1. Crossen-Sills, Jackie PT, PhD
  2. Toomey, Irene RN, MBA
  3. Doherty, Meg MSN, ANP-CS, MBA

Article Content

One third of patients 65 years of age and older discharged from the hospital are readmitted within 3 months. This study examined the common reasons for patient readmittances from home healthcare and introduced a three-step strategy to reduce the rate. In 9 months, the Norwell Visiting Nurse Association (NVNA) was able to identify and define the problem, investigate common reasons for hospital readmittance (through literature review and quantitative and qualitative analysis data), and develop a three-step intervention process that consisted of changing the service delivery model, implementing an agency-wide education and training program, and implementing early home telemonitoring.


The study found that after 6 months, the NVNA was able to decrease the hospitalization rate by 2.6%.


How can a home healthcare agency reduce the occurrence of unplanned hospitalizations? This question has plagued many home health agencies (HHAs) since the introduction of the utilization outcome reports by the Centers for Medicare & Medicaid Services (CMS). Many HHAs participate in outcome enhancement projects through regional quality improvement organizations (QIO). These outcome enhancement processes have been described as interpreting outcome reports, selecting target out-comes (that are meaningful and statistically sig-nificant), analyzing numbers of cases, examining the magnitude of outcome differences, correlating data collected to agency relevant goals, establishing clinical significance of information, investigating care processes, identifying problems/strengths and "best practices, " developing action plans, monitoring the plan of action, and re-assessing patient utilization outcomes (Shaugh-nessy et al., 2002). The following are some of the outcome enhancement measures used by the Norwell Visiting Nurse Association (NVNA) in an effort to reduce unplanned hospital readmittances.


Problem Identification

Home healthcare is transitioning to a new, relatively untested payment system as CMS moves to implement the pay for performance (P4P) system. The new P4P initiative encourages home care agencies to use valid quality measures to assess and monitor patient improvement. These measures are closely linked with evidence-based clinical guidelines, utilization outcomes, andclinical outcomes of care. One utilization outcome is that of acute care hospitalization, and through various initiatives, agencies are being encouraged to decrease acute care hospitalizations. Patients and their families are confronted with considerable personal and emotional turmoil every time a hospital readmittance occurs. In addition, there is a financial toll to the healthcare system every time a patient is readmitted to an acute care hospital. As the length of stay in acute care hospitals decreases, patients are discharged to the home earlier and in poorer health (Anderson et al., 2005; Bowles & Cater, 2003). Thirty-three percent of patients 65 years of age or older who were discharged from a hospital were readmitted within 3 months (Schwartz, 2000). The most critical period for the occurrence of a readmittance was noted to be within the first 3 weeks after admission to home care (mean, 18 days) (Madigan et al., 2001). CMS reported that 25% of unplanned hospitalizations for home healthcare patients occurred within 7 days of the start of their home health episode, and nearly 58% of these readmittances occurred within the first 3 weeks of home health-care, with the median risk-adjusted rate for hospitalizations reported at 29.03% (CMS, 2005). In 2003, more than 1.8 million patients aged 65 yearsand older were treated in emergency departments for fall-related injuries, and more than 421,000 were hospitalized (Centers for Disease Control, 2005). Recognizing that the NVNA already had an ex-tensive fall-prevention program in place, it was decided to expand on this in an attempt to decrease our acute care hospitalization rate while improving chronic disease management systems.


Step 1: Literature Review-Causes of and Strategies to Reduce Hospitalizations

Hospitalizations A literature review was conducted to identify causes sited by investigators for unplanned hospitalizations in home healthcare. The most common cause identified was difficulty breathing, and the top four diagnoses of patients readmitted to the hospital were congestive heart failure, diabetes, HIV/AIDS, and chronic skin ulcers (Rosati et al., 2003). Other risk factors identified included age, gender, marital status, cognitive impairment, polypharmacology, poor self-rated health, and long length of stay or complications during acute hospital stay (Bowles & Cater, 2003). In addition, low income, living alone, impaired functional status, and difficulty with medication management (compliance and adherence issues) also were reported (Hong et al., 2004; Landi et al., 2005; Naylor et al., 2004; Rosati et al., 2003; Smith et al., 2000). A variety of strategies to reduce unplanned hospitalizations have been cited in the literature. Shaughnessy et al. (2002) espoused the use of out-come enhancement techniques to decrease hospitalization rates. They suggested having agency staff select target outcomes for enhancement, evaluate the key features of how care is providedto patients, and implement a plan of action change specific features of care to enhance patient-level target outcomes (Shaughnessy & Hittle, 2002). Stewart and colleagues (1999) recommended "front loading " visits, offering more services during the first 2 weeks of home care, whereas other researchers recommended using standardized care processes, such as telemonitoring, and specific disease management programs for patients with congestive heart failure respiratory problems (Ehrenberg et al., 2004; Hoskins et al., 2001; Schneider, 2004). A key factor, according to Naylor and colleagues, was the ability to identify patients likely to benefit from specialized interventions. According to the study, early identification of at-risk patients would enhance patient care planning and thereby prevent costly readmittances (Naylor et al., 1994, 1999).


Step 2: Seeking Agency-Specific Qualitative and Quantitative Data

Qualitative: Focus Groups

Under the guidance of the NVNA Performance Improvement Department, focus groups comprised of clinical staff and managers were convened to ex-plore their perceived reasons for patient unplanned hospitalization. The goal of these focus groups was to collect useful information on the area of acute care hospitalizations. Multiple stake-holders participated in the discussions in an attempt to identify the reasons for hospitalization. As a result of these meetings, a cause-and-effect diagram, called a fishbone, was developed to explore possible explanations for hospitalizations among HHA patients. The reasons were analyzed and arranged categorically and resulted in a visual representation of relationships and a hierarchy of hospitalization events. This technique assisted the agency in its search for some of the root causes by identifying problem areas and comparing their relative importance. The brainstorming sessions were lively, as the multidisciplinary staff offered their insights into potential causes for unplanned hospitalizations. The fishbone diagram used for this intervention is shown in Figure 1.

Figure 1 - Click to enlarge in new windowFigure 1. Clinicians' perceived causes for unplanned hospitalizations. ALF = assisted living facilities; ER=emergency room.

Quantitative: Patient Profiles

Records of all patients hospitalized during the month of January 2005 were reviewed to measure clinical, functional, and demographic factors. Based on the literature and focus group findings, specific patient variables were collected. The data allowed the agency to determine if the patient pro-370file of patients readmitted to the hospital for the NVNA was similar to that cited in the literature and suggested by staff. The variables included primary diagnosis, sociodemographic, clinical, and functional data. Frequencies and measures of central tendencies were obtained for all variables. The mean age of the sample was 79.13 years, with a range from 22 to 97 years. Of these patients, 22% resided in assisted living facilities, and 26% lived alone. An analysis of the number of days patients were on service before returning to the hospital found that 45% were readmitted within the first 15 days on service. See Table 1 for details. One third of the patients readmitted made the decision to go to the hospital without medical input. The decision makers in this category were defined as the patient, family member, significant other, or private paid caregiver. See Table 2 for details. Patient diagnostic profile at time of readmittance found 25% of the patients experienced difficulty breathing or chronic obstructive pulmonary disease (COPD), 14% had congestive heart failure (CHF) or other cardiac-related problems, and 7% were readmitted with wound problems. The resulting profile of NVNA patients readmitted to the hospital was found to closely parallel that of CMS 2003 benchmark data for HHA. CMS data providea national comparison of Medicare-certified HHA. See Table 3 for details.

Table 1 - Click to enlarge in new windowTable 1. Days to Rehospitalization
Table 2 - Click to enlarge in new windowTable 2. Patients Sent to Hospital
Table 3 - Click to enlarge in new windowTable 3. Diagnostic Reasons for Hospitalization Based on M0895 Responses

Step 3: Program Implementation-Service, Education, and Telemonitoring

A multifaceted approach was devised to address unplanned hospitalization. The plan included aug-menting the delivery of clinical services, stafftraining and education, and the increased use of telemonitoring for patients with CHF or COPD. To assist the agency in training and development, consultant firm, RBC Limited, healthcare and management consultants (Straatsburg, NY), was selected for its expertise in training clinical and managerial staff in outcomes and OASIS standardization.


Delivery of Services

New agreed-upon clinical practice guidelines for visit frequencies were entered into the patient's electronic medical record at admission. This was a change in practice from equal visits throughout the course of service to "front loading " clinical visits during the first 2 weeks of care and decreasing visits as the episode of care progressed. In addition, during team meetings, clinicians were able to discuss care management and coordinated individual care throughout the week, thereby minimizing multiple visits on the same day by the various care professionals (nursing, physical therapy, occupational therapy, social work, dietitian, and home health aide). This added step provided the patient professional care and monitoring more days per week. If a change in patient status was noted by any clinician, prompt intervention occurred, thereby preventing worsening of symptoms and potential hospitalization.



The NVNA Performance Improvement Department created educational programs to increase the knowledge and awareness of both OASIS assessment and clinical skills. All staff members receive initial training in OASIS data collection at orientation and undergo periodic training to ensure understanding and compliance with CMS-established standards. In April 2005, a series of educational programs were developed and implemented. The first of the series was entitled "Connecting the Dots. " This inservice reeducated clinicians about the relationship between OASIS assessments, both at admission and discharge, and CMS outcomes and emphasized their importance to the optimal provision of quality healthcare. The second clinically focused inservice was "Understanding Respiratory Equipment in the Home. " This inservice introduced staff evidence-based practice and the current technology used by patients who experienced respiratory problems in home healthcare. Another component of staff education was the ongoing monitoring of patient hospitalizations. Through "real-time " analysis of hospitalization data, clinicians heightened their awareness of the reasons for patient readmittances. The data were posted in graphic form for staff review and analysis. Discussions occurred at weekly team meetings and monthly staff meetings. The meetings provided the clinical staff an opportunity to learn from each other by sharing successful strategies in patient management, thereby preventing unnecessary hospitalizations. Educational tools were developed to assist clinicians in performing uniform assessments and interventions. Through the use of a laminated cue card system (that could be easily attached to clinical bags) the staff had at their fingertips best practices and agency-specific standards for uniform patient care. Initial cue cards included standardized pain assessment, dyspnea assessment, and OASIS assessment guidelines and progressedto measuring edema and auscultating heart sounds. Patient educational materials were standardized, and uniform teaching tools were compiled and distributed to assist staff in the educational process of patients and family. The cue cards represented in Figure 2 depict "The Sweep, " a technique that was created by the consulting firm RBC Limited to assist clinicians in organizing the OASIS assessment visit. These cards assist the clinicians in uniformly assessing patients in their home. This helped our staff to organize the components of the patient assessment by gathering information from each patient encounter in thehome. With this technique, the clinician is prompted to use every patient contact/interaction as an opportunity to obtain pertinent OASIS data. With the knowledge that staff reliability in OASIS assessment was essential for outcome enhancement, the next step included a total agency retraining in the proper interpretation and completion of the OASIS documentation. Our home care agency recognized that any improvement in outcomes required that our clinicians be skilled in accurately assessing patients at the time of all OASIS completions (start of care, resumption of care, transfer, and discharge). The training was atwo-part process consisting of inservice training and interrater reliability (IRR) testing. IRR is defined as two clinicians performing the OASIS assessment simultaneously, while scoring each item independently. After the visit, the clinicians compare their results for consistency and accuracy based on the CMS OASIS definitions. The first part was training the staff and managers on the importance of OASIS accuracy. The second part involved IRR testing in the field on patients. This area encompassed the 23 critical OASIS M00s that affect reimbursement and key clinical and functional outcomes. Initially, clinical manager to clinical manager IRR occurred. The goal of this IRR was to achieve >95% accuracy. Once consistency was achieved, clinical managers performed covisits with clinicians. After the joint assessments, clinicians and managers discussed OASIS results, comparing answers in an effort to improve overallstaff consistency and reliability with the OASIS assessment.

Figure 2 - Click to enlarge in new windowFigure 2. "The Sweep " and "The Sweep " Cue Card. Dx = diagnosis; meds = medication; PICC = peripherally inserted central catheter; IV = intravenous. From Norwell Visiting Nurse Association, Inc. (C) RBC Limited, reprinted with permission.

Inservices on "Dietary Restrictions for Patients With CHF and Hypertension " and "Do You Hear What I Hear? " (a breath sounds inservice), improved the overall assessment skills for patient care in these areas. Another inservice was a five-part physical assessment series. This provided the staff with an indepth review of the admission visit; cardiac assessment; respiratory assessment; neuromuscular assessment; and abdominal, genitourinary, and gastrointestinal assessment. The physical assessment series was developed and conducted by NVNA nurse practitioners and advanced clinical staff members.



With the expansion of telemonitoring for all patients with CHF and COPD at time of admission, the NVNA was able to closely monitor some of the most vulnerable patients on a daily basis. Tele-monitoring patients for early signs and symptoms, the exacerbation of an existing problem, or development of a new problem were essential components of care management. For this reason, tele-monitoring units were installed during the first or second visit. This allowed more precise monitoring during the first 2 to 3 weeks of service by the telemedicine nurse for patients with CHF or COPD.



Strategies to decrease readmittances to the hospital during a 6-month period resulted in an incre-mental decrease in readmittance rates. Unplanned hospitalizations decreased by a rate of 2.6% during a 6-month period based on CMS utilization out-come data.


Implications for Home Care

How can agencies better care for patients at home so they do not return to an acute care facility? The NVNA took a number of steps to reduce the frequency of unplanned readmittances. These steps included altering care intervention patterns, staff education in patient assessment, patient education using standard processes and tools focusing on signs and symptoms of disease processes, statistical modeling of hospitalized patients for "real-time " monitoring of patient status, and early installation of telemedicine for all appropriate patients with CHF or COPD. The results of these processes allowed the NVNA to successfully reduce hospitalizations.


Specialty care teams and master clinicians, defined as clinicians with advanced coursework and training, worked closely with staff providing consultation, joint visits, and inservices to reinforce best practices and agency specialty resources. The comprehensive education and training, intensive patient intervention within first 2 weeks of admission to home care, and a care focus emphasiz-ing patient education and disease management, allowed the agency to realize a 2.6% drop in unplanned hospitalizations during a 6-month period. The commitment of the clinical staff was an essential component in the program implementation. Through ongoing updates, the staff were able to recognize a continual decline in the percentage of unplanned hospitalizations as identified by the transfer OASIS during the 6-month period. The use of a point-of-care system that provided real-time data allowed the agency to be proactive in the identification of high-risk patients and the overall management of unplanned hospitalizations. Through small changes in practice and large changes in communication, the staff became aware of the procedures to address potential problems.


Where Do We Go From Here?

There are a number of areas the agency continues to work on in an effort to decrease overall hospitalization rates. One area is the increased use of specialty teams to work intensively as clinical resources to create discipline-specific customized care pathways based on contemporary evidence-based content and care. One study of care pathways for patients with CHF found that patients whose care was managed by care pathways had 48% fewer readmittances (Hoskins et al., 1999). The development, training, and implementation of discipline-specific care pathways are essential for optimal patient care in home healthcare. Once the specialized pathways are finalized and implemented, they will be integrated into an electronic documentation system so that the staff can be prompted in proper interventions as the daily note is being entered into the medical record. Another area under development is compiling an integrated hospitalization risk assessment tool that can be integrated into the electronic documentation system. The importance of identifying risk factors for hospitalizations has been noted by several authors (Bowles & Cater, 2003; Rosati et al., 2003).


One additional area the agency is focusing on is the 24-hour emergency call system for patients and their families. This provides 24-hour nursing through an on-call system to assist patients with medical-related concerns. The system is emphasized by clinicians at the time of admission and routinely throughout patient episode of care to assist the patient experiencing any difficulty.



Patient profiles and patterns of service can be useful to home care agencies for optimal planning and utilization of services. A close examination of reasons patients are admitted to the hospital can provide insight into optimal caremanagement. Through intensive staff education, front loading visits, and introducing telemonitoring, the NVNA decreased the agency's hospitalization rate. Recognizing that reducing readmittance rates at the NVNA is a work in progress; the Agency has taken positive, productive steps in the education and training of its staff and the patients they serve.




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