the performance improvement team develop strategies to implement them. Staff education on the new processes and strategies for the selected areas occurs in July and August. "We are currently working on improving urinary incontinence and improving the status of surgical wounds," she says.

"We are fortunate to have a certified wound, ostomy, and continence nurse on our staff," Fleming points out. "As our in-house expert, she has given inservice classes on identification and staging of wounds," she says. By making sure that staff members understand different types of wounds, they can better choose treatments for the wound, she adds.

"We also want our nurses to better identify patients who may have continence problems," says Fleming. Staff education that offers tips on how to better assess the patient are important, she says. "Patients are not likely to tell you they are incontinent because they assume it is part of growing older and because they are embarrassed," she points out. Nurses need to be on the lookout for diapers in the trash, as well as the smell of urine on clothes or in the house, she suggests. Once a nurse confirms that the patient is incontinent, exercises and medications that can help are discussed, she adds.

Once the staff education has been conducted, outcomes for the selected performance improvement areas are shared at staff meetings and posted on bulletin boards in all agency offices, says Fleming. "Our staff drive these improvement projects, so it is important that we keep them up to date on our progress," she says. "It is also a good way to pat everyone on the back for a job well done."