Approach The agencies started this performance improvement initiative by focusing on one patient subgroup (heart failure patients) served by one of the agencies (NEHC). New approaches were tried, and effective approaches were codified through training, on-the job coaching, and performance feedback to front-line clinicians. This approach facilitated the spread of these changes to the second agency, and subsequently both agencies expanded their focus beyond heart failure to other common diagnoses in the home health population.
Changes to Standard Care Practices Based on identified opportunities for improvement, the agency incorporated modifications to standard care utilizing existing resources and within the construct of a certified Medicare home health episode (Medicare’s required specific services, assessments, and other activities that a home health agency must provide in order to bill for an episode). First, working with managers and front-line clinicians, they focused on establishing successful contact during the first 3 days of an episode of care. Front-line staff reported that some patients did not respond to the first attempt to establish contact, and staff thought that it indicated that the patient did not want home health care. The agency designed a new initial contact protocol to increase the likelihood of a successful first contact with the patient. Second, staff increased the frequency of contact in the first 3 days of the episode, either through home visits or phone calls. Increased contact served to allowed the home health staff to get to know the patient and have more points of reference upon which to identify whether symptoms were developing or changing. In addition, increase initial frequency served to increase the comfort and confidence that the patient and their family had in the agency. Third, in the context of increasing the frequency and effectiveness of contacts in the first 14 days, home care staff were trained to adopt an “active surveillance” approach. This staff development and re-training initiative instructed staff on practices to increase their awareness and recognition of patient needs or changing circumstances, outside the specific problem-defined focus area(s) of the home health episode. Frequent contact in the first 14 days creates an opportunity for home health staff to intervene proactively in the confusion or symptoms that lead patients or their families to call 911. Fourth, home care staff received professional development training specifically focused on heart failure, called “Heart Failure Boot Camp.” This training provided a review and update on the clinical management best practices for home care for heart failure patients. This training was conducted by the agency’s staff clinical educator at each local field office. Once all the agencies’ existing staff were trained, the training materials were included in new employee orientation. Rate of acute care hospitalizations was tracked and reports were provided to each local field office on a quarterly basis. Agency leadership included review of these data with local field office managers in their existing management meetings to reinforce the importance of this initiative for the agency at the highest levels. As the efforts to reduce hospitalizations evolved to include patients with conditions other than heart failure, the agencies developed a readmission risk assessment that included the number of medications ( < 5; 6–10; 11–15; 16–20; or > 20) and number of hospitalizations within the past 12 months. Staff could act upon the risk elements identified to reduce each individual patient’s risk of readmission.