Cut hospitalization rates with 24-hour availability, visits at start of care

Top performers share best practices in national study

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

As performance improvement programs and the ability to track data and trends from OBQI reports have become more sophisticated, home health agencies report improvements in all categories, except hospital readmission rates.

That lag was the primary reason hospital reduction was chosen as the topic for a national home health study conducted by the Briggs Corp. and co-sponsored by the National Association for Home Care & Hospice and Fazzi Associates Inc.

"The national average for hospitalization from the home health care setting is 28%," points out Robert Fazzi, EdD, president and CEO of Fazzi Associates, a benchmarking and consulting company in Northampton, MA. While the average has not changed significantly in a negative direction, it also has not improved over the years, he adds. "We wanted to identify the best performers, the agencies that were in the top 10% of this category, and document what strategies they were using to reduce their hospitalization rates," he explains.

After identifying and contacting slightly more than 700 agencies that are in the top 10% of agencies with the lowest hospitalization rates, more than 200 agencies were resurveyed in the final stage of the study, which focused on specific strategies used to reduce hospitalization.

"While 333 agencies responded to the first contact with descriptions of strategies they used, we went back to the final 205 because they were intentionally using these strategies in an effort to reduce hospitalization," he explains. "We did find that the most successful agencies used multiple strategies rather than only one," he adds.

The most prevalent strategies used to prevent hospitalization by study participants were:

• Falls prevention

The elderly population cared for by home health makes fall prevention a high priority for many agencies, Fazzi points out. A total of 66% of survey respondents use environmental assessments of the home, evaluation of medications that can cause dizziness, and identification of balance difficulties as key efforts to prevent injuries from falls, he adds.

• Front-loading

The most unexpected strategy to make the top of the list was front-loading, a method used by 64% of agencies in the study, says Fazzi. "These agencies identify patients at risk for hospitalization and adjust their visit schedule to see the patient more frequently in the first few weeks after admission," he explains.

The staff at Washoe Home Care in Reno, NV, attribute their agency's hospitalization rate of 17% to front-loading. "We work closely with the hospital discharge planner to identify high-risk patients and we meet with the patients before their discharge," says Martina Petersen, RN, interim director of the agency. "If home care is appropriate for the patient but we think the patient and the caregiver will need extra support, we schedule extra visits in the first two weeks to provide extra care and education," she explains.

• Management culture and support

Sixty-one percent of agencies in the study identified their organization's culture as a key factor in reducing hospitalization, Fazzi says. "All staff members are involved and no person puts a 2 p.m. crisis on hold. Everyone addresses a patient's problem as soon as possible so that the patient doesn't feel like he or she needs to go to the hospital for care," he explains.

"All of our staff members know that outcomes matter," says Patricia Fleming, RN, chief clinical officer for VNA of Rhode Island in Lincoln. "Outcome data are presented every two months to our board members, every quarter to our quality council, and every month at our supervisors' meeting," she says. Supervisors share information with their staff members and outcome data are posted on bulletin boards, she adds.

Before you can share outcome information, you do have to make sure that someone is reviewing and evaluating the data on a regular basis, Fleming points out. While she is the point person for reviewing the data, all staff members become involved in identifying areas that need improvement and tactics to improve outcomes.

• 24-hour availability

Answering services, nurses on call, and triage teams are used by 59% of the study participants to keep patients at home, says Fazzi. "Some agencies even offer a guarantee of a returned call within one-half hour," he says.

"We are fortunate that our hospital has an RN-staffed answering service for patient calls after hours," says Eileen Sube, manager of regulatory compliance for Conemaugh Home Health in Johnstown, PA. "The nurses use standardized protocols developed for our patients to triage the patient," she says. The protocols include questions to identify the cause of the patient's symptom and offer suggestions on what the patient should do, she says. "If the nurse believes that the patient needs attention beyond the protocol, home health nurses are on call to make phone contact or visits to patients," she adds.

• Medication management

Because medication can affect a patient's risk for falls and different medications can interact with each other to create unanticipated complications, 59% of agencies in the study focus on accurate lists of medications that patients are using and regularly review this information, Fazzi says.

"Our patients may be on as many as 20 different medications so we check medications every time we visit the patient," Fleming says. Nurses and therapists are instructed to go through medications at each visit, update lists in the chart, and check for contraindications with software on their laptops, she explains. "We tell patients to place all of their medications on the kitchen table so we can be sure to see everything," she adds. "The only way we can avoid complications from medications is to check the medications every time, and make sure patients understand what they are taking and how they should take it," she says.

• Case management

Fifty-two percent of study participants use case management to manage patient care, says Fazzi. Having one person who oversees a patient's care, no matter how many disciplines are involved, increases the likelihood that a change in condition or symptoms that indicates a decline, will be noticed, he adds.

While her agency doesn't use case managers, Sube points out that the use of a primary nurse for each patient is also effective. "Our nurses are responsible for between 10 and 25 patients that they visit," she says. "The nurses are also responsible for receiving communications about the patient from other staff members, such as therapists, who visit the patient," she explains. Because the primary nurse knows the patient well, she can identify changes or symptoms that might indicate a problem that could lead to hospitalization, she says.

• Patient and caregiver education

"We revised the teaching handouts that we have always used for patients and have found that improved education reduces trips to the emergency room and the hospital," Sube says. A total of 48% of the participants in the hospital reduction study reported that patient and caregiver education was a crucial strategy in their efforts to reduce hospitalization.

"We've always used written handouts for patients and their caregivers, but two years ago we rewrote the handouts to use lay language rather than medical language," explains Sube. "We also increased the size of the type to 14 points and we used bullet points and short sentences," she adds. The one-page handouts that are designed for different conditions clearly spell out signs and symptoms for which patients should be looking.

"By explaining the disease and by clearly and simply describing early warning signs of trouble, we are able to better educate the patient and caregiver," says Sube. Patients say that they refer to these handouts more often because they are easy to read, she adds, and nurses reinforce the information on the handouts by using them as teaching tools when they make visits.

Best strategies are low cost

"It is interesting that the top strategies don't cost a lot of money," Fazzi points out. "These strategies don't involve investment in technology or additional staff, but they do require development of policies and staff education," he says.

Other strategies such as telemonitoring did not show up as a top strategy but that doesn't mean it isn't effective, he adds. Only 8% of study participants used telemonitoring as a hospital reduction strategy; but only 5% to 10% of all agencies in the country use telemonitoring, he points out.

"We have used telemonitoring for any of our patients with chronic conditions that may require extra monitoring," says Fleming. By using a telemonitor to capture and transmit information, such as blood pressure, weight gain, and oxygen levels, nurses are able to intervene before the patient reaches a crisis point, she explains.

Home health managers are fortunate that so much data on outcomes are collected and available in a benchmark format, but it is important to use the information to initiate improvement, suggests Fazzi. "Home health managers need to look at Home Health Compare, see where they rank in relation to other agencies, choose a quality improvement project, and set specific targets to reach. Studies that share best practices can help agencies identify ways to reach their goals."