OASIS Alert

Deluge of advice overwhelms agencies.

It's easy to feel overwhelmed when you compare the volumes of information available about how to prevent acute care hospitalization with the limited resources most agencies have. Here are some strategies to keep you on track.
 
The challenge: The difficulty agencies are having improving the national acute care hospitalization outcome -- stubbornly stuck at 28 percent since Home Health Compare began in 2003 -- reflects how many factors contribute to the outcome, experts say.  

The solution: Figuring out which factors are the major contributors in your agency is a first step, said Donna Thorson, with quality improvement organization HealthInsight in Las Vegas, NV, in her March 28 audioconference "Process Reliability and Acute Care Hospitalization." Home health agencies, hospitals, doctors, patients and caregivers all contribute to the problem.

Example: A hospitalization can be necessary if the hospital referred a patient who was inappropriate for home care, or an agency admitted a patient even though no caregiver was available, or a patient incorrectly thought a caregiver was available.

The result: "If your acute care hospitalization rate is improving, identify why and market it," says Vicky Agramonte, performance improvement coordinator with Community Health Center Home Care in Johnstown, NY. If it's not improving, reevaluate the direction of your efforts.

Concentrate On Resources That Address Your Problems

The Centers for Medicare & Medicaid Services' 2007 Home Health Quality Improve-ment National Campaign is three months old and focuses on preventing acute care hospitalizations. The campaign already has provided extensive material to agencies, with about 4,900 home health agencies registered as of April 13, the Institute for Healthcare Improvement reports. The material is also available to HHAs that have not registered.

The percentage of agencies participating in a given state varies widely. The top three states are Delaware with 100 percent, North Dakota with 96.2 percent and North Carolina with 95.8 percent. The states with the fewest agencies participating are Texas with 38.5 percent, Florida with 38.4 percent and Nevada with 27.4 percent.

Resources available: Over the next year, the campaign will provide monthly packages that address many of the concerns agencies are focusing on to decrease unplanned hospitalizations. For example, the March package focuses on hospitalization risk assessment, the April package addresses patient emergency plans and the May package will cover medication management. Other packages will consider front-loading visits, phone monitoring, telehealth, fall prevention and physician relationships.

Tip: Choose one person in your agency who will review these packages as they come out and select the parts that are appropriate for your agency to consider, IHI suggests.

Select Strategies for Success

Not every unplanned hospitalization can be prevented. Before you can tackle a problem, you need to define it more clearly. The Acute Care Hospitalization Event Tree is a tool experts recommend. Using this decision tree, you can determine whether a patient's hospitalization was necessary and unavoidable, necessary but avoidable, or unnecessary. Then you can follow the appropriate pathway to clarify the underlying reasons for the hospitalization.

Next, plan to begin at least one intervention. Some interventions -- such as frontloading visits or providing the patient with an emergency care plan -- are used by most of the best-performing agencies. (For a sample HHA protocol of interventions for patients at high risk for hospitalization, see p. 47).

As you decide how to improve your hospitalization rate, consider this advice:

1. Look at what you can control. You may not be able to control what the physicians decide about admitting patients to the hospital, but you can control hospitalization risk assessments or patient emergency care planning, said Marian Essey, with Quality Insights of Pennsylvania, speaking at the October 2006 National Association for Home Care & Hospice's conference in Baltimore.

2. Decide what you can do. Even if you can't manage a full quality improvement project, resist the temptation to do nothing, Essey encouraged. Maybe you can at least begin with staff education, she suggested.

3. Start small. Increase your chances of success in your efforts by starting with something you can do right away, experts say. Instead of spending a lot of time studying and meeting, select something that will demonstrate that a different approach can work and build on that.

Strategy: If you're just beginning to try a hospitalization risk assessment, ask one or two of your best clinicians to try it with their next five patients. Then talk about what worked and what didn't. Share successes with the rest of your staff. (For a risk assessment tool, see OASIS Alert, Vol. 8, No. 2. p. 16 or go to www.medqic.org.)

Note: For a copy of the Acute Care Hospi-talization Event Tree, email marianc@eliresearch. com with "Event Tree" in the subject line.