QMs will be 'cops' policing care planning after COPs become final
QMs will be cops’ policing care planning after COPs become final
COPs’ new emphasis requires objectivity, regulation
You’d think care planning and coordination aspects of home care that the Health Care Financing Administration is watching more closely would fall in the quality manager’s lap. After all, ensuring that patient care has been well thought-out and coordinated among the various disciplines relates directly to quality.
Yes, it does relate to quality. No, quality managers should not expect to have direct oversight of care planning and coordination. Instead, experts say, case managers and field nurses who deal directly with patients will be responsible for coordinating care and promoting interdisciplinary communication.
The quality manager, however, is not removed from planning and coordination. Rather, the quality manager should act in a regulatory fashion, policing an agency’s planning and coordination processes, ensuring they are followed, and trying to find ways to improve them. At the same time, quality managers should be ready to cooperate with case managers to achieve improved quality of care.
For example, quality managers will likely be more involved in outcomes research as they more closely investigate their agencies’ processes pathways, methods of interdisciplinary communication, and documentation, to name a few and implement improvements when needed.
"Quality managers are independent," says Cathy Nielsen, RN, CPHQ, vice president of clinical services for Minnetonka, MN-based In-Home Health. "They need to remain that way so they can make unbiased observations about quality. I think their value comes from their objectivity."
Agencies accredited by the Joint Commission on Accreditation of Healthcare Organizations already have had to deal with care planning and coordination. Looking at accredited agencies, Debra Payne, RN, BS, associate director in JCAHO’s department of standards and interpretations unit, sees more case managers taking responsibility for care planning and coordination.
"To me, if you have a nurse case manager handling care planning and coordination, she will know more of what’s going on because she works directly with the patient," Payne says.
But it’s the agency’s process that will dictate how the nurse/case manager approaches care planning. That process is where the quality manager affects how care planning and coordination is handled. "It goes back to how an agency defines its process," Payne says.
Care planning and coordination in acute care settings are characterized by greater interaction between quality managers and case managers, says Vanita Bellen, BSE, BCOM, MHSc, director of quality and case management at Columbia Medical Center in Aurora, CO. Home care often follows in the footsteps of hospitals, Bellen says. She maintains that home health agencies need to adopt the kind of interaction that is so prevalent in the acute care setting.
"I would like to see the two [quality managers and case managers] complementing each other," Bellen says.
At Columbia Medical Center, Bellen oversees both quality managers and case managers. This structure allows case managers to handle day-to-day planning and coordination while quality managers review the process. This promotes a total quality improvement approach, she says.
"In my opinion, in acute care settings, the two areas are less compartmentalized," Bellen says. "There is definitely a need for integration a link between the two."
Bellen says between the two positions, process enhancements that improve quality as well as reducing lengths of stay and costs are achieved.
After understanding what role the quality manager plays under the revised COPs, evaluating processes is the next step.
First, care planning and coordination should be looked at as a process in which quality managers are the watchdogs. For each service an agency provides, there is a process in which care is delivered. Adopting a single process is the result of shared experiences, Bellen says.
For example, as the quality manager you may be monitoring congestive heart failure outcomes. You may notice a high rate of hospital readmissions for CHF patients. In such cases, quality managers need to review, with the help of case managers, the critical pathway and look for variances in care. If there is a high number of variances, the quality manager should find out why. If it is not a variance problem, then the effectiveness of the pathway needs to be investigated.
In the end, the quality manager, with input from case managers, will have found a way to improve the process.
One area of care planning and coordination that needs to be addressed is interdisciplinary communication, another process quality managers need to monitor to ensure quality care.
The revised COPs reveal HCFA’s desire to see home care agencies work closely with physicians and other professionals, such as occupational therapists and social workers.
"HCFA is trying to make sure there is coordination and communication with the physician," says Kathryn Crisler, MS, RN, senior research associate at the Center for Health Policy and Research in Denver. "They are also trying to say that in cases where there is more than one service being provided, they want to make sure the care plan has been commonly discussed and arrived at.
"It’s an attempt to say that one of the advantages of home care is that you can bring these various disciplines together in the patient’s place of residence. The patient doesn’t have to run to the outpatient clinic, and then to the doctor’s office, and then here, and then there. But there needs to be coordination."
Again, looking at interdisciplinary communication as a process, quality managers should examine their agencies’ current means of interdisciplinary communication and its effectiveness.
"I think there are a lot of creative ways to do [interdisciplinary communication]," says Crisler.
Moving toward interdisciplinary care planning and coordinated services requires a commitment to establishing mechanisms in which various disciplines can communicate. Agencies can be imaginative in devising ways to achieve this, says Crisler. The only rule, she says, is that agencies work with their current processes in order to reduce the impact these proposed rule changes may have.
"Examine the mechanisms you have for interdisciplinary communication," Bellen says.
Crisler says the process should allow time for caregivers to meet face to face or at least talk directly to one another. "It’s my experience that voice mail messages or written communications does not have the same emphasis as direct contact," she says.
Nielsen warns that agencies should approach interdisciplinary meetings on a case-by-case basis, and that agencies should not designate a set number of meetings per case to satisfy the requirement.
"I don’t think you can make a flat statement as far as the frequency of meeting," Nielsen says. "It’s truly dependent on your patient population and on the individual patient. There are some patients who are only receiving personal care services. They aren’t going to need an interdisciplinary team conference."
Getting subcontractors to adhere to agency policies regarding interdisciplinary communication may prove to be a challenge as well. Both Crisler and Nielsen stress that agencies will ultimately be responsible for the care delivered by subcontractors.
Removing subcontractors from the process of care may prove to be the answer for some. At Abington (MA) VNA/Affiliated Community VNA, there is movement afoot to replace all subcontracted disciplines with employees, says Sandra Fleischmann, RN, BSN, quality management nurse. "It’s easier to do multidisciplinary communication when everyone is part of the same agency," she says. "I think it would be difficult for a small agency because it would cost a lot to bring the agencies under one roof."
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