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How to Start a Home Health Care Business in Pa

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					  Home Health Quality
    Improvement

Innovate. Inspire. Improve.
     Eve Esslinger, BSN, MS
  Project Manager, Home Health
  Quality Insights of Pennsylvania
               Objectives
• Review impact of acute care hospitalization
  rates for home health
• Recognize acute care hospitalization as a
  national priority for home health
• Identify strategies to promote reduction in
  acute care hospitalization
      Where we’ve been….
7th Scope of Work(7 SoW) 2002-2005
 Educated on OBQI
 Worked with all home health agencies on any
  of the 41 OBQI measures
 Promoted public reporting
                        7th SOW Results – 4419 HHAs
75% HHAs nationally were taught Outcome Based Quality Improvement (OBQI)
    Absolute change in unweighted average from baseline to remeasurement
                        ( May01-Apr02 to Feb04-Jan05)

                                                    Non-participating                  Participating
                                                      14.60%
                  15%
                           11.97%
                                                                                                   9.87%
Absolute change




                  10%                                                                                                                  8.69%
                                                                     7.30%                                          7.06%
                                                   5.04%
                  5% 4.12%                                                                                                     4.08%
                                                               2.82%
                                                                             1.36%            1.84%

                  0%
                                    -0.63%                                         -0.53%                     -1.89%




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  Where we are today….

     8th   Scope of Work

August 1, 2005 – July 31, 2008
 8 SoW Home Health Activities
 Acute Care Hospitalization and other
  Publicly Reported Outcomes’
 Pneumococcal and Influenza
  Immunizations
 Organizational Culture Change
 Telehealth to Reduce Avoidable
  Hospitalizations
 Home Health Priority Topic:



Acute Care Hospitalization
                           National ACH Rate
 Baseline Rate* (By QIO Round) = 31.86%
 Target Rate (By August 2007) = 29.20%




                                                                                                                  29.20%




* Risk-Adjusted rates from OBQI Roll-Up Reports (downloaded 8/31/2005) from HHAs with at least 10 episodes of care from 41 QIOs
     with statewide risk-adjusted rates above 25% as of April, 2005 data.
              Outcome Performance Gap:
              Opportunity for Improvement
                           Acute Care Hospitalization
                              (lower rates are better)
                     50%

                             47.38%
Risk-Adjusted Rate




                     40%


                     30%                 30.80%

                                                         Avg - highest quartile
                     20%
                                                         Avg - lowest quartile
                                          17.35%
                     10%                                 National Agency Avg


                     0%

                                 Apr03-Mar04
                                                                             %
                                    Ba




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12-Month Period Ending with Month        05

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                                                                                                           National ACH Progress




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           Georgia
Acute Care Hospitalization Rate




              Information On Home Health Compare
              March 2005-February 2006
Georgia: Progress to date
  Reasons for Hospitalization
 Emergent   84.63%

 Urgent     6.19%

 Elective   5.89%
  Home Health Length of Stay
    Prior to Hospitalization
Home Health LOS   Patients
                  Hospitalized
Within 1 week     25.44%

Within 2 weeks    44.65%

Within 3 weeks    57.83%
                               Estimated Savings
 Achieving national target rate will result in an estimated 46,534 fewer
  hospitalizations from Sep. 2006 – Aug. 2007
 Savings to Medicare Trust Fund over this 12-month period could equal $356.4
  Million*




                                                                                                                           $356.4
                                                                                                                           Million




* This figure represents the estimated number of prevented hospitalizations multiplied by the average Length of Stay (5.9) and average
     Medicare Reimbursement per day ($1,298) of Medicare short-stay hospital utilization from the CY 2003 MEDPAR Data.
ACH in the National Spotlight
               1. Fall Prevention
               2. Front-Loading Visits
               3. Culture
               4. 24 Hour
                  Availability/Response
                  Program
               5. Medication
                  Management
  ACH in the National Spotlight
6. Case Management
7. Patient/Caregiver
    Education
8. Special Support
    Services
9. Disease Management
10. Physician
    Relationships
 Acute Care Hospitalization…
…putting the puzzle pieces together…
Pay for Performance
      Pay for Performance
Incentives are based on quality outcomes
Quality must be the number one priority
with senior leaders
Change is driven by the Leader’s vision
Knowledge of quality and priorities are
understood by all employees
Hospitalization Risk Assessment
Hospitalization Risk Assessment
Do you know which patients are at greater risk
for hospitalization?
Factors: Prior pattern of hospitalizations,
chronic conditions, lives alone, confusion, etc.
Assess at Start of Care/Resumption of Care
Customize existing tools to meet your agency’s
needs: www.medqic.org
Strategy B.2 and C.2
Emergency Care Plans
    Emergency Care Plans
Educates patients and caregivers
  When and how to contact the HHA
  Self-monitoring for exacerbation of acute signs and
  symptoms that could lead to rapid deterioration
  When and how to seek emergency assistance
Left in home and discussed at SOC and ROC
Posted in a visible place (refrigerator)
Reviewed weekly (minimally); every visit
(optimally)
Customize existing tools to meet your agency’s
needs: www.medqic.org
Strategy A.2
Falls Prevention
          Falls Prevention
Definition: A strategy which uses specific
interventions to help specific patients or all
patients avoid the risks for falling in an effort to
reduce hospitalizations.
Falls are the leading cause of injury or death
for those age 65 or older [CDC,2001]
Approximately 35-40% of those age 65 or
older, living at home, fall annually [AGS]
Falls Prevention
Problem: Patients at risk for falls are NOT identified
  Being Female                 History of Stroke
  Being Male                   History of Parkinson’s
  Being White                  Neuromuscular Disease
  Previous Fall !!             Taking > 4 Medications
  Visual Problems              Taking Psychotropic
  Balance Problems              Medications
  Gait Problems                Urinary Incontinence
  Having Physical              Postural Hypotension
   Limitations                  Cognitive Impairment
  Having > 1 Chronic           Wearing Shoes with Thick,
   Illness                       Soft Soles…”sneakers”
         Fall Prevention Plan
• Fall Risk Assessment

                         • Interventions/Protocol
         Keys to Prevention
• Interventions include multiple components
• Exercise
• Medications
Front Loading Visits
       Front Loading Visits
Definition: A strategy whereby the agency increases the
visit frequency or services at the beginning of care in
order to reduce the potential for unplanned
hospitalizations.
Planned higher frequency of visits at SOC/ROC
Usually select disease specific or high risk patients
Goal is to reduce avoidable acute care hospitalizations
(ACH), improve outcomes & patient satisfaction
           Research Based
 Case Western Reserve University with
  University Hospital Health Systems – Home
  Care Service (2005)
   Disease Specific
      Heart Failure Rehospitalization rates range from 25 – 40%
   New York Heart Classification (used by Case
    Western Reserve)
   Clinical Pathways
   Agency Protocols
        Case Western
     Heart Failure Results
               Front    Non-Front
               Loaded   Loaded
Total Visits   9.5      15.5
 RN (Days      4.6      8.6
 1-14)
 RN (Days      1.1      5.0
15 – 60)
PT             3.2      4.7
          Case Western
    Heart Failure (HF) Results
                      HF        HF
                     Front   Non-Front
 Rehospitalization
              Rate
                     15.8%    39.4%
 Rehospitalization
   in 14 Days Rate
                     7.0%     15.2%
 Rehospitalization
for Admit Dx Rate
                     7.9%     14.4%
 Rehospitalization
for Admit Dx in 14   3.5%     6.8%
         Days Rate
Medication Management
             Medication Management
     Up to 30% of all hospitalizations and perhaps 45% of
     re-admissions among the elderly can be attributed to
     medication mismanagement.*
     VNSNY/Center for Policy and Research Study: One-
     third of the home health care patients surveyed had
     evidence of a potential medication problem or were
     taking a drug that is considered inappropriate for older
     people.**
     Shift the focus from Assessment to Action
*American Association of Health Plans, 2002
**Center for Policy and Research, 2002
Physician Communication
   Physician Communication
Identified as a significant factor impacting hospitalization
by many HHAs
Questions for your HHA:
– How does your agency communicate with physicians?
– Do you have consistent communication processes?
– Do all staff know your communication processes and follow them
  consistently?
– Are you viewed as an asset to physicians and physician offices?
– Do you improve the efficiency of physicians and their offices or do you
  add chaos and confusion?
SBAR Tool (Situation, Background, Assessment,
Recommendations) (www.ihi.org) (Adapted for HH)
Home Telehealth
        Home Telehealth
Telemonitoring, Phone Monitoring, Teletriage
Start simple….but just START!!!
Assess where your HHA can improve
Open discussions with all staff: nurses, aides,
clerical, therapists, managers
Incorporate actions into your Acute Care
Hospitalization Plan of Action (POA)
               Telemonitoring
Telemonitoring includes
the collection of clinical
data and the transmission
of such data between a
patient at a distant
location and a health care
provider through
electronic information
processing technologies.
           Phone Monitoring
Phone monitoring is the scheduled
remote care delivery or monitoring
in which scheduled patient
encounters via the
telephone occur
between a
health care provider
and a patient
and/or caregiver.
                  Teletriage
• Initiated by the patient or caregiver
• Requires a thorough assessment to determine:
   Risk level
   Interventions
   Need for follow-up or evaluation
Your aunt is a patient
at your home health agency
and calls the agency with
complaints of increased
weight and SOB
Are you confident that all staff know your teletriage
protocols?
Would each staff member handle this situation in the same
fashion?
Are there differences in how your staff would handle the
call during business hours and off hours?
ACH Awareness in your HHA
Acute Care Hospitalization…
    What’s your target?

             What is your
              target for ACH?
             What is your
              ACH best practice
              compliance rate?
                STAR
    Setting Targets Achieving Results
 Accelerating
  improvement
 Using “real time” data to
  measure change
 Preparing for quality
  improvement of the
  future: P4P
 “Live Demo Today!”
   Where we’re going….
The CMS Vision


The right care for every
 patient every time.
             How to get there…..
• Putting the Puzzle together piece by piece to
  achieve Transformational Change
    Change which enables a provider to deliver care meeting
     the goals of safety, effectiveness, efficiency, timeliness,
     patient-centeredness, equity
• Results from the implementation of four strategies:
   –   Measure and report performance
   –   Adopt HIT and use if effectively
   –   Redesign care processes
   –   Transform organizational culture
Measure and Report
Performance
 Home Health
  Compare/Publicly Reported
  Measures
 Benchmarking
 STAR – Setting Targets
  Achieving Results
 Best Practice Compliance –
  Measuring Real Time Data
      Adopt Health Information
     Technology (HIT and Use it
            Effectively)
 Telehealth to reduce avoidable
  hospitalizations
 Developmental work preparing for future
  HIT home health endeavors
  Redesign Care Processes
IIncorporate pneumococcal and influenza
immunizations into HHA comprehensive
assessment
CCare Behaviors
   Organizational Culture and
             ACH
 What is organizational
  culture?
 Connection with
  ACH?
 Teamwork
 Coordination of Care
 Communication
 Leadership
How is your home health agency
  positioned for the future?
                                             QUESTIONS???
           .




This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization Support Center for Home Health, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS
policy. Publication number 8SOW-PA-HHQ06.177.

				
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