1. Marren, Joan M. MEd, RN
  2. Harrington, Charlene PhD, RN, FAAN
  3. Kluger, Malvina assistant coordinator

Article Content

FOCUS ON: Improving Safety and Outcomes in Home Care

Because chronically ill older adults account for a disproportionate amount of health care costs, improving safety and outcomes in that population is a major focus of attention. The vast majority of patients served in the home are elderly, and the services most often provided involve nursing care. In order to collect clinical data and monitor outcomes, home health care agencies nationwide make use of a standardized assessment instrument, the Outcome and Assessment Information Set (OASIS). Data collected are benchmarked against a Centers for Medicare and Medicaid Services (CMS) national data set and used for quality improvement and public reporting purposes.


The following articles highlight the impact that nurses can have on home care of the elderly. Using data to make improvements in home care will become increasingly important to nurses as the CMS implements its "pay for performance" initiatives and holds all providers more accountable for clinical outcomes. -Joan M. Marren, MEd, RN


Improving Wound Care Outcomes

Wound care constitutes a large proportion of home care. In 2004, 60.5% of patients served by home health care agencies in the United States had open wounds or lesions at the start of care. 1 The average age of patients served by home health care agencies in 2004 was 75 years; 52% of them were dependent in living skills, and 37% were dependent in personal care. 1 If not properly managed, wounds can necessitate hospitalization or emergent care and can threaten the life of an older adult.


The Visiting Nurse Service of New York (VNSNY) is the largest voluntary home health care agency in the United States, with an average daily census of 26,400 patients, according to the VNSNY 2004 annual report. In 2004, 34.9% of patients admitted to the VNSNY's home care program had open wounds or lesions. 1 Approximately 62.2% of patients were over age 65, with an average of four comorbidities.


The VNSNY Wound Care Management Learning Collaborative was a nine-month quality-improvement initiative in 2002 and 2003 modeled on the Institute for Healthcare Improvement's Breakthrough Series. 2 Thirteen multidisciplinary teams from New York City and the Nassau County branch participated to test and spread within the agency best practices associated with reducing adverse events in patients with wounds. Data from OASIS were used for comparison. Strategies that yielded positive outcomes in this small-scale initiative included


* evidence-based wound care treatment orders at intake: nurses obtained these orders using a two-page protocol to guide discussions with physicians.


* wound care rounds, in person or by teleconference: these structured weekly or bimonthly multidisciplinary meetings focused on evaluation of wound-care management, review of visit utilization, and assessment of the need for consultation with clinical nurse specialists and wound-resource nurses.



The percentage of wound care orders matching evidence-based protocols at intake at the VNSNY increased from 40% to 82% in five months. Requests for consultation with clinical nurse specialists (as consistent with agency protocols) also increased from 75% to 88% in eight months.


These two strategies were then implemented across all 91 VNSNY adult care teams and were tracked. Strategies for disseminating best practices were adapted from the work of Green and Plsek. 3 By December 2003 and throughout 2004, the VNSNY experienced a further decline in the CMS reported rate of emergent care for wound infection or deteriorating wound status. The organization continues to make sure that wound rounds are held and that evidence-based orders are obtained at intake. -Joan M. Marren and Ann Marie Hess, MSN, ANP




1. Centers for Medicare and Medicaid Services. Case mix profile at start/resumption of care [Outcome-based quality improvement report]; 2004. [Context Link]


2. Institute for Healthcare Improvement. The breakthrough series: IHI's collaborative model for achieving breakthrough improvement. Cambridge, MA: The Institute; 2003. (Innovation Series 2003, no. 3). [Context Link]


3. Green PL, Plsek PE. Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative. Jt Comm J Qual Improv 2002;28(2):55-71. [Context Link]

Quality Improvement in Home Health Care


Home health care is dominated by nursing services, and so the positive results of quality improvement efforts in this setting can be attributed largely to nurses. The CMS initiated a national home health quality improvement initiative from 2002-2005 through the Quality Improvement Organizations (QIOs) program.


A total of 5,693 home health care agencies out of approximately 7,000 Medicare-certified agencies received training in outcome-based quality improvement (OBQI) from QIOs; of these, 4,419 submitted to their QIO 5,810 plans. As part of the OBQI process, each participating agency chose to focus its quality-improvement activities from among 41 outcome measures.


The analyses examined the amount of change in the outcome rate (the proportion of episodes in a 12-month period achieving the outcome) between two periods: from baseline (May 2001 to April 2002) to remeasurement (February 2004 to January 2005). For the improvement outcomes, the desired direction of change is an increase; for acute care hospitalization and emergent care the desired change is a decrease. For the top-10 targeted outcomes, the rates improved more among agencies participating with their QIO (that is, those that submitted a quality-improvement plan) than among the nonparticipating agencies. Participating agencies chose target outcomes according to OBQI guidelines: those with average rates worse than the national average at baseline.


For four of the 10 outcomes ("Improvement in Pain Interfering with Activity," "Improvement in Management of Oral Medications," "Improvement in Transferring," and "Improvement in Ambulation or Locomotion"), the average rates in participating agencies improved to the point that the rate for the remeasurement period was close to or better than the national average. However, for the remaining six outcomes, participating agencies' average rates in the remeasurement period remained inferior to the national rates, although their rates had improved more than those of nonparticipating agencies (see Figure 1, at right). Future analyses will examine the association between baseline rate and the amount of change achieved.


In August 2005 CMS's quality improvement initiatives for home health care agencies began to focus on reducing acute care hospitalization rates and improving other publicly reported outcomes. More information can be found at These analyses were conducted by the Delmarva Foundation under contract with CMS, but do not necessarily reflect CMS policy. -Karen Beckman Pace, PhD, RN, and Karen E. Johnson, MS



In 2005 the percentage of older adults living in the community with functional or cognitive impairment or both was 14% for people ages 65 to 74 years, 20% for people ages 75 to 84 years, and 34% for people ages 85 years and over.1


While the national average for unplanned hospitalizations from home care in the United States has remained at 28%, in 2005 10% of home care agencies had rates under 19%. All but four states had at least one agency in this top 10%.2


In a four-year period beginning in 2000, the number of profit-making home care agencies increased by 539, while hospital-based agencies decreased by 375.3



1. Kaiser Commission on Medicaid and the Uninsured. The distribution of assets in the elderly population living in the community. Washington, DC: The Henry J. Kaiser Family Foundation; 2005. Report #7335. [Context Link]


2. Fazzi Associates, et al. National Hospitalization Reduction Study: agencies eligible to participate by state; 2005. p. 2. [Context Link]


3. National Association for Home Care and Hospice. Basic statistics about home care. Washington, DC: The Association; 2004. [Context Link]