OASIS Alert

Consistency -- not dollars spent -- made the difference.

Would you like to reduce your acute care hospitalization outcome by 12 percent in one year? Here's how one agency did it.

Problem: When Silver Springs, NY-based Wyoming County Health Department Certified Home Health Agency began addressing unplanned hospitalizations among its patients, this outcome was well above state and national averages, says its director of nursing, Lori Roche. A chart audit gave the rural agency the following information:
 
• Seventy-one percent of patients hospitalized were admitted to the hospital in the first three weeks of home care. Thirty-three percent of these admissions occurred in the first week and another third took place in the second week of the home health episode.

• Nurses often visited only once a week in the first three weeks, especially in weeks two and three.

• Most patients hospitalized were admitted for breathing difficulties or wound problems.

• Patients received erratic teaching from clinicians, especially patients with congestive heart failure.

• Physician notification and response were inconsistent.

Good news: Continuity of care was not an issue. Patients usually saw the same nurse for most of the visits. And each nurse teamed up with a "buddy" who visited when the primary nurse could not, so at least two nurses were familiar with each patient.

First step: The agency focused on developing agency parameters for treating patients with diabetes, heart failure, vital signs problems etc., Roche tells Eli. The HHA also requested standing orders that correlated with physician notification requests.

For example, if a physician wanted to be notified when the patient gained three pounds, the agency also asked for a Lasix order or other standing order to use in that event.

Next steps: The agency began providing consistent education to patients with CHF. This included an emergency plan, posted near the phone or on the refrigerator, to tell the patient and family when to call the agency and when to call 911 (for a sample emergency plan, see Eli's OASIS Alert, Vol. 7, No. 4, p. 34).

Front loading visits helped to accomplish the needed teaching before a crisis occurred, Roche says. Nurses visit several times a week in the first three weeks and supplement these visits with phone calls, especially in the first week.

Next Decision Delighted Doctors

To improve consistency of physician notification and to increase the response rate, the agency decided on fax notification unless the physician insisted otherwise. Roche sent a letter to all the referring physicians explaining this policy and its goals: better communication with the patient's health care provider and a decrease in unnecessary hospitalizations.

The fax notification form -- adapted from one the agency's quality improvement organization (IPRO) provided -- quickly told the provider whether the fax was urgent, non-urgent, or just for the provider's records.

"The response was huge, doctors love it," Roche reports. The agency immediately saw better response to its notification, nurses had an easier time keeping track of whether they had gotten a response and clinicians liked the space on the fax where they suggested an action the physician could take, she says.

Result: IPRO awarded Wyoming County HHA the "2006 Quality Award for Outstanding Performance" for attaining the highest relative improvement of all New York State HHAs for reducing avoidable acute care hospitalizations.

Lesson learned: Fairly simple changes can have big results, Roche tells Eli. It helps to concentrate first on the things you already know you should be doing, such as patient teaching and physician communication, she adds.

What next: Because discharging pa-tients too early from the hospital appears to be the cause of many of the unplanned hospitalizations, Wyoming County HHA is addressing that issue next. Hospitals are unlikely to change much because of pressures on them, Roche expects. So the agency is focusing on educating hospitals about what home health can and can't do, encouraging more effective transition planning and improving how the HHA addresses the sicker patients they now get, she says.

Remaining focused on preventing un-planned hospitalizations is also very important, Roche adds. If an agency loses focus, the outcome rate can creep back up while you're addressing other issues.

Note: For a copy of the physician letter and fax form Wyoming County uses, email Marian Cannell at marianc@eliresearch.com, with "fax notification" in the subject line.