Home rehab service requires hybrid QI program
Home rehab service requires hybrid QI program
Combining hospital and home health QI
With any new program, the task of developing a quality improvement system is daunting. But for Dana Trainor, CRRN, CCM, it was doubly hard. As program and case manager for Bryn Mawr Rehab Hospital’s Rehab at Home program in Philadelphia, Trainor had to take elements of both hospital quality improvement programs and home health QI initiatives and marry them. Two months into the program, Trainor says it is taking shape, but will probably evolve over time.
Rehab at Home provides daily rehabilitation service in the home on either an acute level at least three hours of therapy per day, six days a week or a subacute level. The team providing care includes a physiatrist (rehabilitation physician), nurses, case managers, physical and occupational therapists; and speech, nutrition, and psychology professionals as needed.
Standards came from many sources
Because Rehab at Home is not exactly like an inpatient program, and not exactly like a home health service, Trainor says it took months of research to develop an effective quality improvement program. She says she had to look at standards from such organizations as state and local health boards, the Joint Commission on Accreditation of Health Care Organizations, and Medicare requirements. She also looked at what others in like organizations recommended, such as the home health agencies that the hospital used. Trainor also studied standards from the Congress on Accreditation of Rehabilitation Facilities (CARF). "We pulled the standards from each that made the most sense for us," she says.
For instance, hospitals have policies and procedures telling what to do when patients leave against medical advice. "We are in these people’s homes, so leaving’ doesn’t apply. They can tell us to get out, though."
Trainor developed a policy that requires the caregiver to provide a form listing other care options. The patient must sign the form, verifying they have been given other options. The form also gives Rehab at Home permission to tell the patient’s primary care physician of the termination of care.
Once Trainor had policies and procedures in place, she started on a quality improvement program. "First we had to have quality assurance; then quality improvement," says Trainor. "First we use policies and procedures to prevent sentinel events. Then we have to decide what to do if a sentinel event occurs, how to determine what went wrong, and what needs to change to prevent it from happening again."
Helen Cioschi, PRRN, administrative director of the program, says if a sentinel event occurs, it will be reviewed by the entire care team, as well as appropriate people from outside that team.
For instance, one sentinel event along with death, rehospitalization, and adverse drug reactions is a lapse in employee safety.
"I’m from the city, and safety is a concern for nurses working in urban areas," Trainor explains. She has schooled her staff on safety issues, giving periodic quizzes on the topic. There have also been inservices given by a former state trooper who now runs a home health escort service. That service advises Trainor on the risks involved with working in a particular service area and provides escorts when needed.
Should an employee run into trouble, the first task is to provide any necessary medical care to that employee, she says. Appropriate authorities also would be notified. Then Trainor says the employee’s manager would get a formal written description of what happened. This would be forwarded to the risk management department at the hospital and the home health escort service. Both would provide reports to her on any obvious safety mistakes that were made that can be corrected in the future.
Once she had the individual feedback from those people, she would meet with them to talk about the incident, its causes, and future prevention. Any changes in policy resulting from that meeting would be forwarded to the program’s oversight committee and passed on to staff members once approved.
"We will rely on our oversight committee to look at our QI program regularly to determine not only that it complies with the hospital regulations, but also for feedback," says Cioschi.
Trainor also hopes to make use of her own network of colleagues within and outside the hospital for feedback on the QI program. "I know that what we have developed may change. But I believe that by networking and using the resources around me, I can develop a good program."
Rehab at Home uses several tools for its QI program, among them the Functional Indepen dence Measure, which is completed on admission and discharge. But Trainor says she also will complete the measure over the phone six months after discharge to ensure patients don’t deteriorate.
Some tools created in-house
Several tools, like the patient satisfaction survey, had to be developed from scratch to reflect the hybrid nature of Rehab at Home, says Trainor. She will also use payer and referring physician satisfaction surveys as modified to reflect the inpatient and home care aspects of Rehab at Home and call primary care physicians for feedback on a weekly basis.
The environmental assessment was another item developed in house. "Our physician and occupational therapists have done a lot of work with the elderly on how to keep a home livable," she says. "They were instrumental in helping us."
Trainor says quality and standards of service for contracted companies also will be measured as part of the Rehab at Home QI program. For instance, if a non-emergency ambulance is required for a follow-up visit, then patients will be asked about the service provided and how their ride was, she says. And as part of any arrangement between such an ancillary service and Rehab at Home, Trainor asks to see the ancillary provider’s internal quality programs, as well as information on its accreditation.
So far, Rehab at Home has only a few patients. But Trainor thinks she must be on the right track because managed care organizations are starting to express interest. "It’s hard to get people to think outside the box sometimes," she says. "On a Friday afternoon, getting a discharge planner to approve a patient for our program when he or she isn’t sure it will be covered is hard. But it will get easier when they see how much more cost-effective the care is, and how much better the patients like being at home."
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