Indiana agency cuts costs, LOS by addressing ADLs
Indiana agency cuts costs, LOS by addressing ADLs
Having OT evaluation works, agency finds
As any smart appliance shopper will tell you, sometimes you have to spend a little more up front to save money in the long run. And one agency has found that same philosophy holds true when it comes to home care outcomes.
Riverfront Home Health in Vincennes, IN, had sharp declines in both the overall cost per patient and the number of visits per patient that were at least partly due to the agency’s implementation of a program in which an occupational therapist routinely visits new patients to evaluate their ability to handle activities of daily living (ADLs).
For example, the agency’s total number of visits per patient for patients who received at least one occupational therapy visit fell from 58.38 in the second quarter of 1998 to 42 visits in the first quarter of 1999. Likewise, the costs per patient fell 39% in that same period, from $5,922.65 to $3,596.88.
"We found that with all the changes in the home care industry in trying to get people’s episodes of care shorter, we needed to push our occupational therapy service," says Lana Manning, RN, director of performance improvement for Riverfront, which serves southern Indiana with 48,000 visits a year.
Benchmarking signals problem
Manning first became concerned about the agency’s ADL results after seeing a benchmarking report from Outcomes USA of Indianapolis. Outcomes USA collected data from Indiana home care agencies on functional outcomes and health outcomes, then sent each agency a report that compared their results with those of their peers.
The functional outcomes included measures of patients’ improvement in ambulation, stabilization in ambulation, improvement in bathing, stabilization in bathing, improvement in oral medication, and stabilization in oral medication.
Riverfront’s report, dated April 29, 1998, showed the agency’s outcomes in the category of improvement in bathing was only 32%, a whole 7% below its peers’ score of 39%.
"So we wanted to look at why we were lower, and why our patients weren’t doing as well as the other agencies’ patients," Manning says. "We took that to our performance improvement [PI] committee, and made that a priority for improvement."
First, make an evaluation
The PI committee decided the best way to improve bathing outcomes and other ADLs was to have an occupational therapist evaluate patients at admission.
First, they tried to study the success of these evaluations by comparing results in a group of patients that received the automatic OT visits to the group who did not. (See Riverfront’s study information guide, inserted in this issue.)
"We did that for one quarter. Unfortunately, we had too small of a volume of patients for a comparison, so at that point, we decided to just make the OT visit with each patient we admitted," Manning says.
Now, Riverfront contracts with another company to have an occupational therapist evaluate each patient, and occasionally make additional visits to patients who need the help. The program has helped the agency increase its standing when compared with peers. Slowly, the agency closed the gap between its own bathing outcomes and the statewide aggregate, and the latest difference was Riverfront’s bathing improvement outcome was 3% lower than its peer group’s outcome.
The OT evaluation takes about an hour, depending on the patient’s needs, says Chris Reed, OTR-L, director of rehab services for Allserve Therapies in Evansville, IN. The company contracts for home care OT, physical therapy, and speech therapy.
Each evaluation includes the following:
• assessing patient’s range of motion, strength, and flexibility;
• assessing patient’s performance on a simulated dressing task;
• collecting patient’s medical history, including whether patient has arthritis or joint deformities;
• documenting how well patient does with the Dynamometer, a machine that assesses grip strength;
• administering the manual muscle test to assess patient’s different joint functions;
• determining whether patient has associated problems, such as low endurance;
• assessing patient’s sitting balance and standing balance;
• identifying any sensation problems, such as nerve impairment;
• assessing patient’s cognitive ability, such as how well the patient understands directions given;
• determining any visual perception problems, particularly for patients who’ve had a stroke or cataracts;
• interviewing family to learn what patient’s ADLs were before current episode.
"The evaluation covers the whole aspect of care, not just their bathing and dressing skills," Reed says. "It looks at everything, because their whole body is involved."
So Reed examines patients’ feeding skills and bed mobility — such as how they roll in the bed and move from supine to sitting position.
If after the evaluation, the physician prescribes OT services, the occupational therapist will assist the patient in improving his or her ADLs.
"We’re able to identify what their deficits are, and then we can set them up on a treatment program," he adds. "We’ll go out and interact with them and provide them with adaptive equipment that they might be able to use, or teach them different techniques."
Sometimes occupational therapists will work with home health aides, showing them which areas to help patients improve.
While nurses might be able to do some of the same type of assessment, it’s much more efficient to have a skilled OT conduct the evaluation, Manning says.
"Nurses with different backgrounds tend to think differently in terms of functional ADLs, and we wanted these evaluations to be consistent," she explains.
Also, the routine OT evaluation has also contributed to the agency being able to cut down on home health aide visits, because the occupational therapist can identify patients who are functioning well enough that they may not need much aide support.
Riverfront’s next step is to increase physical therapy visits, Manning says. "The whole point is we want to get in and get out quicker. We feel like initiating these therapies up front will make our episodes shorter, and our patients will be more functional and become independent quicker."
Sources
• Lana Manning, RN, Director of Performance Improvement, Riverfront Home Health, 413 N. First St., P.O. Box 681, Vincennes, IN 47591. Telephone: (812) 885-2767.
• Chris Reed, OTR-L, Director of Rehab Services, Allserve Therapies, 8601 N. Kentucky, Suite F, Evansville, IN 47711. Telephone: (800) 442-6018. Fax: (812) 867-4866.
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