1. Volland, Jennifer DHA, RN, CPHQ, NEA-BC, FACHE
  2. Blockberger-Miller, Sue BSN, MSN, RN


Legislative enactment of the Patient Protection and Affordable Care Act in 2010 created an impetus for change within the healthcare industry. As a result, the entire healthcare continuum is under greater scrutiny and incentives for performance levels and subsequent outcomes. Home healthcare clinicians have a vital role in the emerging spotlight of care transitions from hospital to home. Home healthcare clinicians will need to understand the concepts of patient engagement and patient activation, and have tactical plans for success. Understanding best practices and recommendations will be an element of competitive differentiation. This article reviews these concepts, along with interventions to target health literacy, communication with patients and families, and the use of motivational interviewing.


Article Content

In March 2010, the Patient Protection and Affordable Care Act (PPACA) was enacted into law, creating a tide of ripples throughout the healthcare industry. The entire healthcare continuum came under greater scrutiny as providers became increasingly incentivized for their performance levels and subsequent outcomes. The structure of Value Based Purchasing in FY2015 includes a total of 26 measures with diagnosis-related group (DRG) operating payments increasing to 1.50% and the readmissions reduction program placing an emphasis on hospital 30-day readmission rates for conditions such as pneumonia, myocardial infarction, and heart failure. Hospitals must now focus on patient experience metrics, clinical process of care measures, and efficiency outcomes, as well as how well they close the gaps in care transitions to avoid unnecessary patient returns from preventable complications. It is estimated that approximately one-third of Medicare patients discharged from the hospital setting with home health service placement are readmitted (Mullaney, 2014). The top drivers for hospital 30-day readmissions include a lack of primary care follow-up, poor care coordination (such as follow-up testing and medication reconciliation), and poor ownership of responsibility by patients (Readmissions and Care Transitions Survey, 2012). The home care clinician can play a vital role in mitigating these factors during the hospital-to-home transition process and home health episode of care.

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Section 3024 of the PPACA created a program designed to target selected participants, including primary care practices that provide home-based primary care to the chronically ill. This program, known as the "Independence at Home Demonstration," is being conducted under the Center for Medicare and Medicaid Services for testing service delivery and incentivized payment models (Independence at Home Demonstration, 2014). The 3-year program, which began in 2012, is intended to provide greater support to 10,000 home-limited Medicare beneficiaries through longitudinal, comprehensive, care coordination with a goal of 5% reduction in expenditures. The 16 organizations initially selected for the demonstration will test whether delivering primary services in the home setting and optimizing person-centered support, can improve both the quality of care being provided and reduce costs that have been growing in the U.S. healthcare system. Improved care coordination has become a national imperative and focus across all segments of the healthcare continuum.


The Need for Seamless Care: Closing the Gap

The home care nurse has a direct role in care coordination and patient transitions. The American Nurses Association (ANA) position statement, Care Coordination and the Registered Nurses' Essential Role, affirms the value of the nursing role as integral to care coordination excellence as a core professional standard (ANA, 2012a). In June 2012, the ANA released a white paper, "The Value of Nursing Care Coordination" which further underscored the importance of nursing as a professional competency and the significant contribution that nurses can make to patient-centered, cost-effective care (ANA, 2012b).


In 2014, three care transition metrics become publically reported for hospitals administering the Hospital Consumer Assessment of Health Plans Survey (HCAHPS) to gauge the self-reported patient experience. Three questions form the "Care Transition Measures" composite. The questions include: (1) "The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital"; (2) "When I left the hospital I had a good understanding of the things I was responsible for in managing my health"; and (3) "When I left the hospital, I clearly understood the purpose for taking each of my medications" (HCAHPS, 2013). Although the questions focus on hospital discharge, the consequences of poor understanding, education, and communication of preferences by the hospital to the home health agency, are all issues to which home care clinicians can relate.


The Agency for Healthcare Research and Quality [AHRQ] (2007) brought to the attention of practitioners not only the importance of care coordination as a key strategy but also the fragmentation of vernacular being used in the industry. From their review, over 40 different definitions of care coordination and related terminology were identified. AHRQ has put forward the following as a common definition in creating a unified framework for understanding:


Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care (AHRQ, 2007).


Partnering for improved care outcomes involves coordination between all segments of the healthcare continuum including: hospital units upon patient discharge, emergency departments, patient-centered medical homes, long-term care facilities, and home health agencies. Creating unified and integrated strategies for patient transitions and hand-offs between differing sections of the healthcare continuum can help to bridge alliances, build referral bases, and become a competitive differentiator based upon the quality of services that healthcare clinicians provide within their home health agency. It is the coordination of delivery and the quality of services rendered, that become part of the agency brand as a direct outcome of the care provided by home care clinicians. To thrive in the newly emerging healthcare environment of tomorrow, the home care clinician must become the key coordinator between the hospital, physician and patient, in creating the competitive differentiation to lead market share through new referrals. How the organization and staff message their value to healthcare partners, the terminology selected as a traditional "home care" service or a provider of chronic condition management and coordination, and the ability to leverage existing relationships, will determine how providers will view the home health agency's value in return.


In this new landscape, lacking a clear alignment with what the shareholder perceives as value can become an area of vulnerability. With the hospital's focus on 30-day readmissions, to whom they refer a service after a patient's discharge, becomes a partnership where the hospital has reimbursement dollars at stake. Under this type of symbiotic relationship, the hospital becomes a key stakeholder in home health agencies. Home health agencies need to be ready to provide evidence of outcomes superior to the competition as a method of increasing visible and demonstrable value to those being assessed under Value Based Purchasing and the PPACA.


In Context: A Focus on the Drivers for Hospital 30-Day Admissions

Home health agencies across the country are working carefully to align with partners along the care continuum. The focus on hospital 30-day readmissions has initiated research and education on identifying and defining best practices for home health clinicians. Looking beyond traditional approaches, new opportunities to enhance and expand clinical practice and improve patient outcomes are emerging. The Institute of Medicine states that outcomes-driven care demands a delivery model that encourages and drives patient engagement. Patient engagement is necessary to improve quality, lower costs, and decrease hospitalizations. Healthcare organizations are recognizing patient-centered care as a comprehensive, ongoing process inclusive of nurturing and empowering practices to promote purpose and meaning to life. Specifically, patient-centered care allows for a comprehensive interdisciplinary approach that results in improved patient outcomes (Institute of Medicine, 2014). In providing a patient-centered approach to care, team communication and development of an appropriate care plan related to the top drivers for hospital 30-day readmissions are the priorities. The start of care admission visit is critical to bridging the gap from patient discharge to home. The priorities of the first visit include ensuring a follow-up physician appointment has been scheduled for the patient, determining if any follow-up medical or laboratory testing has been ordered, and conducting medication reconciliation. This may require telephone calls back to the referral source or primary care provider to determine patient needs. Henry Ford Home Care takes an additional step of front-loading patient visits for those who have been identified as high-risk for readmission. In addition to the first visit within 24 to 48 hours of the referral, additional visits are scheduled, as needed, the first week. Ensuring the patient has resources to attend the primary care physician appointment is an important component of the initial assessment (Henry Ford Health System Care Coordination and Readmissions Update, 2013).


When patients transition from hospital to home, a second medication reconciliation process is necessary when the patient returns to their home environment (Volland, 2011). Verifying patient medications by comparing the medications in the home setting versus a list received from the referral source or primary care provider is critical. Home Health Quality Improvement (HHQI) recommends best practices within their Best Practice Intervention Package (BPIP) for the review and documentation of a patient's medications (inclusive of over-the-counter medications, herbal products, and dietary supplements) (HHQI, 2014). These include:


* A full medication review and documentation for all patients, beyond those that require OASIS-C. This also includes patients receiving only therapy services.


* Identification of any potential medication adverse effects or reactions.


* Assessment for any ineffective drug therapies, significant side effects, drug interactions, duplicate drug therapies, and potential noncompliance with drug therapy.


* Notification to the physician of any medication adverse effects or reactions.


* Addressing any medication issues that may affect the patient.



Patient Engagement

Patient engagement is an additional key element to bridging gaps and reducing avoidable hospitalizations. Patient engagement is "...a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly" (Health Affairs, 2013). One of the goals of patient engagement is to spark patient activation, where an individual is able to engage in self-care and is an active participant in achieving the highest level of wellness possible. In part, the success of population health management will be contingent upon the ability of clinicians to effectively manage the health of an increasing elderly population. A critical element will be ensuring patient education and activation is sufficient for self-care as they make the transition from hospital to home (Volland, 2014). Patient activation progresses along a four-step continuum: (1) beginning to take a role in self-management, (2) building knowledge and confidence, (3) talking action, and (4) maintaining behaviors (Insignia Health, 2009). The home care clinician has a role in raising a patient's level of awareness, education, health, and activation, through the continuity of services being provided.


The concepts and tools of health literacy, communication, and motivational interviewing are integral to patient engagement and activation. These interventions are often new to home care clinicians. The Visiting Nurse Associations of America (VNAA) Blueprint for Excellence (2014) provides multiple tools and critical interventions related to health literacy, communication with patients, and motivational interviewing.


Health Literacy

To help address needs related to limited health literacy, the patient should be provided with materials that are at an appropriate education and reading level. Additional skills that should be brought to the interaction include the use of plain language rather than medical vernacular, and adhering to best practices within the Health Literacy Universal Precautions Toolkit, which has been endorsed by AHRQ. The Toolkit was developed by the North Carolina network consortium in coordination with the University of North Carolina at Chapel Hill and has been broadly used across the United States. It includes a quick start guide, a path to improvement outlining a six-step implementation model, and 20 tools that can be effectively used in the home health setting (Health Literacy Universal Precautions Toolkit, 2010).


Communication with Patients and Family

Engaging patients effectively in their care requires the home care clinician to have strong communication skills. Some of the best practices promoted by the VNAA Blueprint for Excellence (2014) include adopting the Teachback technique, using appropriate and consistent teaching materials, collaborating with partners, and using tools to measure patient understanding of their care. Organizations such as Sutter Health have developed tools (available online) to assess whether or not a clinician is effectively demonstrating the Teachback method during interactions and have elevated this skill to the level of a competency (Sutter Health Teachback Method Competency Checklist, n.d.). The home care clinician can also facilitate cross-continuum coordination and empowerment through role-playing questions for the primary care provider with the patient and family (Edgington, 2014).


Motivational Interviewing

The technique of motivational interviewing involves coaching and support to develop patient-centered goals for enhanced engagement and self-management. Using tools such as the importance and confidence ruler, allows for readiness assessment by asking the patient about items related to the importance of engaging in a behavior and their confidence level (Rollink et al., 1999). Placement into a four-quadrant grid (low importance, low confidence; low importance, high confidence; high importance, low confidence; high importance, high confidence) provides the ability for profiling and ongoing assessment and intervention. The importance and confidence ruler equips the home care clinician with both knowledge and awareness of how to engage the patient better in their plan of care.


Project Better Outcomes by Optimizing Safe Transitions (BOOST) advocates using "The 8Ps" as part of the risk assessment arsenal. These include: (1) problems with medications (polypharmacy, high-risk medications such as anticoagulants); (2) psychological (patients who screen positive for, or have a history of, depression); (3) principal diagnosis (reason for hospitalization related to cancer, stroke, diabetic complications, chronic obstructive pulmonary disease, pneumonia, end-stage liver disease, or heart failure); (4) physical limitations (frailty, deconditioning, or other limitations of participating in self-care); (5) poor health literacy; (6) poor social support (absence of a reliable care giver); (7) prior hospitalization in the past 6 months; and (8) palliative care (having a progressive serious illness or if the clinician wouldn't be surprised if the patient died within one year) (Society for Hospital Medicine, 2014). Each of the "Ps" should trigger risk-specific interventions by the home care clinician, with the patient understanding the home care nurses concerns, the risks identified, and engaging the patient in strategies to mitigate risks.


An Interdisciplinary Imperative

Success in an outcomes-based environment does not exist solely in the hands of the home care nurse. Patients need the expertise of physical, occupational, and/or speech therapists, pharmacists, social workers and health coaches. The interdisciplinary team is comprised of all these disciplines. This team must work together in providing care and treatment to maximize outcomes. Establishing patient goals begins with a patient evaluation by the appropriate therapist and/or home care nurse. The evaluation is accomplished by performing the comprehensive assessment, which includes the Outcome and Assessment Information Set (OASIS) data set. Integral within the OASIS are items that evaluate the risk of the patient in several areas. Fall risk and hospitalization risk are two examples. Risk for hospitalization is determined by factors such as a history of falls, multiple hospitalizations, and taking five or more medications. Coordination of care across all disciplines is necessary to create collaborative teamwork, in addition to the avoidance of hospitalization, and the prevention of an exacerbation of patient issues.


Communication becomes a critical factor for the interdisciplinary team to provide effective care and attain patient goals. Many home care clinicians are using the Situation, Background, Assessment and Recommendation (SBAR) technique to enhance communication practices. Originally developed by the United States Navy as a communication method on nuclear submarines, it was introduced into healthcare in the late 1990s (Safer Healthcare, 2015). The SBAR technique has become a Joint Commission stated industry best practice for standardizing communication. Structuring the dialogue between home care clinicians, and the regular use of an SBAR format is important to establishing a culture of quality, promoting effective communication during times of disagreement, increasing patient safety, and creating high reliability (Safer Healthcare, 2015). A progression of SBAR in a dialogue could be:


Situation: Here is the situation... (Description of the situation that is prompting the conversation or phone call).


Background: The supporting background information is that... (Brief history of the patient and pertinent data. Usually only a couple of sentences).


Assessment: My assessment of the situation is that... (Information about assessment and condition provided).


Recommendation: I recommend that.... Do you agree? (Recommended next steps provided with an action statement to secure mutual agreement).


Using the linear progression of SBAR in a conversation creates a mental communication model to ensure individuals are on the same page during the conversation (Safer Healthcare, 2015).


With the increasing focus on chronic care management, all disciplines have an important role in engaging, teaching, and guiding, the home care patient. In tandem with care delivery that provides the best patient outcomes, a realization of the importance and willingness to use an interdisciplinary approach is needed. Interdisciplinary teamwork and collaboration allows examination of the patient's condition from multiple sources of expertise, which further promotes the value of a home health agency. Interdisciplinary teamwork will secure current referral sources and relationships, as well as attain new partnerships for the future.


A New Era for Home Care Clinicians

Healthcare priorities shifted under the PPACA, and patient care coordination has become the responsibility of the entire healthcare team, across the continuum of care. The metrics used to gauge a home health agency's operational success is shifting to referrals and outcomes. In the future, hospitals will have a greater incentive to refer patients to the most efficient agencies with low hospital readmission rates. The ability to drive referrals through outcomes creates a strong competitive advantage and opportunity for differentiation in the marketplace (Wyatt Matas and Associates, 2010). Hospital and home care clinicians are united in the belief that the hospital to home transition process must be improved (Smith & Alexander, 2012). The changing healthcare environment has resulted in a new framework for practice with a need to understand the impact and responsibility around care coordination, avoidable readmissions and emergency department visits, communication strategies aimed at patient activation, and patient engagement. With this knowledge the home care clinician will continue to be an integral part of both the healthcare and home care team toward improving patient outcomes.


Box 1. Relevant Clinician Take-Aways


* Closing the gap on care transitions will be a major focus in 2015 for the entire healthcare continuum. Communication and partnerships remain essential.


* What determines agency "value" will be based on outcomes, and for home care clinicians this equates to quality of care, referrals, and preventing avoidable readmissions.


* Team communication, spacing of visits, the "8 Ps" as a risk assessment approach, and medication management should be priorities.


* Patient engagement and the ability to engage in self-care can be fostered by every home care clinician. Elements to consider include patient activation, patient-centric approaches to care, health literacy level, and the use of motivational interviewing to guide assessments and outcomes.


* Multiple resources are available to help support the daily work and tasks of home care clinicians as they interface with patients, families, and loved ones (see Resources for Best Practice).


Box 2. Resources for Best Practice

Health Literacy Universal Precautions Toolkit. The toolkit includes multiple techniques for working with low health literacy individuals, in addition to resources such as videos, handouts, and checklists.


Home Health Quality Improvement Best Practice Intervention Packages. The Web site includes guidelines and recommendations on many topics and disease conditions including underserved populations, patient self-management, fall prevention, and medication management.


Importance and Confidence Ruler. The handout is an assessment tool which can be used with patients to determine their stage of readiness for change and quadrant placement.


Project BOOST implementation toolkit. Provided by the Society for Hospital Medicine, the toolkit provides the 8Ps to be monitored for risk assessment and implementation tips.


Sutter Health Teachback Method Competency Checklist. The checklist provides criteria for assessing staff effectiveness when interacting with patients and can be used as a formal competency by organizations.


VNAA Blueprint for Excellence. The Web site provides multiple tools and critical interventions for clinician checklists, handouts for patients, and downloadable pamphlets.




Agency for Healthcare Research and Quality. (2007). Closing the quality gap: A critical analysis of quality improvement strategies. Retrieved from[Context Link]


American Nurses Association. (2012a). Care coordination and registered nurses' essential role. ANA position statement approved 6/2012. Retrieved from[Context Link]


American Nurses Association. (2012b). The Value of Nursing Care Coordination. A white paper of the American Nurses Association. Retrieved from[Context Link]


Edgington S. (2014). Care transitions: Don't lose your patients. National Health Care for the Homeless Council. Retrieved from[Context Link]


Health Affairs. (2013). Patient engagement. Retrieved from[Context Link]


Health Literacy Universal Precautions Toolkit. (2010). Retrieved from[Context Link]


Henry Ford Health System. (2013). Care Coordination and Readmissions Update. Retrieved from[Context Link]


Home Health Quality Improvement. (2014). Best practice intervention packages. Retrieved from[Context Link]


Hospital Consumer Assessment of Health Care Providers and Systems. (2013). HCAHPS Fact sheet. Retrieved from[Context Link]


Independence at Home Demonstration. (2014). Fact Sheet. Center for Medicare and Medicaid Services. Retrieved from[Context Link]


Insignia Health. (2009). Patient Activation Measure. Retrieved from[Context Link]


Institute of Medicine. (2014). Retrieved from[Context Link]


Mullaney T. (2014). MedPAC endorses readmissions penalties for home health, hospice benefit for Medicare Advantage. Retrieved from[Context Link]


Readmissions and Care Transitions Survey. (2012). Health Leaders Media. Retrieved from[Context Link]


Rollink S., Mason P., Butler C. (1999). Importance and confidence ruler. Retrieved from[Context Link]


Safer Healthcare. (2015). Why is SBAR communication so critical? Retrieved from[Context Link]


Smith S. B., Alexander J. W. (2012). Nursing perception of patient transitions from hospitals to home with home health. Professional Case Management, 17(4), 175-185. [Context Link]


Society for Hospital Medicine. (2014). Risk Assessment-8P. Project BOOST implementation toolkit. Retrieved from[Context Link]


Sutter Health. (n.d.). Teachback method competency checklist. Retrieved from[Context Link]


VNAA Blueprint for Excellence. (2014). Tools and critical interventions: Patient engagement. Retrieved from[Context Link]


Volland J. (2011). Aligning hospital outcomes and accountability for patient safe transitions to home. California Association of Healthcare Quality (CAHQ) Journal, 35, 18-21. [Context Link]


Volland J. (2014). Where population health management and risk collide: Risk propensity as a critical competency. American Society for Healthcare Risk Management (ASHRM) Forum. Retrieved from[Context Link]


Wyatt Matas and Associates. (2010). How home healthcare thrives with healthcare reform. Retrieved from[Context Link]