Home Care Today: Preventing Rehospitalization Through Effective Home Health Nursing Care

Monica S. Vasquez RN, BSBA, COS-C

Home Healthcare Nurse – Featured Journal
February 2008
Volume 26 Number 2
Pages 75 – 81

Of the 10 outcomes listed in Home Health Compare, acute hospitalization has been the main focus of many home health agencies. After the Medicare change in payment for services, the prospective payment system, improving outcomes has been a difficult journey for most home health agencies, but many have been able to accomplish this great task.

The Centers for Medicare and Medicaid Services (CMS) have made drastic changes in reimbursement for home health agencies in an effort to decrease the cost of care for patients. Because of these changes, to make a profit, agencies are limited to only a few visits to provide care for each patient. More than 2.4 million elderly and disabled people are Medicare beneficiaries, receiving care from the more than 8,100 Medicare-certified home health agencies throughout the United States ( CMS, 2006 ). Home health agencies must devise new ways to provide quality care with limited funding.

On October 1, 2000, the home health prospective payment system (PPS) was implemented ( Outcome Concept Systems, Inc. [OCS], 2004 ). Under PPS, home health agencies receive a single payment for a 60-day episode of care for a Medicare beneficiary. A standardized assessment tool called the Outcome and Assessment Information Set (OASIS) was developed to calculate a base payment and to evaluate the quality of care provided by Medicare-certified agencies ( OCS, 2004 ).

In the future, CMS will be changing home healthcare reimbursement from PPS to pay for performance. According to CMS (2006) , pay for performance “will link to actual activities and efforts of providers using evidence-based practices and systems (in the form of structural measures that will be collected at agency level) to promote use of such practices.” This means that all home health agencies must strive to show an improvement in outcomes to receive a higher reimbursement rate for their efforts. It is critical for a home health agency to monitor its own outcomes and devise ways to improve each outcome.

Acute Hospitalization After Home Health Admission

The growing population of patients discharged to home health is chronically ill and elderly with complex clinical needs ( Daily & Newfield, 2005 ). In 2003, 42% of seniors 65 to 79 years were admitted to the hospital via the emergency room and 52% of those 80

years of age or older ( Giacini & Lehmann, 2004 ). This is one of the reasons why CMS has selected the acute hospitalization measure for national focus and will be identifying a target-attainable rate and goals for a reduction in hospitalization rates ( Home Health QIOSC, 2005 ).

Between April 2003 and March 2004, the national episode rate for acute hospitalization after home health admission was 28.13% of all episodes, and the average agency rate was 30.80%. Among all home health agencies, 25% had rates lower than 23.16%. The average rate for the 25% of agencies with the best rates was 17.35%, and the average rate for the 25% of agencies with the highest rates was 47.38% ( Home Health QIOSC, 2005 ).

Findings show that one fourth of all hospitalizations of home health patients occur within 7 days after admission to a home health agency, and that 58% occur within 3 weeks after admission ( Home Health QIOSC, 2005 ). According to a study sponsored by Briggs Corporation and cosponsored by the National Association for Home Care and Hospice and Fazzi Associates, Inc., the “unplanned or preventable hospitalization was 28% when CMS first began reporting this measure on 11/03/03. It is 28% today, which means that every year, more than 1 million patient episodes result in unplanned hospitalization” ( Briggs Corporation, 2006 , p. 1).

Case Scenario

Mr. William Smith is a 68-year-old man discharged from the hospital with a diagnosis of heart failure, non–insulin-dependent diabetes mellitus, hypertension, and high cholesterol. He had been hospitalized for complaints of chest pain and after many tests received a diagnosis of myocardial infarction with 4 coronary arteries affected.

Mr. Smith underwent quadruple coronary artery bypass and was discharged after 7 days. Before this hospitalization, he independently performed all activities of daily living, and he and his wife Betty Smith were planning a vacation. This hospitalization set him back in his plans, and he fears things will not be the way they were before it occurred. He is referred to ABC Home Care to be followed at home. Mr. Smith is not familiar with home health and is a little anxious about his situation. Mary Ann Jones is his home health nurse and case manager.

Nursing Interventions

What is the best way for Mary Ann to care for Mr. Smith? Few clinical practice guidelines have been developed specifically for home health. Of 1,026 guidelines summarized in the National Guideline Clearinghouse™ (2003) , only 35 (3.4%) mention “home care” ( Peterson, 2006 ).

Nurses working in the home health setting must devise creative ways to care for their patients. In the home, the nurses do not have all the supplies and equipment found in a hospital setting. According to Daily and Newfield (2005) , home care nurses not only need to understand current laws and practice standards, but also must develop and use successful strategies to manage risks. Daily and Newfield (2005 , p. 94) also state that “home health nurses are uniquely prepared to promote improved care outcomes, thereby reducing costly legal exposure, preventable rehospitalization, and emergency use; other adverse events; and premature or preventable long-term care institutionalization.”

According to Medicare standards, and those of CMS, a registered nurse shall make the initial patient assessment and continue to reevaluate patient needs throughout the course of care ( Fairnot & Hogue, 2006 ). The home health nurse must look at the patient as a whole. According to Fairnot and Hogue (2006) , the assessment of an elderly person, in particular, should cover a broad range of conditions including medical, mental, nutritional, and functional conditions, as well as home safety. The nurse must examine the patient’s environment to determine whether the home is appropriate for home health.

What the Top Agencies Are Doing to Improve Outcomes

Many strategies are used by top home health agencies. These strategies are described in the following discussion. According to Briggs Corporation (2006) , some of the strategies performed by home health agencies are as follows:

* Front-loading visits

* 24-Hour availability/response programs

* Medication management

* Case management

* Disease management programs

* Patient/caregiver education

* Telehealth.

Frontloading Visits

Front loading visits are a strategy whereby the agency increases visit frequency or service at the beginning of care to reduce potential for unplanned hospitalization ( Briggs Corporation, 2006 ). Mary Ann develops a plan of care and ensures that Mr. Smith is seen 3 times in the first 2 weeks for assessment and teaching and will have follow-up visits throughout his episode of care. This is the most critical time to ensure that Mr. Smith does not have an unplanned hospitalization.

24-Hour Availability/Response Program

The 24-hour availability/response program involves availability of a nurse around the clock ( Briggs Corporation, 2006 ). Mary Ann ensures that Mr. Smith has the numbers to call for any questions any time of the day. She teaches him reasons to call nursing and when to call 911. This is very important. If the patient is misinformed or not given enough information, his first response to any complication of his disease process is to go to the emergency room.

Medication Management

Medication mismanagement accounts for 30% of all hospitalizations and 45% of readmissions among the elderly ( Briggs Corporation, 2006 ). Mary Ann discovers that Mr. Smith is receiving a total of 5 different medications, whereas he was taking only vitamins before this hospitalization. She teaches Mr. Smith and his wife about each of his medications and discusses the reasons the medications were prescribed, the side effects of each medication, the time of day each medication is to be taken, and whether to take the medication with or without food. She also explains the importance of him taking his medications as ordered. Mary Ann explains that one of the best ways to keep up with the times for taking medications and to ensure compliance is to fill a weekly pill box. She assists both Mr. Smith and his wife in setting up his medications in such a box.

Case Management

Mary Ann is not only Mr. Smith’s nurse. She also is his case manager. She is responsible to look at the whole picture and to use community resources as well as other clinicians while ensuring cost-effective outcomes for her patient. Fairnot and Hogue (2006 , p. 53) explain case management duties using the following list:

* Assessing the needs of each patient

* Planning and implementing a care plan

* Coordinating resources

* Monitoring the patient’s progress and the delivery of services

* Evaluating the medical status of each patient on an ongoing basis.

Mary Ann performs the initial assessment. She then plans and implements a care plan that includes goals for Mr. Smith to achieve before discharge. She coordinates resources that Mr. Smith’s needs and refers Mr. Smith to physical therapy to help improve his endurance and develop a home exercise program. She will continue to monitor his progress with each visit and to evaluate his status through interdisciplinary communication. Mary Ann will continuously evaluate his status in meeting each of his goals. She documents the date each goal is met, and if Mr. Smith does not meet a goal within the allotted time frame, the care plan is revised.

Fairnot and Hogue (2006) further explain that the “more attuned the nurse case manager is in assessing the patient’s needs, the better the case management process will be in providing access to the right care resources and in preventing unnecessary emergency room visits, hospital admissions, and life-threatening complications.”

Disease Management Programs

A disease management program is a system of evidence-based coordinated healthcare interventions and communications developed for specific diseases to improve patient care and prevent unplanned hospitalizations. The patient and caregiver play a vital role in these programs. (To Be continued…..)