Home Health One Agency’s Quality Improvement...

180 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

“Decreasing rehospitalization among home care patients felt like being held responsible for factors many of which are outside of our control when too many external forces really determined rehospitalization decisions.”

This was the prevailing thought in one home health agency (HHA) as rehospitalization rates often exceeded the 30th percentile in Outcome-Based Quality Improvement (OBQI) scores. OBQI scores are calculated by the Centers for Medicare and Medicaid (CMS) to compare achievement of patient outcomes among HHAs. These scores also allow agencies to compare their scores with the national average (benchmarking). Decisions made by physicians, patients, and their families appeared to be a determining factor in most HHA patients’ emergency room usage and rehospital-ization, with the HHA only hearing about the ad-mission afterwards. This prevented the HHA from providing any intervention to possibly pre-vent the rehospitalization. Yet, we and other HHAs are being held responsible. In “Pay for Performance” or “value-based purchasing” being developed by CMS, HHA reimbursement rates will be determined in part by these rehospitalization rates. As CMS also began to pilot bundling, HHAs

will need to work with other providers along the patient’s care continuum (MedPAC, 2010, March). This was a call to action for our HHA.

The Role of HHAs in Preventing RehospitalizationsHospital readmissions from home health and long-term care among Medicare beneficiaries remained frozen at 28% from 2003 to 2006 and actually increased to 29% in 2007, despite con-certed efforts by providers and insurers to decrease these rates (MedPAC, 2010, June, p. 207). Rehos-pitalizations create a significant strain on the federal Medicare budget and were estimated at $12 billion in 2005 at an average cost of $7500 per admission (MedPAC, 2007). Jencks et al. (2009) reported findings with an estimated cost for unavoidable rehospitalizations in 2004 at $17.4 billion. Surprisingly, there are no more recent findings available from MedPAC on cost of rehos-pitalization as of September 2010.

Merrily Evdokimoff, RN, MS

U T I L I Z I N G A T R A N S I T I O N S M O D E L

Home HealthAgency’s Quality

Improvement Project to Decrease Rehospitalizations

One

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Literature ReviewThe literature was reviewed and several trends were found to be instrumental in preventing un-necessary rehospitalization. These include care transitions, chronic disease management, and coaching.

Care Transitions

Care transitions are defined by the American Geriatrics Society as “a set of actions designed to ensure the coordination and continuity of health-care as patients transfer between different loca-tions or different levels of care within the same location” (Coleman & Boult, 2003, p. 556). Care transitions are identified as a time of increased vulnerability for patients, particularly those with complex care needs (Coleman, 2003). The

HHA SnapshotThis organization is a small, municipal-based Medicare-certified HHA/public health nursing agency and provides service to five area towns, providing a public health nurse to two of the participating towns. The HHA budget is approxi-mately $800K with a patient census of 40 to 50. There are 14 other certified agencies, providing significant competition, including the local hospi-tal having its own HHA. Remaining competitive in this environment requires being competitive in Home Health Compare with OBQI rates. Home Health Compare is a CMS Web site providing a detailed comparison of individual agencies ser-vices and risk-adjusted outcomes available for public review to aid in their decision making when selecting an agency (CMS, 2010).

vol. 29 • no. 3 • March 2011 Home Healthcare Nurse 181


182 Home Healthcare Nurse www.homehealthcarenurseonline.com

medical management. Four in five healthcare dollars (78%) are spent on behalf of people with chronic conditions. Ninety percent of seniors have at least one chronic disease, and 77% have two or more chronic diseases (Anderson & Horvath, 2004).

MedPAC (2009, June, p. 12) re-ports: “the most costly beneficiaries tend to be those with multiple chronic conditions, those using in-hospital services and those who are in the last year of life.” Of the top 10 hospital DRGs accounting for the greatest share of total Medicare expenditures, seven are chronic illnesses. Of these DRGs, all are included in the top 10 home care

diagnoses (USDHHS, 2007). Thus, the most costly Medicare beneficiaries are the typical home care/hospice patients: several comorbidities, recent hospitalization, and often in the last year of their life.

Fortunately, with the plethora of information available on the Web and an increasingly computer-savvy population, there is an increased demand by patients for input into their healthcare deci-sions. Also, with the increasing percentage of the population 65+ and the decreasing numbers of primary care providers, access may also become more difficult, placing a greater responsibility for healthcare on the patient.

Coaching

Encouraging patients to identify their own health goals and then developing the POC around those goals is critical to increasing a patient’s self-management skills with chronic illness. Health coaching has been described as an “approach of partnering with patients to enhance self-management strategies for the purpose of pre-venting exacerbations of chronic illness and supporting lifestyle change” (Huffman, 2007, p. 271). Coaching differs from health education as the coach is seen as a facilitator to assist the patient in establishing goals and time lines. When acting as a health educator, the goals are identi-fied by the clinician and the interventions estab-lished. This has been shown to be less effective when the desired outcomes require long-term behavioral changes. The emphasis in coaching is on a partnership between patient and clinician,

transition between healthcare facility and home creates a shift in emphasis of care delivery with a decrease in the role of the professional and additional responsibility for family members or other “care partners” to implement follow-up plans of care, adhere to complex medication regimens and other therapies, as well as assure follow-up with primary care provider (PCP)’s and specialists. A focus on involving the patient and care partner in the plan of care (POC) at this juncture in the patient’s movement along the healthcare continuum from hospital to home is essential, knowing the increased vulnerability of patients and the increased responsibility of the patient and care partners (Parry et al., 2006).

Care transition is a complex phenomenon cre-ated in part by the introduction of diagnostic-related groupings (DRGs) as a determinant of hospital reimbursement in 1983 (Naylor, 2000). Earlier discharges place additional pressure on families and post acute healthcare providers such as home health agencies to provide addi-tional care due to the increased acuity of the needs of the discharged patient (Shaughnessy et al, 2002; Levine et al, 2010). The occurrence of increased rehospitalizations led to the recogni-tion of the need to focus on the “transitions” as a time of increased vulnerability to patients result-ing in poor outcomes (Naylor et al., 2004).

Chronic Illness

Chronic illnesses are often described as “lifestyle” diseases, meaning their management depends as much on the patient’s lifestyle decisions as on

Assuring the patient has transportation

to the appointments is often a critical

issue the clinician may be involved in

solving. Encouraging the patient to write

down questions in the PHR prior to the

appointment and encouraging the patient

to also take the PHR to the appointment

to ask the listed questions further

enhances communication.



of clinicians was examined, including nurses, social workers, and community workers, although no rehospitalization rates were reported in the study (Parrish et al., 2009).

Home care nurses are well positioned to lead an intervention directed at patient self-management, as home care nurses have established an ongoing care management relationship with the patient and care partners in the home setting, are knowl-edgeable about the availability and access to community resources, and have knowledge re-garding use of adult learning principles, goal setting, and patient education materials. These activities are an essential part of the role of the home care nurse (ANA, 2008). In addition, the experience of working with elders in their homes immediately after a hospitalization provides the home care nurse with a realistic view of the chal-lenges these patients and their families face.

Using this information, the organization began to examine the Four Pillars of the Coleman Care Transitions InterventionSM.

Coleman interviewed patients and their fami-lies after a recent hospital discharge to better understand the challenges faced by older adults after an acute care hospitalization. The issues identified by participants included lack of (a) infor-mation transfer, (b) patient/caregiver preparation, (c) support for self-management, and (d) empow-erment skills to assert preferences. Findings of this study led to the development of four pillars or interventions to resolve these issues identified as creating the most difficulty and turmoil to patients and their care partners following discharge from the hospital (Coleman, 2003; Coleman et al., 2002).

and the clinician provides expertise to support patient-identified goals. When coaching, clinicians ascertain the patient’s goals by asking questions such as “What is the most important part of your recovery to you?” and it may elicit a response of “playing a round of golf” or “sitting on the floor to play with my grandchild”. The clinician then de-velops the POC to support attainment of these patient-identified goals and link teaching and in-terventions to goal attainment. The POC, developed with input from the patient and care partners, helps to determine realistic goals of what may and may not be accomplished during a home care admis-sion. Coaching or motivational interviewing has been identified as a more effective method of as-sisting patients with chronic illnesses in learning to develop the lifestyle changes necessary to cope with a chronic illness on a daily basis.

A Call to ActionAs part of a program to introduce evidence-based practice into the HHA, a review of current recom-mended interventions to prevent rehospitalization from the home health setting was initiated. Al-though there are other models, the HHA focused on two. These were the Quality Cost Model of Advanced Practice Nurse Transitional Care de-veloped by Naylor (Naylor, 2000) and the Care Transitions Model developed by Coleman (Coleman et al., 2006).

The research has focused on interventions using acute care–based nurses, both general and advanced practice nurses, following the patient from the hospital to the home (Coleman, et al., 2006; Naylor, 2000). Although these approaches are effective in our situation, there are several reasons why using advanced practice/acute care nurses may not be the best model:

• Increased implementation costs • Duplication of services concurrently being

provided by certified home care agency • Lack of reimbursement under Medicare • Lack of recognition of the specialized skills

of the home care clinician • Inefficient use of Advanced Practice Nurses,

needed in primary care due to the projected shortage of primary care providers with the aging population (Naylor & Kurtzman, 2010).

In later research utilizing Coleman’s Care Tran-sitions InterventionSM, the use of various levels

Table 1. The Four Pillars of the Coleman’s Care Transition InterventionSM

■ Assistance with medication self-management

■ Use of a patient-centered health record

■ Early, consistent communication/follow-up with primary care providers and/or the medical specialist

■ List of personalized “red flags” indicative of a deteriorating condition.

Data from Coleman, E. A., Parry, C., Chalmers, S., & Min,

S. J. (2006). The Care Transitions Intervention: Results of

a randomized controlled trial. Archives of Internal Medi-cine, 166(17), 1822-1828.



centered health record; (c) early, consistent communication/follow-up with primary care providers and/or the medical specialist; and (d) a list of personalized “red flags” in-dicative of a deteriorating condition.

Coleman identified the need to focus on coaching or motivational interviewing to assist patients and their care partners in becoming more able to “self-manage” their chronic illnesses (Coleman et al., 2006).

Implementing the PlanStaff, including nursing and therapists, were included in the discussions regarding interventions to decrease rehospitalizations. Rehospitalization-focused staff meetings were utilized as the time and venue to develop the intervention. At the end of our every other week case conferences time

was also carved out to plan the interventions. This multidisciplinary approach was necessary to develop an effective intervention. Buy-in from all members was key to a consistent intervention that would continue over time. The initial litera-ture review was conducted by the administrator of the HHA as part of a doctoral program of research. The staff was presented with the cur-rent available research. Once the Four Pillars of Coleman’s Care Transitions InterventionSM was selected, staff began discussion on how to imple-ment or operationalize the selected intervention. Ideas were generated; the administrator devel-oped samples and policies incorporating the suggestions and then presented them to the staff for their review and feedback. Topics of the meetings included:

1. What is a Care Transition? 2. Elements of Coleman’s Care Transition Inter-

ventionSM with the Four Pillars 3. Samples from other care transition programs 4. What do we want for our patients? 5. Review of each of the Four Pillars

a. How does this apply to HHA patients? b. How can we incorporate the information

into the HHA admission process? c. What additional information would staff

need?

Coleman and colleagues identified these Four Pillars (Table 1) to provide tools to the clinician and the patient for preventing the most common adverse events from occurring after discharge from the hospital (Coleman et al., 2006). The do-mains or pillars identified to prevent these issues from occurring included (a) assistance with medication self-management; (b) use of a patient-

Table 2. Contents Included in Basic PHR

■ Introductory Letter with Purpose

■ Calendar for Appointments

■ Medication Record

■ Vital Sign Grid

■ Immunization Record

■ Anticoagulant Log

■ Goal Sheets

■ Medical Appointment Log with Questions Noted

■ Red Flags

■ Home Health Aide Care Plan

■ List of Helpful Web Sites

■ Teaching Guidelines (patient specific)

Hospital readmissions from home health

and long term care among Medicare

beneficiaries remained frozen at 28% from

2003-2006 and actually increased to 29% in

2007, despite concerted efforts by providers

and insurers to decrease these rates

(MedPAC, 2010). Rehospitalizations create

a significant strain on the federal Medicare

budget and were estimated at $12 billion

in 2005 at an average cost of $7500 per

admission (MedPAC, 2007).



medication list accompanying the patient home from the hospital or physician’s office and what the patient reports they actually take at home. This information is also required to enable com-pletion of the OASIS-C document.

Tools for the patient may include paper or electronic forms depending on the preference of the patient. Ability to update the list is the pri-mary goal of form selection. In addition, appro-priate supports to assure medication compliance such as pillboxes, prepackaged medications, and/or reminder systems may be needed. Of primary importance is assessing the patient’s ability and/or willingness to comply with the medication regimen (Table 3).

Along with a current medication list, the clini-cian also needs access to information on medi-cation use and side effects, a list of high-risk medications such as Beers Criteria (Fick et al., 2003; Beers, 1997) or Institute of Safe Medication Practice (ISMP, 2008), and agency policies re-garding interventions related to these high-risk medications. In addition, a helpful document to assist in identifying the medication reconcilia-tion process is the Medication Reconciliation Tool (Coleman et al., 2005) to identify common medication discrepancies and how they are resolved (Figure 1).

Personal Health Record

Use of the PHR assists the patient in communicat-ing with the various medical providers involved in their care. Table 4 lists tools for the clinician and the patient to utilize the PHR.

d. How do we assure consistency/continuity with this intervention?

There were forms and other tools that needed to be created. Development of the various forms, including the Personal Health Record (PHR), took approximately 3 months, with an additional pilot testing of the various forms over the next month. All of the above were considered as the PHR was being developed. The PHR was considered the cornerstone of the intervention. The final plan was then presented to the Group of Professional Per-sons (GPPs) for their suggestions and approval. At this HHA, the GPP comprises community members representing the various professionals active in the agency, such as nursing, physical, occupational, and speech therapists, and a social worker as well as a physician, a pharmacist, and a public health nurse and a consumer. The function of the GPP, as outlined in the Home Health Agency Conditions of Participation, is to provide community input into policies related to admission and discharge criteria, medical supervision and plans of care, emergency care, clinical records, personnel qualifications, and program evaluation (CMS, 2005). The initial version was finalized and implemented.

A revision of the forms was conducted after approximately 18 months of usage based on com-ments by clinicians and patients. These included a greater emphasis on goal setting, additional spe-cific records to provide data to PCP, and the addi-tion of a Fall Prevention Teaching Guide.

Creating a Tool Kit for Clinicians and PatientsCreating a tool kit for clinicians and patients began with an introduction to the staff of the Coleman Care Transitions InterventionSM. We then examined each “pillar” and identified what would be needed for clinicians and patients to utilize these pillars (Table 1). The contents of the initial PHR (Table 2) utilized in the quality improvement project described in this article were then expanded to include examination of additional tools listed in the “tool kit” below. The additional tools are available to clinicians for patients as they deem appropriate.

Medication Reconciliation

Medication reconciliation is a requirement of the home care admission visit, in order to respond to the often-conflicting information between the

Table 3. Tools for Medication Self-Management

■ Tools for Staff • Medication list from referral source • Medication information at fingertips • Medication Reconciliation Tool (Figure 1) • Policy on Identification of High-Risk Medications

■ Tools for Patient/Care Partner • Current, easily updatable, readable medication list • Information on medication: purpose, side

effects, reactions • Pill box or reminder system, if needed



Figure 1. Medication Discrepancy Tool. (Courtesy of Eric Coleman.)

Medication Discrepancy Tool (MDT)MDT is designed to facilitate reconciliation of medication regimen across settings and prescribers

Medication Discrepancy Event Description: Complete one form for each discrepancy✍

✓ Causes and Contributing Factors :: Check all that apply :: Italicized text suggests patient’s perspective and/or intended meaning

Patient Level __________________________________________________________________________

System Level __________________________________________________________________________

✓ Resolution :: check all that apply ® Advised to stop taking/start taking/change administration of medications ® Discussed potential benefits and harm that may result from non-adherence ® Encouraged patient to call PCP/specialist about problem ® Encouraged patient to schedule an appointment with PCP/specialist to discuss problem at next visit ® Encouraged patient to talk to pharmacist about problem ® Addressed performance/knowledge deficit ® Provided resource information to facilitate adherence ® Other__________________________________________

Medication Discrepancy ToolTM developed by Eric A. Coleman, MD, MPH, Care Transitions Program (www.caretransitions.org).

® Adverse Drug Reaction or side effects® Intolerance® Didn’t fill prescription® Didn’t need prescription® Money/financial barriers® Intentional non-adherence

“I was told to take this but I choose not to.”

® Non-intentional non-adherence (ie: Knowledge deficit) “ I don’t understand how to take this medication.”

® Performance deficit “ Maybe someone showed me, but I can’t

demonstrate to you that I can.”

® Prescribed with known allergies/intolerances® Conflicting information from different

informational sources. For example, discharge instructions indicate

one thing and pill bottle says another.® Confusion between brand & generic names® Discharge instructions incomplete/inaccurate/

illegible Either the patient cannot make out the hand-

writing or the information is not written in lay terms.

® Duplication. Taking multiple drugs with the same action

without any rationale.® Incorrect dosage® Incorrect quantity® Incorrect label® Cognitive impairment not recognized® No caregiver/need for assistance not

recognized® Sight/dexterity limitations not recognized



tool, the ability to have rapid information ex-change is possible. Providing tips to the family on preferable times to contact the PCP (avoid lunch time, after 4 PM, or Monday mornings, as these are high-volume call times). Because there is often a delay in the PCP receiving hospital discharge information, faxing critical information to the PCP may also facilitate more timely com-munication of patient condition.

Use of SBAR

In addition to assuring early face-to-face contact with the PCPs, educating the patient regarding when to contact the PCP and what information is needed is critical for supporting patient self-management.

The updated medication record, along with the goal identification sheets for the patient, and a form to list questions to ask at the PCP visit all serve to increase collaboration between patient, care partners, and clinicians. It is also important to have the patient identify their “care partner” as the person they perceive as being the most supportive in meeting their healthcare goals. This may be a family member, friend, significant other, healthcare proxy, or even a neighbor. Having another person who is knowledgeable of their healthcare needs can assist them as the role of the home care nurse, therapist, and home health aide decreases. Also, encouraging the pa-tient to take the PHR to the PCP/specialist visit provides an opportunity for dialogue and to update the PHR. Table 2 includes the contents of the PHR.

Having the ability to visit the patient more frequently early in the episode (front-loading visits) is encouraged, as this is when the patient is most vulnerable to rehospitalization (Rogers et al., 2007).

CommunicationCommunication among care providers and pa-tient, family, and other care partners is a neces-sity in decreasing rehospitalization (Tanner, 2010). The increase in use of hospitalists has further fragmented the communication, as the PCP is often neither aware of the patient’s hospi-tal stay nor knowledgeable regarding the new diagnoses and treatments resulting from the hospitalization. Facilitating an appointment with the PCP and/or specialists within 2 weeks of hospital discharge has been shown to decrease hospital readmissions (Jencks et al, 2009). Assur-ing the patient has transportation to the appoint-ments is often a critical issue the clinician may be involved in solving. Encouraging the patient to write down questions in the PHR prior to the appointment and encouraging the patient to also take the PHR to the appointment to ask the listed questions further enhances communi-cation.

Communication tools for the patient and clini-cian are listed in Table 5. The clinician must have current information regarding the patient’s various physicians. Policies for formalizing communication lines between clinician, patient, and PCP/specialists are critical. As more medical practices implement email as a communication

Table 4. Tools for Personal Health Record Usage

■ Tools for Staff • Personal Health Record Admission Packet • Motivational Interviewing/Coaching Skills

■ Tools for Patient/Care Partner • Personal Health Record • Goal Sheets • Care Partner • SBAR (Situation-Background-Assessment-

Recommendation) Guide

Table 5. Tools for Early, Consistent Communication with PCP/Specialist

■ Tools for Staff • Accurate PCP/Specialist Information • Ability to front-load visits • Communication ability with MD-speed memo,

e-mail, telephone • Knowledge of SBAR • Hospital Discharge Information

■ Tools for Patient/Care Partner • SBAR

Communication Techniques for Patients and Advocates

• Transportation to medical appointments • Clear communication lines with MD • Medical Appointment Log with questions noted • PHR to take to appointment



A. Use the following modalities according to physician preference, if known. Wait no longer than 5 minutes between attempts.1. Direct page (if known)2. Physician’s Call Service3. During weekdays, the physician’s office directly4. On weekends and after hours during the week, physician’s home phone5. Cell phone

(Before assuming that the physician you are attempting to reach is not responding, utilize all modalities. For emergent situations, use appropriate resident service as needed to ensure safe patient care.)

B. Prior to calling the physician, follow these steps:1. Have I seen and assessed the patient myself before calling?2. Has the situation been discussed with resource nurse or preceptor?3. Review the chart for appropriate physician to call.4. Know the admitting diagnosis and date of admission.5. Have I read the most recent MD progress notes and notes from the nurse who worked the shift

ahead of me?6. Have available the following when speaking with the physician: • Patient’s chart • List of current medications, allergies, IV fluids, and labs • Most recent vital signs • Reporting lab results: provide the date and time test was done and results of previous tests for

comparison • Code status

C. When calling the physician, follow the SBAR process:(S) Situation: What is the situation you are calling about?

• Identify self, unit, patient, room number. • Briefly state the problem, what is it, when it happened or started, and how severe.

(B) Background: Pertinent background information related to the situation could include the following: • The admitting diagnosis and date of admission • List of current medications, allergies, IV fluids, and labs • Most recent vital signs • Lab results: provide the date and time test was done and results of previous tests for comparison • Other clinical information • Code status

(A) Assessment: What is the nurse’s assessment of the situation?(R) Recommendation: What is the nurse’s recommendation or what does he or she want?

Examples: • Notification that patient has been admitted • Patient needs to be seen now • Order change • Document the change in the patient’s condition and physician notification.

This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition.

Figure 2. Guidelines for Communicating with Physicians Using the SBAR Process. (Courtesy of Kaiser

Permanente.)



SBAR Communication Technique for Patients and Advocates

Situation

I am______________________________(state your name)

I am the___________________________(relative, advocate, friend, Medical Power of Attorney) for _________________________(state patient’s name)

I am concerned about___________________________________________________

Background

The patient came to the hopsital because___________________________________

The patient’s diagnosis is_______________________________or is unknown at this time

The patient’s physical or mental limitations are_______________________________ (Examples: dementia, hearing loss, difficulty walking, unable to communicate,

language barriers)

The patient is_______________________________(Examples: on oxygen, receiving new medications, having procedures or surgery, awaiting test results)

Assessment

New symptoms I have noticed are_________________________________________

What has changed in the patient’s condition is _______________________________ (Examples: pain level, vital signs (blood pressure, temperature, pulse), breathing, mental

status, color of skin, sweating, agitation, dizziness, lack of energy)

The patient seems to be__________________________________________________ (Examples: stable, unstable, declining or deteriorating, in serious trouble)

Request

I would like to discuss the following possible actions __________________________ (Examples: consultation/evaluation, a second opinion, calling the Attending Physician,

scheduling a family meeting, additional tests or monitoring, transfer to another unit or facility)

If a change is ordered, how and when should I contact you if there is no improvement?_______________________________

An Empowered Patient® publication, used under license by The Empowered Patient Coalition. Copyright © 2009 Dr. Julia A. Hallisy and Helen W. Haskell. For more information please visit www.EmpoweredPatientCoalition.org.

S

B

A

R

Figure 3. SBAR Communication Technique for Patients and Advocates. (Copyright 2009, Dr. Julia A.

Hallisy and Helen W. Haskell.)



personalized to the individual patient, with an area for specific recommendations to be added. General areas that may be included are signs of heart failure, wound infection, urinary tract in-fection, anticoagulant toxicity, and changes in mental status. In addition, when to call 911 im-mediately should be listed, along with specific emergency planning information such as what to do if electricity goes off and there is oxygen or IV equipment in the home. Specific parameters of when to seek assistance should also be noted, such as “weight gain greater than 3 pounds in a week” or “pulse above 110.” Use care in using medical jargon or abbreviations such as “hold”, systolic blood pressure or SBP < 60. Teaching guides appropriate to patient diagnosis and lit-eracy level should also be placed in PHR. Recog-nition of the need to be cognizant of vision needs and health literacy principles led to the

SBAR (Situation, Background, Assessment, Request) has been utilized by clinicians to sup-port clear communication across disciplines (Figure 2). In addition to professional clinical staff, inclusion of home health aides in learning SBAR is essential. Providing them with a pocket card can assist them in communicating their observations to other care providers. SBAR may also be utilized by patients and their care partners to organize the information prior to contacting the physician. (Denham, 2009). A sample guideline for patients and care partners can be provided in the PHR (Figure 3).

Red FlagsIdentification of personalized “red flags” enables the patient and/or care partner to recognize a change in condition prompting notification of nurse (Table 6 and Figure 4). The list should be

Acton Public Health Nursing Servicexxx-xxx-xxxx

Figure 4. Red Flags. (Courtesy of Acton Public Health Nursing Service.)

This plan outlines what to do in case of an emergency. Please keep this information where you can find it. Our Agency has nursing staff on call 24 hours a day including nights, weekends and holidays.

Please call the nurse if you have:

Heart/Lung Problems❑ A productive or frothy cough❑ New congestion❑ Increased shortness of breath❑ More swelling in your legs or feet❑ Weight gain of ______ in 24 hours

Signs of Infection:❑ Increased redness❑ More or different drainage❑ Wound/area gets bigger❑ Temperature of 100 or more❑ Change or new odor from a wound

Other Problems:❑ No bowel movement for 3 days❑ New skin problems❑ Change in balance, coordination or strength❑ Fall with or without injury❑ Confusion or increased forgetfullness

Signs of Ineffective Anticoagulant Therapy❑ Bleeding from nose, mouth, gums, rectum❑ Bruising❑ Leg pain❑ Tarry stools

Urinary Problems❑ Foul odor to urine❑ Catheter not draining❑ Back or flank pain❑ Not able to urinate❑ Increased weakness❑ Bloody, cloudy or change in urine color

Other:_____________________________________________________________________________________________________________________________________________________________________



cian groups are also concerned with decreas-ing rehospitalization rates and so we had something they wanted and understood—the perfect marketing tool!

• Additional in-service education in coaching provided by the agency via online courses, instructional manuals, and role-playing within agency can provide additional knowl-edge and support to staff as they develop in the coaching role (Box 1).

ConclusionDecreasing rehospitalization is a challenge for all sites along the healthcare continuum, but in home healthcare there is often a feeling among staff that the decision to rehospitalize a patient

development of a document with numerous pic-tures and diagrams (Figure 4). Numerous teach-ing tools are available on the Web to meet health literacy needs (AHRQ, 2010) (Box 1).

Impact of Intervention on Patient OutcomesImplementation of the Four Pillars of the Coleman Care Transition’s Model resulted in a 12 percentage point decrease in rehospitalization among Medi-care beneficiaries (Table 7). This statistically significant finding (P = <.05) brought the HHA well below the national case-mix adjusted aver-age of 23% to 24%. The HHA also experienced a 6% decrease in emergent care visits, but were un-able to achieve the national benchmark of 18% to 19% (Table 8). One possible explanation for this continued use of emergent care may be that pa-tient’s deteriorating condition was being identi-fied earlier, and stabilized in the emergency room, thereby possibly avoiding hospitalization. Also, culturally, the community takes pride in its local hospital and it has been suggested that some see emergency room visits as “supporting the hospital.” This belief system presents a chal-lenge to the HHA clinicians who encourage the patient to “call us first.”

Six Lessons LearnedImplementation of this intervention provided many lessons for our agency:

• Identifying “champions” in the agency whose actions supported the project through the challenges that occur during implementation.

• Staff buy-in was critical: inclusion of multi-disciplinary staff in planning and implement-ing the project helped guarantee success. Participation and success created a feeling of teamwork and pride in the project and organization.

• There was a cultural shift within the agency as staff and patients alike were empowered to prevent rehospitalization with the provi-sion of the various tools and planned inter-ventions.

• Incorporating the project into current pro-cedures, such as the admission visit, cre-ated ease of use and less of an impact on productivity.

• Marketing tools came from our successes: referral sources such as hospitals and physi-

Table 6. Tools for Use of Red Flags

■ Tools for Staff • Hospital Discharge Information • Red Flags Document • Access to disease-specific information

■ Tools for Patient/Care Partner • Red Flags Document • Applicable, health literacy appropriate Teaching

Guides/Booklets • Emergency Plan

Table 7. HHA Rehospitalization Rates

Implementation 6 mos 12 mos

N 87 104 103

Agency 32.2% 20.2%* 20.4%*

National 23.6% 23.0% 24.0%

*P = <.05.

Table 8. HHA Emergent Care Rates

Implementation 6 mos 12 mos

N 86 102 101

Agency 33.7% 24.5% 25.7%

National 19.0% 18.3% 18.8%



Address for correspondence: 154 N. Shore Dr., Stow, MA 01775 ([email protected]).

The author of this article has no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educa-tional activity.DOI: 10.1097/NHH.0b013e31820c158d

REFERENCES

American Nurses Association (ANA). (2008). Home Health Nursing: Scope & Standards of Practice. Silver Spring, MD: Nursesbooks.org.

Anderson, G., & Horvath, J. (2004). The Growing bur-den of chronic disease in American. Public Health Reports, 119(3), 263-270.

Agency for Healthcare Research and Quality (AHRQ). (2010). Retrieved from http://www.ahrq.gov/qual/pillcard/pillcard.htm

Beers, M. (1997). Explicit criteria for determining po-tentially inappropriate medication use by the elderly. Archives of Internal Medicine, 157(14), 1531-1536.

Center for Medicare & Medicaid Services (CMS). (2005). 42 CFR Ch IV. 484.16: Conditions of Participation: Home Health Agencies. Group of Professional Person-

is made by others, without their input. These interventions may prevent the patient and phy-sician from reaching the point of needing to make a decision regarding rehospitalization by teaching the patient how to prevent serious exacerbations and when to intervene earlier in the illness trajec-tory to prevent the need for rehospitalization by providing treatments available in the outpatient setting. The application of the Four Pillars of Coleman’s Care Transition InterventionSM and the special skills of home healthcare clinician can aid in avoiding rehospitalization by teaching the patient appropriate self-management skills.

Acknowledgment

The author thanks the staff of Acton Public Health Nursing Service for their support of this project.

Merrily Evdokimoff, RN, MS, was Administrator, Acton Public Health Nursing Service, at the time this article was written. She is currently a PhD candi-date at Boston College, Connell School of Nursing, Chestnut Hill, Massachusetts.

BOX 1.

Useful Additional Resources

Web Sites

Care Transitions• http://www.caretransitions.org/CTI_FAQ.asp• Care Transitions Coaching Fact Sheet:• http://caretransitions.tmf.org/Portals/21/Documents/

Care/Tools/CTIFact%20Sheet.pdf

Coaching/Motivational Interviewing• National Society of Health Coaches: http://www.

nshcoa.com• http://www.healthsciences.org/infocus/InFocus_

Moving_to_an_Evidence- Based_Health_Coaching_Practice.html

Health Literacy• Health Resources and Services Administration

http://www.hrsa.gov/publichealth/healthliteracy/

Medication Self Management:• Online med management system: http://www.

mypillbox.com• High alert Medications: http://www.ismp.org/Tools/

highalertmedications.pdf• Pill cards: http://www.ahrq.gov/qual/pillcard/pillcard.htm• Blood thinner medication safety: http://www.ahrq.

gov/consumer/btpills.htm#booklet

Patient Safety• Institute for Healthcare Improvement (IHI) http://www.

ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTrainingScenariosandCompetencyAssessment.htm

• Institute of Medicine (IOM) http://www.iom.edu/Global/Topics/Quality-Patient-Safety.aspx

Further Reading Resources

American Nurses Association. (2008). Home Health Nursing: Scope & Standards of Practice. Silver Spring, MD: Nursesbooks.org.

Huffman, M. (2009). Health coaching: A Fresh approach to improve quality outcomes and compliance for patients with chronic conditions. Home Healthcare Nurse, 27(8), 491-496.

Institute of Medicine. (2000). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press.

Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

Lorig, K., & Holman, H. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26(1), 1-7.



Medicare Payment Advisory Commission. (MedPAC). (2007, March). Report to congress: Medicare payment policy. Washington, DC: US Printing Office.

Medicare Payment Advisory Commission. (MedPAC). (2009, March). Report to congress: Medicare payment policy. Washington, DC: US Printing Office.

Medicare Payment Advisory Commission. (MedPAC). (2009, June). Report to congress: Improving incen-tives in the Medicare program. Washington, DC: US Printing Office.

Medicare Payment Advisory Commission. (MedPAC). (2010, June). A Data Book: Health Care Spending and the Medicare Program. Washington, DC: US Printing Office.

Naylor, M. (2000). A Decade of transitional care re-search with vulnerable elders. Journal of Cardiovas-cular Nursing, 14(3), 1-14.

Naylor, M.D., Brooten, D.A., Campbell, R.L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transi-tional care of older adults hospitalized with heart failure: a randomized controlled trial. Journal of the American Geriatrics Society, 52(5), 675-684.

Naylor, M. D., & Kurtzman, E.T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899.

Parrish, M. M., O’Malley, K., Adams, R. I., Adams, S. R., & Coleman, E. A. (2009). Implementation of the care transitions intervention: sustainability and lessons learned. Professional Care Management, 14(6), 282-293.

Parry, C., Kramer, H. M., & Coleman, E. A. (2006). A qualitative exploration of a patient-centered coach-ing intervention to improve care transitions in chronically ill older adults. Home Care Services Quarterly, 25(3-4), 39-53.

Rogers, J., Perlic, M., & Madigan, E. A. (2007). The effect of frontloading visits on patient outcomes. Home Healthcare Nurse, 25(2), 103-109.

Shaughnessy, P. W., Hittle D. F., Crisler, K. S., Powell, M. C., Kramer, A. M., Schlenker R., Engle, K. (2002). Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement. Journal of the American Geriatrics Society, 50(8), 1354-1364.

Tanner, E. (2010). Transitions of care: What is the role that home care plays? Home Healthcare Nurse, 28(2), 61-62.

U.S. Dept. of Health and Human Services, Health Care Financing Administration, Office of Research and Demonstrations (USDHHS). (2007). Data from the Medicare Data Extract System. Health care financing review. Statistical supplement. Baltimore, MD: US Gov. Office of Information Services. Retrieved from http://www.nahc.org/facts/08HC_Stats.pdf.

nel. Retrieved from http://edocket.access.gpo.gov/cfr_2005/octqtr/pdf/42cfr484.16.pdf

Center for Medicare & Medicaid Services. (2010). Home Health Compare. Retrieved from http://www.medi-care.gov/HHCompare/Home.asp?version=default&browser=Firefox|3.6|WinXP&language=English&defaultstatus=0&pagelist=Home&CookiesEnabledStatus=True

Coleman, E. (2003). Falling through the cracks: Chal-lenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555.

Coleman, E., Boult, E., & American Geriatrics Society Health Care Systems Committee. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriat-rics Society, 51(4), 556-557.

Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The Care Transitions Intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828.

Coleman, E., Smith, J., Frank, J., Eilertsen, T., Thiare, J., & Kramer, A. (2002). Development and testing of a mea-sure designed to assess the quality of care transi-tions. International Journal of Integrated Care, 2(1), 1-9. Retrieved from http://ijic.org.

Coleman, E. A., Smith, J. D., Raha, D., & Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing factors. Archives of Internal Medi-cine, 165(16), 1842-1847.

Denham, C. (2009). SBAR for patients. Journal of Patient Safety, 4(1), 38-48.

Fick, D. M., Cooper, J. W., Wade, W. E., Waller, J. L., Maclean, J. R., & Beers, M. H. (2003). Updating the Beers criteria for potentially inappropriate medica-tion use in older adults: results of a US consensus panel of experts. Achives of Internal Medicine, 163(22), 2716-2724.

Huffman, M. (2007). Health coaching: A New and excit-ing technique to enhance patient self-management and improve outcomes. Home Healthcare Nurse, 25(4), 271-274.

Institute for Safe Medication Practice (ISMP). (2008). Retrieved from http://www.ismp.org/Tools/highalertmedications.pdf

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine, 360(14), 1418-1428.

Levine, C., Halper, D., Peist, A., & Gould, D. A. (2010). Bridg-ing troubled waters: family caregivers, transitions, and long-term care. Health Affairs, 29(1), 116-124.

For 10 additional continuing nursing education articles on quality improvement topics, go to nursingcenter.com/ce.


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