1. Pierotti, Danielle PhD, RN, CENP, CHPN
  2. Glasheen-Wray, Mary Beth MMSC
  3. Huertas, Andrea R. MBA, RN
  4. Price, Naomi

Article Content

Success in the future of home care relies on the seamless integration of clinical care, agency operations, and financial considerations. Teams who can merge the diverse skill sets of every member will find ways to excel to the benefit of the patient and the agency. Christiana Care Visiting Nurse Association (CCVNA) serves patients across Delaware. They provide over 300,000 visits annually with over 600 employees deployed from two offices. As part of an integrated health system, concerns about readmission rates started as a hospital concern and moved into home care with the implementation of the home care quality measures. Conversations among financial leaders focused on the costs of readmissions and the organizational need for managing finances. Simultaneously, clinical leaders recognized that the people they cared for also wanted to avoid readmission. This recognition merged two conversations into one shared goal. This merger of financial and clinical priorities formed the critical first step toward innovation and success.


To get started, CCVNA examined their data about rehospitalization and chose to focus on one key measure; acute care hospitalization (ACH) risk-adjusted rate. This measure is included in the 5 Star Quality program on Home Health Compare and is a measure of the percent of patients cared for by home care agencies who are admitted to the hospital within 60 days of admission to home care. In 2014, CCVNA's rate was 25.11%. Approximately one in four patients admitted to their services was hospitalized sometime in the following 60 days. In comparison, a national benchmark from a data analytics firm used by CCVNA reported a rate of 23.70%.


Recognizing the opportunity to improve the care they delivered to patients, the clinical team identified case conferences as a standard, but an underutilized structure that could be central to reducing hospitalizations. At the time, case conferences were held most weeks, but since the average discussion lasted 30 minutes per patient, only three or four patients were reviewed. Reviews occurred at various points in the episode of care, not specifically on admission, the best time to reduce risk. The core of the conversation was often unfocused, with large amounts of time devoted to sharing social-based components of care or reporting out specific details of past medical history. After identifying opportunities to improve, the team planned for how they wanted the case conferences to evolve. Keeping the ultimate goal of reducing hospitalizations in mind, key leaders and clinicians attended Integrated Case Management training by Sutter Health Center for Integrated Care (Sutter Home Health Network, 2016). Actively applying the model led them to design a process focused on good planning, good structure, and good facilitation.


Good planning is anchored in consistency and predictability. They chose a standard meeting day, time, and location and established a standard process for identifying patients for review. They also adopted the Situation, Background, Assessment, Recommendation (SBAR) model of communication. This model has demonstrated success in reducing readmissions by streamlining the discussion, keeping the conversation focused on patient-centered goals and risk for hospitalization (Townsend-Gervis et al., 2014). Time and resources were devoted to ensure the entire organization shared a commitment to making the changes. The move to use SBAR was one of the biggest changes. Implementation required extensive education, training, and coaching for all team members. The meeting agenda is a key tool to reinforce this learning. Each week it prompts participants to plan their comments by including reminders about how to use SBAR complete with links to training tools (Figure 1).

Figure 1 - Click to enlarge in new windowFigure 1. SBAR Communication.

Good structure is reflected in the commitment to start and end the meeting on time, keep to the agenda, maintain the SBAR format, and start all cases by reviewing the patient's goals for care. Agendas are distributed at a consistent time, in a consistent format, and focus on patients at risk for hospitalization. Additionally, the team shares key components of the medical record by projecting it on a large screen. By actively sharing the patient's chart; including medication lists, visit frequency, and care plans, everyone has the chance to provide feedback, support patient care, and reinforce teamwork. The SBAR report is documented in the record during the meeting to ensure adherence to the structure.


Good facilitation is reflected in the commitment to coaching, supportive feedback, and staff growth. Facilitators ensure the plan and structure are adhered to during the meeting, close each case by stating the next steps, and intentionally recognize team members for positive contributions, effort, growth, and involvement.


The program was implemented in January 2015. By the end of 2015, meetings had evolved to include a conference call line to support clinicians in the field and also the opportunity for team members to request a review of a nonadmission, but complex case. Case presentations average 6 minutes per patient, allowing for 20 reviews per week and the ACH rate has fallen for 2 consecutive years (Figure 2) from 25.11% in 2014 to 19.36% in 2015 to 14.31% in June 2016. In less than 18 months, these changes reduced the chance that a patient cared for by CCVNA would be admited to the hospital from one in four to just over one in seven. For every 100 patients cared for, 9 more people are able to stay home compared to just 18 months ago.

Figure 2 - Click to enlarge in new windowFigure 2. Acute Care Hospitalization (ACH) Adjusted Rate.

The team continues to build on the model. Commitment to the planning, structure, and facilitation of the model are critical. Facilitators adhere to time lines and are purposeful about coaching and encouraging team members. New ideas to improve the case conference include incorporating video conferencing and the ability to share documents electronically. The clinical team is also working with financial experts to calculate the impact the reduction in ACH rate has had on revenue and expense.


CCVNA demonstrates the potential for success when fully integrated teams share goals, rely on shared data, commit to a process, and follow the outcomes. Without universal commitment to the same project, the time invested in planning and preparing all team members for a successful change may not have been possible. By linking financial and clinical success together, the organization exceeded the orginal targets to reduce hospitalization and continues to identify new ways to support the patient.




Sutter Home Health Network. 2016. Integrated care management training and certification. Retreived from[Context Link]


Townsend-Gervis M., Cornell P., Vardaman J. M. 2014. Interdisciplinary rounds and structured communication reduce re-admissions and improve some patient outcomes. Western Journal of Nursing Research, 36(7), 917-928. [Context Link]