Be proactive: Improve patients’ quality of life

Extra help for frail elderly, chronically ill

(Editor’s note: This is the second of a two-part series that looks at innovative approaches to patient care and expansion of services by home health agencies. Last month’s article examined partnerships with other community organizations. This month’s article looks at the approach of two agencies that have found a way to offer a more holistic approach to patient care.)

As outcomes are emphasized more in the home health industry with Home Health Compare, home health managers are looking for ways to be proactive with their patients and make sure that the best outcomes possible are achieved.

"The switch to the prospective payment system did give home health agencies flexibility and did emphasize outcomes," points out Robert L. Heineman, LPT, MS, MBA, director of rehabilitation for Holy Redeemer Home Health and Hospice Services in Philadelphia. "Collection of OASIS [Outcome and Assessment Information Set] data have also helped us identify exactly who our patients are and where we need to enhance services in order to improve outcomes," he adds.

Holy Redeemer’s approach to enhancing services was to develop a disease-management program that focused upon the frail elderly. The program, Life Assess, enabled the agency to become the first health care organization in the country to be certified for a frail elderly program by the Joint Commission on the Accreditation of Healthcare Organizations.

Life Assess addresses the needs of patients 85 and older who are admitted to Holy Redeemer’s service for an acute episode, Heineman explains. "We know that we will see the patients only for an acute episode, but we also know that frailty is a comorbidity that increases the need for services for reasons other than the reason for referral to home health," he says.

"Our philosophy is that frailty is not an end-of-life issue; it is a period of life that requires additional support in order to stay at home," notes Heineman. "Our program is not designed to do more for the patients, but to identify what their extra needs may be and help them find the resources they require to address those needs to improve their quality of life at home," he says.

It does not matter what the reason for referral to home health is, all patients ages 85 and older automatically are screened for depression, dementia, falls risk, and urinary continence problems, Heineman adds.

All field staff members are given screening tools to use when they visit Life Assess patients, he says. "We may have a patient who is being seen by a physical therapist following a stroke. In the past, the therapist would do his or her job by working with the patient to strengthen balance and reduce the risk of falls, but the therapist might not recognize signs of other problems."

The Life Assess screening tool is a simple mechanism that, along with staff education, can help any field staff member identify other areas of need for the patient, he adds.

"I had one physical therapist who suspected depression in her 89-year-old patient after conducting the screening. The therapist pointed out that the patient seemed sad, but the patient declined the therapist’s offer to pursue a referral to someone who could help," Heineman says.

"Seven months later, the therapist saw the patient out in public, and the patient came up to her and said that the therapist had changed her life," he adds.

"The patient stated that no one had ever asked her how she felt and after the therapy ended, the patient did seek help from her doctor. Just because the therapist recognized a potential problem and brought it into the open, the patient felt comfortable seeking help," Heineman explains.

Sometimes, the problems that are identified are fairly simple to address, he points out. "If incontinence is a problem, it may be a matter of the bathroom being too far away, and we suggest equipment or tools to help."

The Life Assess tool provides a pathway for clinicians to follow as they evaluate a patient’s needs. "All of our tools are evidence-based and rely upon an interdisciplinary approach to patient care," Heineman adds.

Because the initial assessment visit usually is jam-packed with questions and forms to complete, the Life Assess evaluation usually is not performed until after the first or second regular visit, he explains. "Patients in this age group are not usually comfortable talking about depression or dementia with someone they don’t know, so a visit or two is necessary for the staff member and the patient to feel comfortable discussing something other than the initial reason for home health," Heineman says.

One reason Life Assess has a positive effect on patients’ quality of life is the agreement of different disciplines of care to work together on committees to plan, develop, and oversee the progress of the program, he says. Although Holy Redeemer staff members do not follow patients beyond the acute episode of care, Heineman says his agency is pursuing grant funds to set up some sort of follow-up.

Students provide care

Visiting Nurse Association (VNA) of Connecticut patients who are part of the CareLink program do receive follow-up care once they are discharged from the acute episode care provided by VNA. The CareLink program was developed by the VNA and the University of Connecticut in New Britain.

"The partnership addresses two needs," says Karen Reid, RN, BSN, director of public health services for the agency. "The program provides real-life training for nursing students, and it also provides free, on-going care for patients with chronic conditions once they no longer have a need for acute home health care," she explains.

Patients admitted to the CareLink program are between ages 60 and 90, with the average age being 75, says Reid. "The only other criteria for admission is that they have a chronic condition such as diabetes or cardiovascular disease, and that they are willing to learn how to control their condition," she says.

Patients with dementia or mental health issues are not eligible for the program because a key part of the student nurses’ training is patient education. Therefore, the students need to work with patients capable of learning, she explains.

Once a patient is discharged from VNA into the CareLink program, student nurses take over patient care. Supervised by the nursing school with the VNA available for additional resources, the student performs health assessments, health teaching, monitoring of chronic illnesses, referrals to other resources, and telephone support. The students follow their patients throughout the semester, and they usually see between two and four patients per semester, says Reid.

"By seeing the patients for a period of time, the students have an opportunity to see the effects of their intervention," she adds. About 200 patients are enrolled in the CareLink program.

An added benefit of this program is the availability of graduate students to perform research regarding outcomes and to develop additional interventions to help patients. Pet therapy is one additional service added to CareLink as a result of data collected in the program.

Although patients are no longer under VNA care once discharged to CareLink, VNA stays involved through ongoing communication with the school of nursing, says Reid.

"The coordinator of the program is employed by both the VNA and the university, so we are able to provide resources the students may need," she says. The agency does absorb the cost of supplies such as glucometer strips, gloves, soap, and towels, but the expense is not great.

"The student nurses are not providing direct services such as wound care, so the supply cost is minimal," she says.

Patients appreciate the program because it gives them extra support as they learn to manage chronic conditions and it also provides a sense of security, Reid points out.

"Because the student nurses are constantly assessing the patient’s condition, any change or exacerbation of their condition is noticed. This has resulted in a number of patients being referred back to us for acute care in a timely manner," she explains.

[For more information on these home health programs, contact:

  • Robert L. Heineman, LPT, MS, MBA, Director of Rehabilitation, Holy Redeemer Home Health and Hospice Services, 12265 Townsend Road, Philadelphia, PA 19154. Phone: (215) 698-5586. E-mail:
  • Karen Reid, RN, BSN, Director of Public Health Services, Visiting Nurse Association of Central Connecticut, 205 W. Main St., New Britain, CT 06052. Phone: (860) 826-6313. E-mail:]

Suggested reading

1. Bernal H, Shellman J, Reid, K. Essential concepts in developing community-university partnerships. Public Health Nurs 2004; 21:32-40.