OASIS Alert

Here's what the most successful agencies do.

Sample Home Health Agency Protocol Interventions for Patients at High-Risk for Hospitalization

Purpose: To designate a specific set of evidence-based interventions for patients identified as being at high risk for hospitalization, and to implement these interventions to increase patient self-management skills and to decrease the hospitalization rate for this population of agency patients.

Goals:      
     • Achieve and maintain agency OASIS hospitalization rate at 23 percent or less.
     • Prevent avoidable emergent care and hospital admissions.
     • Support the development of patient self-management skills.

Procedure:
The patients'ability to engage in self-management activities requires that the patient have the necessary support from the agency in the critical first three weeks of service. The following protocols will be initiated on all patients designated as high-risk at the SOC visit:

Frontload Visits
    • Sixty-five percent of SN visits will be provided in the first three weeks of service.
    • High-risk patients will have daily SN visits X three days.
    • SN frequency on 485 will reflect frontloading protocol. 
    • Average number of SN visits provided to the patient will be unchanged.
 
Emergency Care Plan
    • A patient-specific and disease-specific emergency care plan will be initiated on the SOC visit and completed by the second SN visit.
    • PRN orders will be obtained on admission and included in the 485 for exacerbation of disease process, non-compliance with self-monitoring program or significant changes in the patient condition.
    • Patient will be provided with Zone Tool for symptom management for a primary or secondary or secondary diagnosis of CHF, COPD, asthma or diabetes at SOC visit. Education will be completed by the third SN visit.
    • Patient education of the Test of Agency On-Call Procedure will be initiated by the admitting  staff and completed by on-call staff the evening of the day of the SOC/ROC.

Telehealth Phone Monitoring Program
    • All patients designated as high-risk will have the telehealth phone monitoring protocol instituted on the fourth day of service.
    • During first three weeks of service, high-risk patients will have daily contact via phone or on-site visit.
    • Phone monitoring visits will support and reinforce patient's self-management of their disease process, s/s of worsening condition and the appropriate response to changes in their condition.

Evaluation and Monitoring of Program
    Monitoring data will be collected to evaluate the effectiveness and implementation of the program, including such data as:
    • Percent of high-risk patients with 65 percent of SN visits frontloaded;
    • Percent of high-risk patients with daily contact during first three weeks of service;
    • Percent of patients with patient-specific/disease-specific care plan by second SN visit;
    • Percent of SOC/ROC who have a test of on-call completed on day of assessment.

Source: TMF Health Quality Institute, the Medicare QIO for Texas (www.tmf.org)