Functional Outcomes of Home Health Patients in a Randomized Trial of the Home Health Aide Partnering Collaborative

Functional Outcomes of Home Health Patients in a Randomized Trial of the “Home Health Aide Partnering Collaborative” Penny Feldman Miriam Ryvicker Robert Rosati Gil Maduro Theresa Schwartz Sally Sobolewski Center for Home Care Policy & Research, Visiting Nurse Service of New York Funded by the Assistant Secretary for Planning and Evaluation, U.S. Dept. of Health and Human Services Organizational Context: Visiting Nurse Service of New York     Largest not-for-profit home care agency in U.S. Serves an average of 25,500 patients daily  New York City, Nassau, and Westchester County Patients assigned to service teams based on geography and service needs Contracts with Licensed Agencies for home health aide services HHA Partnering Collaborative Inter-related Goals and Strategies Improve HHA Field Support Use of the “Five Promises” Tool Increase HHA Field Supervision Increase Support for Patients’ Selfmanagement of Functional Health Better Match Services to Patients’ Needs Proactive Communication Strategies between Service Teams and Licensed Agencies Establish a “Core” of HHAs on each team Increase HHA Job Satisfaction and Retention Integrate HHA into Patients’ SelfManagement and Functional Improvement Increase HHA Field Supervision Use of a Functional Health Improvement Tool Proactively Shape Patient Expectations Use of the “Five Promises” Tool Adapting the IHI Breakthrough Series Model of Collaborative Learning PDSA Cycle: Rapid-cycle tests of change % Patients Improve in Ambulation Expand test to larger group; continue to adapt strategy to improve outcomes Continue to refine the tool and test on small scale; measure progress Test strategy on small scale; measure progress; revise strategy Facilitating positive communication COC / HHA Interaction: The “Five Promises” EVERY TIME you are in a patient’s home together, take 5 minutes for the following interaction…….. 1. Introduce yourself and show your I.D. 2. Discuss the progress the patient is making toward achieving his/her functional health goals. 3. Review together, any changes in PPOC and/or duty sheets. 4. Discuss any observations or concerns about the patient that you have today. 5. Thank each other. Make sure you communicate about the next Nursing visit and the ongoing or changing Home Health Aide schedule and/or assignment. Make sure contact phone numbers are in the home. Important note for the CoC: Your interaction constitutes a Supervision! Please document this in the HHA section of the Visit Documentation system. Improving support for patient self-management PATIENT’S NAME: _______________________________ Patient Case Number:______________________________ Date of Visit: _________________Team________________ ACTIVITIES OF DAILY LIVING WEEKLY PROGRESS REPORT: BED MOBILITY & TRANSFERS (PAGE 1), BATHING (PAGE 2), AMBULATION (PAGE 3) COC - Check the areas in “check deficit area” where the patient initially needs assistance AND check “progress made” at week 4. Patient - Check the areas in the “Patient Indep” that you feel you can perform independently. Home Health Aide - Check the areas in the “HHA Assist” where the patient continues to needs your assistance. DIRECTIONS: Progress Made Activity/Components: Week 1 Baseline Week 2 Update Week 3 Update Week 4 Update Bed Mobility and Patient HHA Patient HHA Patient HHA Patient HHA Achieved Ongoing Transfers Indep Assist Indep Assist Indep Assist Indep Assist Rolls from back to right  side Rolls from back to left  side Moves from back to  sitting up Moves from sitting up to  lying down Can get in and out of bed  Can get walker, cane, or  crutches Sets self up safely to get  up Can get up from all  surfaces safely HHAs, Therapists, and Nurses indicate ADDITIONAL COMMENTS or identify tips for promoting patient independence (continue on back as needed). EXPLAIN why there may be differences among COC, Patient, and HHA scores OR if there is a DECLINE IN SCORE: Check Deficit Area Intervention & Evaluation Timeline DEVELOP TOOLS & STRATEGIES Start: June ’03 GAIN MOMENTUM FOR SPREAD Start: Sept. ’04 EVAL. PHASE I: RANDOMIZED TRIAL April ’05 – Sept. ’05 EVAL. PHASE II: SPREAD TO REMAINING TEAMS Feb. ’06 – July ’06 ORIGINAL COLLAB. TEAMS (n=7) EARLY ADOPTER TEAMS (n=18) X     USUAL PRACTICE X  R A N D USUAL PRACTICE O M I Z A T USUAL PRACTICE I O N   INTERVENTION TEAMS (n=22) CONTROL TEAMS (n=23) USUAL PRACTICE X  USUAL PRACTICE  USUAL PRACTICE X  ‘X’ indicates involvement in the HHA Partnering Collaborative. Patient sample Inclusion criteria  Exclusion criteria       Admitted during intervention period, discharged by December 30, 2005 At least 1 HHA visit Room for improvement in at least 1 of 3 ADLs studied  Severely cognitively impaired Bedridden Requires 24-hr care Life expectancy < 6 months Highest levels of dependency in ADLs at admission  Data source: Outcomes Assessment and Information Set (OASIS)  OVERALL N=3,290 Methods  Outcomes defined as change in ADL score from start of care to discharge (Transferring, Ambulation, and Bathing) Two-step modeling procedure:    Case-mix adjust for demographic, clinical, and functional characteristics Analysis of variance with nested effects to control for clustering of patients in teams Variables included in case-mix adjustment Demographic Sex Age English-speaking Non-white Payer source Referral source Live alone No primary caregiver Functional Ambulation score at admission Bathing score at admission Transferring score at admission Clinical CHF Diabetes Hypertension COPD Ischemic HIV Stroke Comorbidities Regimen change Wound Pressure ulcer Stasis ulcer Surgical wound Urinary incontinence Dyspnea (medium) Dyspnea (high) Pain (medium) Pain (high) Cognit. Impairment (medium) Cognit. Impairment (high) Confusion (medium) Confusion (high) Analysis of variance: Transferring Change in Transferring from Admission to Discharge Effect Study group Team Error R-square DF Sum of Squares Mean Square F Value P-value Effect size 1 3.2285 3.2285 4.32 0.0436 0.0037 44 32.9195 0.7482 2.23 <.0001 0.0375 2510 840.65 0.3349 0.041 Adjusted means of residuals Control 0.046 Treatment -0.0473 Analysis of variance: Ambulation Change in Ambulation from Admission to Discharge Effect Study group Team Error R-square DF Sum of Squares Mean Square F Value P-value Effect size 1 1.6312 1.6312 4.07 0.0496 0.0017 44 17.6134 0.4003 1.3 0.0903 0.0184 3039 936.6404 0.3082 0.019 Adjusted means of residuals Control 0.0185 Treatment -0.0421 Analysis of variance: Bathing Change in Bathing from Admission to Discharge Effect Study group Team Error R-square DF Sum of Squares Mean Square F Value P-value Effect size 1 1.6118 1.6118 0.69 0.4098 0.0005 44 102.4203 2.3277 2.3 <.0001 0.0305 3211 3256.1753 1.0141 0.031 Adjusted means of residuals Control 0.0598 Treatment 0.0021 Clinically reported measures: Transferring 70 60 50 40 30 20 10 0 2.2 1.8 Improved Stabilized Declined 61.0 53.3 44.5 37.3 Control Treatment Clinically reported measures: Ambulation 60.0 50.0 40.0 30.0 20.0 10.0 0.0 4.3 4.0 Improved Stabilized Declined 37.4 36.0 59.7 58.6 Control Treatment What participants said about the ADL Tool:  Home Health Aides:  Makes better use of aides’ skills  Clinicians: Redundant with usual practice  Time-consuming  Not user-friendly  Conclusions & further questions     The intervention had a significant, but modest effect in ambulation and transferring Unmeasured sources of team variation influence patient outcomes How do we best adapt an evidence-based tool and streamline it with usual practice? What can be done to increase the magnitude of the effect in light of heavy workload and paperwork burden? ADL Tool (cont.) PATIENT’S NAME: _______________________________ Patient Case Number:______________________________ Date of Visit: _________________Team________________ ACTIVITIES OF DAILY LIVING WEEKLY PROGRESS REPORT: BED MOBILITY & TRANSFERS (PAGE 1), BATHING (PAGE 2), AMBULATION (PAGE 3) COC - Check the areas in “check deficit area” where the patient initially needs assistance AND check “progress made” at week 4. Patient - Check the areas in the “Patient Indep” that you feel you can perform independently. Home Health Aide - Check the areas in the “HHA Assist” where the patient continues to needs your assistance. Week 1 Baseline Patient Indep HHA Assist Week 2 Update Patient HHA Indep Assist Week 3 Update Patient HHA Indep Assist Week 4 Update Patient HHA Indep Assist Progress Made Achieved Ongoing DIRECTIONS: Check Deficit Area Activity/Components: Bathing Circle location where bathing presently performed: bed sink tub shower stall Please indicate device(s) used to assist with task performance: Obtains objects from closets/  shelves Knows precautions and safety  strategies Can get into bathing location  Washes face  Washes upper body  Washes chest, trunk and private  areas Washes legs  Washes hair  Adequately dries skin  Grasps comb or brush  Brings comb or brush to top of  head Combs or brushes hair  Gets out of bathing location  HHAs, Therapists, and Nurses indicate ADDITIONAL COMMENTS or identify tips for promoting patient independence (continue on back as needed). EXPLAIN why there may be differences among COC, Patient, and HHA scores OR if there is a DECLINE IN SCORE: ADL Tool (cont.) PATIENT’S NAME: _______________________________ Patient Case Number:______________________________ Date of Visit: _________________Team________________ ACTIVITIES OF DAILY LIVING WEEKLY PROGRESS REPORT: BED MOBILITY & TRANSFERS (PAGE 1), BATHING (PAGE 2), AMBULATION (PAGE 3) COC - Check the areas in “check deficit area” where the patient initially needs assistance AND check “progress made” at week 4. Patient - Check the areas in the “Patient Indep” that you feel you can perform independently. Home Health Aide - Check the areas in the “HHA Assist” where the patient continues to needs your assistance. DIRECTIONS: Check Deficit Area Activity/Components: Ambulation Week 1 Baseline Patient HHA Indep Assist Week 2 Week 3 Week 4 Update Update Update Patient HHA Patient HHA Patient HHA Indep Assist Indep Assist Indep Assist Progress Made Achieved Ongoing Can get cane, walker, or other device  Can get up from surface safely  Can maintain standing  Can move walking device  Can move legs (to take steps)  Can change directions  Can walk backwards (to sit down) HAs, Therapists, and Nurses indicate ADDITIONAL COMMENTS or identify tips for promoting patient independence (continue on back as needed). EXPLAIN why there may be differences among COC, Patient, and HHA scores OR if there is a DECLINE IN SCORE:  Patient Demographic Characteristics Age, mean (SD) Male, % Non-White, % English-speaking, % Live alone, % No primary caregiver, % Payer, % Medicare FFS Medicaid FFS Dually Eligible HMO Private All Other Admitted from, % Hospital Nursing or Rehab Facility Non-Inpatient Facility Other Control (N=1,774) N % / mean Std Dev. 1774 76.21 11.94 492 27.73 743 41.88 1295 73 841 47.41 311 17.53 Treatment (N=1,516) N % / mean Std Dev. 1516 74.86 13.45 396 26.12 727 47.96 1096 72.3 777 51.25 304 20.05 P-val. 0.0024 0.2990 0.0005 0.6518 0.0278 0.0644 1183 87 224 198 79 66.8 4.91 12.65 11.18 4.45 979 92 204 176 64 64.62 6.07 13.47 11.62 4.22 0.1896 0.1441 0.4879 0.6942 0.7454 955 450 364 5 53.83 25.37 20.52 0.28 836 387 287 6 55.15 25.53 18.93 0.4 0.4513 0.9157 0.2547 0.5726 Patient Clinical Characteristics at Admission Control (N=1,774) N % / mean Std Dev. Diagnosis, % CHF Diabetes Hypertension COPD Ischemia HIV CVA Comorbidities, mean Ambulation at SOC, mean Bathing at SOC, mean Transferring at SOC, mean # of Medicines taken, mean 95 121 89 65 62 18 102 1774 1774 1774 1774 1754 5.36 6.82 5.02 3.66 3.49 1.01 5.75 4.08 1.27 2.64 0.92 7.94 1.21 0.62 0.73 0.57 3.96 Treatment (N=1,516) N % / mean Std Dev. 73 126 96 50 56 20 89 1516 1516 1516 1516 1494 4.82 8.31 6.33 3.3 3.69 1.32 5.87 4.12 1.22 2.61 0.85 8.16 1.17 0.61 0.73 0.58 4.3 P-val. 0.4832 0.1058 0.1025 0.5690 0.7596 0.4150 0.8824 0.3413 0.0261 0.2484 0.0001 0.1423 Patient Clinical Characteristics (cont.) Control (N=1,774) N % / mean Std Dev. Clinical Status, % Regimen Change Wound Pressure Ulcer Stasis Ulcer Surgical Wound Urinary Incontinance Bowel Incontinence Dyspnea - medium Dyspnea - high Pain - medium Pain - high Cognitive Impairment - medium Cognitive Impairment - high Confusion - medium Confusion - high 1004 727 68 17 480 363 101 878 22 927 60 313 67 64 3 56.6 40.98 3.83 0.96 27.06 20.46 5.73 49.49 1.24 52.25 3.38 17.64 3.78 3.61 0.17 Treatment (N=1,516) N % / mean Std Dev. 877 578 57 13 398 257 83 820 9 807 85 320 63 84 6 57.85 38.13 3.76 0.86 26.25 16.95 5.52 54.09 0.59 53.23 5.61 21.11 4.16 5.54 0.4 P-val. 0.4686 0.0953 0.9128 0.7618 0.6032 0.0103 0.7950 0.0085 0.0557 0.5757 0.0019 0.0120 0.5782 0.0077 0.2147 ADL Outcomes: Descriptive Statistics Unadjusted ADL outcomes - change from start of care to discharge Treatment (n=1516) Mean SD Transferring Ambulation Bathing -0.4149 -0.3252 -1.3272 0.7055 0.6878 1.2443 Control (n=1774) Mean SD -0.4076 -0.3185 -1.2869 0.7166 0.7001 1.2343 Dichotomous ADL Outcomes: Bathing 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Improved Stabilized 20.3 20.0 6.4 6.1 Declined 73.9 73.3 Control Treatment