Continuum care is built on provider relationships
Continuum care is built on provider relationships
To manage properly, limit home agencies used
In a perfect world, the continuum of care would be seamless. Department heads wouldn’t bicker over turf, and information about patients would flow unobstructed from the physician’s office to acute care to home care and back. No one would fall through the cracks.
But in the imperfect world of modern health care, the flow of information can dry to a trickle when it comes to checking up on patients who’ve left your care.
"When you refer someone out to home care, especially if you don’t have a relationship with that external provider, you’re not going to get much in the way of feedback," says Janice Zimmer, RN, manager of care coordination at the Children’s Hospital of Pittsburgh. "It’s also difficult if not impossible to work with them on guidelines, procedures, or policies, so once the patient leaves the hospital doors, it’s like they become someone else’s patient. The lack of feedback doesn’t help you feel as though you’re viewing this patient from a continuum-of-care kind of basis."
Anne Kobs, associate director for standards with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, agrees that ensuring good feedback from nonaffiliated home health agencies presents a major problem for case managers. "You can usually send the patient and the information somewhere," says Kobs. "Then you may never hear about it again, and that’s a challenge for an organization, because you do want to know the effectiveness of the pattern [of care]."
In Zimmer’s experience, if nonaffiliated home health agencies provide feedback at all, it’s usually to the primary care physician or hospital coordinator, and it’s usually because they want something or because serious problems have arisen. "From a real standpoint of how things are going, it hasn’t been very good," she concedes.
One problem is that, by and large, hospitals and home health agencies have little incentive to coordinate the sharing of information. The Joint Commission, for example, does not even require hospitals to establish how they would share records with a nonaffiliated agency, "though you would hope they would," says Kobs.
The Joint Commission does require hospitals to be able to establish how they would share patient records with home care agencies that are also corporate partners. Nevertheless, Zimmer says much of what JCAHO does require with regard to sharing of information is basic and does little to promote a true continuum approach. Recently, she talked to representatives from her home care providers and expressed concern over the lack of coordination.
"We said, from a Joint Commission standpoint, are there some kinds of policies we need to have between the two of us to look at quality?" says Zimmer. The providers responded by telling her everything was fine as long as the home care group was Joint Commission-accredited and she had a copy of their accreditation. "But that really says nothing about continuum of care," says Zimmer. "I think there are some real big holes."
Another problem is the sheer number of nonaffiliated home health agencies to which most hospitals refer patients, says Larry Strassner, MS, RN, CNA, manager of health care consulting at Arthur Andersen LLP in Baltimore and former director of critical paths at The Johns Hopkins Hospital.
"Blue Cross will have, say, 10 preferred providers for nursing services, and the organizations are just picking and choosing," says Zimmer. "Some just rotate through."
As a result, Strassner adds, the logistics of agreeing to standard policies with a wide variety of providers can prove untenable. "Home care doesn’t want to have 15 different guidelines for 15 different organizations they work with," he says.
One way case managers at the Children’s Hospital of Pittsburgh address the feedback problem is to get information not from the agency itself, but through following up with patients’ families. "We specifically ask them about home care, especially when kids have gone out with more extensive home care needs, like infusion therapy," says Zimmer. They also check in with primary care physicians for information.
Strassner contends that the best possible incentive for home health agencies to turn up the volume of information flow is economic. Specifically, as managed care penetration increases, hospitals accept more financial risk for their patients, and case management programs bloom outside hospital walls, the entire system will feel greater pressure to improve the sharing of information. "But until some of those pieces fall into place, you’ll continue to see the patient in these fragmented sequences acute care, and then that’s over; then home care, and then that’s over; and then back to primary care," says Strassner. "So they’re not really managing the patient across their life continuum."
A more immediate solution is to establish a formal partnership with the one or two home health agencies with which you do the most business. The Children’s Hospital of Pittsburgh, for example, formed such a partnership with a provider that receives about 50% of its referrals for home infusion and other high-tech services. Representatives from the hospital and the agency regularly hold operational meetings to work out logistical problems regarding the sharing of patient information. They’ve also jointly developed an advisory board to ensure that the relationship proceeds smoothly. "But you really almost have to be in an arrangement like this to be able to get those kinds of things," Zimmer says.
For more information about sharing information with home health agencies, contact the following sources:
Anne Kobs, associate director for standards, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd, Oakbrook Terrace, IL 60181. Telephone: (630) 792-5902.
Larry Strassner, MS, RN, CNA, manager of health care consulting at Arthur Andersen LLP, 120 E. Baltimore St., Baltimore, MD 21202. Telephone: (410) 234-3894.
Janice Zimmer, RN, manager of care coordination at the Children’s Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213. Telephone: (412) 692-6021.
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