Home Health Quality Improvement National Campaign II (2010-2011)

On September 19, 2011, Charles Schade made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (3.4 MB). Plugin Software Help.

Slide 1

Home Health Quality Improvement (HHQI) National Campaign II (2010-2011)

Charles P. Schade, MD, MPH
Medical Epidemiologist

WVMI [West Virginia Quality Improvement] QualityInsights

Slide 2

Acknowledgements

• Co-authors of final report:
  • Shanen Wright.
  • Bethany Knowles.
  • Karen Hannah.
  • Eve Esslinger.
• WVMI/QI analytic staff:
  • Jill Manna.
  • Yinghua Sun.
  • John Bowers.
• Cynthia Pamon, Government Task Leader.
• Almost 5,000 participating HHAs.

Slide 3

Disclaimer

The analyses upon which this publication is based were performed under Contract Modification WV0005 to the West Virginia Quality Improvement Organization Contract, HHSM-500-2008-WV9THC, funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. Publication number: 9SOW-WV-HH-BK-081811. App. 8/2011.

Slide 4

Objectives of this talk

• Describe the HHQI National Campaign II:
  • Compare with first campaign (2007).
• Present results of evaluation of the campaign.
• Discuss how the campaign's success might inform future QI efforts involving home health and future national campaigns.

Slide 5

Background

• >3 million recipients of Medicare-paid home health services in the United States each year, including:
  • Medical, nursing, social, or therapeutic treatment.
  • Assistance with the essential activities of daily living.
• Volume increasing over time.
• Patients prefer to stay home when possible, but >25% of home health episodes end in rehospitalization.
• First HHQI national campaign (2007) reduced rehospitalization

Slide 6

HHQI National Campaign II

• Focused on home health patient care quality as measured by:
  • ACH reduction.
  • Improvement in oral medication management.
• Cross-setting initiative.
• Special Project funded by Centers for Medicare & Medicaid Services.
• Patient-centered focus.
• Interdisciplinary.
• Free tools, resources, networking.

Slide 7

Call To Action

• HHQI Summit, January 13, 2010.
• National, state and local stakeholders:
  • National Association for Home Care & Hospice (NAHC).
  • Alliance for Home Health Quality and Innovation.
  • State associations, Quality Improvement Organizations (QIOs), and corporate leaders.

Slide 8

Inter-Connected Movement

Image: A diagram shows the Inter-Connected Movement.

These organizations are show in a circular pattern: Home Health Agencies pointing to Physician Offices pointing to Nursing Homes pointing to Stakeholders (local, state and national) pointing to Hospitals pointing to Community-Based Services pointing to Home Health Agencies.

Slide 9

Cross-Setting Focus

• Efforts to Unite Providers Across Settings:
  • Communication and sharing tools.
  • Campaign supporter designation.
  • Campaign physician advisory panel.
  • Collaboration opportunities at the state level.
  • Cross-setting steering committee.
  • Educational resources.
  • Registration open to all providers—October 2010

Slide 10

Comparison of Campaigns

Slide 11

Comparison of Campaigns (continued)

Slide 12

What is a Best Practice Intervention Package?

• Educational package.
• Top "best practices interventions" for themes of the campaign.
• User-friendly collection of materials designed to be flexible and functional.
• Downloadable from the campaign Web site (and still available).

Slide 13

How Participants Obtained BPIPs

• Login to http://www.homehealthquality.org  to retrieve after registering.
• Available as a complete package or individual sections:
  • Leadership.
  • Disciplines.
  • Tools/Resources.

Slide 14

Image: Screen shot of the HHQI Web site is shown.

Slide 15

BPIP Release Schedule

Slide 16

Fundamentals of Improving ACH

• January 2010.
• The Fundamentals.

"For me, the worst part of playing golf, by far, has always been hitting the ball." Dave Barry

Slide 17

Hospitalization Risk Assessment

• Must know your 'at risk' population.
• Target interventions accordingly.
• Better use of resources.

Slide 18

Emergency Care Planning

• Patient Emergency Plan (PEP).
• Customize for your agency.
• Use on every patient:
  • Modify as appropriate.
• Reinforce.

Slide 19

Compare Interventions

• Intensity.
• Resources.
• Appropriateness.
• Patient Centered.

Slide 20

Improvement in Management of Oral Medications

• April 2010:
  • Accurate Assessment.
  • Medication Reconciliation.
  • Medication Simplification.
  • High-Alert/High Hazard Drugs.

Slide 21

Do We Have a Medication Problem?

• Potentially inappropriate but commonly prescribed medications can contribute to falls, altered mental status, and gastrointestinal bleeding. Medication-induced complications in older adults account for 7% to 11% of their visits to the ED, and contribute to 12% to 17% of their hospital admissions (Fick, Mion, Beers, and Waller, 2008).
• A study by Dr. Eric Coleman and colleagues revealed that 14 percent of elderly patients admitted to the hospital experienced one or more discrepancies between their pre hospital medication regimen, post hospital medication regimen, and what the patient reported actually taking (Coleman, Smith, Raha, and Min, 2005).

Slide 22

Medication Quick Guide: Accurate Assessment

Image: The Medication Quick Guide: Tips for Accurate M2020 Assessment is shown.

Slide 23

High-Alert Drugs

Image: The top part of a table titled "Potentially Inappropriate Medication (PIM) in Older Adults" is shown.

Slide 24

Medication Management: Issues and Opportunity

• Issues:
  • Polypharmacy.
  • Medication Adherence.
  • Preventable hospitalizations from medication adverse events (overuse and underuse).
• Opportunities:
  • OASIS-C comprehensive medication assessment.
  • HHQI Campaign.
• Medication management and reconciliation is key to patient safety and improving care between settings.

Slide 25

Fall Prevention

• July 2010:
  • Multifactorial and Standardized Assessment.
  • AGS/BGS fall prevention guidelines.

Image: A screen shot of the cover page of the publication "Best Practice Intervention Package: Fall Prevention" is also shown.

Slide 26

Fall Prevention

• Accurate Assessment.
• Multifactorial and Standardized Assessment.
• Direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program.
• Evidence Based Interventions:
  • AGS/BGS 2010 Prevention of Falls.

Slide 27

The Impact of Falls

• One out of three adults age 65 and older falls each year.
• Among those age 65 and older, falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma.
• In 2007, over 18,000 older adults died from unintentional fall injuries.
• The death rates from falls among older men and women have risen sharply over the past decade.

http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html

Slide 28

Fall Prevention Resources: Multifactorial Assessment

Image: The Fall Risk Assessment Form is shown.

Slide 29

Fall Prevention Resources: TUG

Image: A Timed Up and Go (TUG) Screening Tool page is shown.

Slide 30

Cross Setting I

• October 2010.
• Coaching.
• Care Transitions:
  • Care Transitions^SM
  • Transitional Care Model.
  • Project RED.
  • Project BOOST.

Slide 31

Do We Have a Care Transitions Problem?

• Patients are at risk of medical errors during discontinuation of care from in patient to outpatient setting and this puts patients at risk of rehospitalization. (Moore, Wisnivesky, Williams, McGinn (2003).
• Almost one-fifth of the Medicare beneficiaries who had been discharged from an acute care facility were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days (Jencks, Williams, and Coleman, 2009).

Slide 32

Use Lessons Learned

• Care Transitions: Barriers and Strategies.
• Read the success stories—what works?
  • Multi-provider meetings.
  • Coaching.
  • Educating staff.
  • Best Practices.

"Focus on remedies, not faults." Jack Nicklaus

Slide 33

Teach Back

Image: An image of publications used for Teach Back is shown.

Slide 34

SBAR

Image: An SBAR worksheet is shown.

Slide 35

Cross Setting II

• January 2011.
• Care Transitions with Chronic Care Patients:
  • Disease Management.
  • Self-Management Support.
  • Telehealth.

Slide 36

Do We Understand the Impact of Chronic Care Issues?

• The costs for hospital care and rehospitalizations increases with the number of different chronic conditions (Friedman et al., 2008).
• "In 2009, 145 million people—almost half of all Americans—lived with a chronic condition" (Robert Wood Johnson Foundation, 2010, p. 5).
• "Between 2000 and 2030 the number of Americans with chronic conditions will increase by 37 percent, an increase of 46 million people" (Robert Wood Johnson Foundation, 2010, p. 7).

Slide 37

Hospital Risk Assessment—For the Patient!

Image: A form titled "Are You At Risk for Going to the Hospital?" is shown.

Slide 38

Top 10 Reasons for Follow-up

Image: A poster titled "Top 10 Reasons You Need Physician Follow-up Within 7 Days After Discharge" is shown.

Slide 39

Cross Setting III

• April 2011.
• Innovative ideas to help prepare for health care changes:
  • Patient-Centered Medical Homes (PCMH).
  • Accountable Care Organizations.
  • Functioning as a provider community.
  • Reducing readmissions while improving quality.
  • Medication reconciliation and medication management from a community perspective.
  • Communication of fall risk with the multi-provider community.

Slide 40

Healthcare Priorities

Center for Medicare & Medicaid Innovation

• Better healthcare.
• Better health.
• Reduced costs

IHI's Triple Aim

• Improve the health of the population.
• Enhance the patient experience of care.
• Reduced, or at least control, the per capita cost of care.

Slide 41

Deciding Whether to Play or Not???

• Since ACOs will be looking for partners to achieve this goal in the most effective and efficient manner, home health agencies must aggressively pursue these groups and convince potential ACOs that they can provide services needed for goal attainment. Mary St. Pierre, CS III BPIP.
• As PCMH models become more widespread, I would expect they would seek close collaboration with Home Care Agencies to meet the needs of these vulnerable populations. Richard J. Baron, MD, MACP, CS III BPIP.

"You must play boldly to win." Arnold Palmer

Slide 42

Best Practices

"The game of golf would lose a great deal if croquet mallets and billiard cues were allowed on the putting green."
Ernest Hemingway

Image: A form titled "Process of Care Investigation Tool—Home Health Agencies" is also shown.

Slide 43

BPIP Downloads* by 6/29/2011

*Individual download of the BPIP or one of its components.

Slide 44

Using Data to Motivate Staff

• HHQI Data Reports:
  • Agency actual data.
  • Current.
  • Focus on ACH and Oral Medications.
• Use HHQI Data Access System Resources:
  • Description of Monthly Report.
  • Data Reports Webinar.

Slide 45

HHQI Data Reports

• Participating HHAs obtained individualized HHQI reports through a separate secure login on the HHQI Web site.
• We required a secure ID from the agency's CASPER Reports for login.

Slide 46

Image: Screen shot of an Acute Care Hospitalization Monthly Report Web site page is shown.

Slide 47

HHQI Resources

• Social Networking.
• HHQI STAR.
• Free Webinars:
  • Home Health and Care Transitions.
  • Making Care Transitions a Reality Through Home Health.
  • Conversations Across the Discharge Divide.
  • Integrating Home Care into Primary Practice to Improve Patient Outcomes.

Slide 48

Webinar Participation

*Page hits to webinar site after webinar through 6/30/2011

Slide 49

Social Networking Opportunities

• Live Chat.
• Discussion Forums.
• Blogs.
• Twitter, Facebook.

Slide 50

Live Chat Participation

Image: A line graph shows the monthly number of live chat participant readers and commenters from April 2010 to May 2011.

Slide 51

Other Social Media Use*

• Facebook:
  • 12 messages.
  • 332-1,447 impressions/view.
• Blog:
  • 2,000 views.
• Twitter:
  • 90 followers.
  • 83 tweets.

* through 6/7/2011

Slide 52

Project Evaluation

• Registered participants.
• Uptake of materials/event participation.
• BPIP evaluations.
• Changes in quality measures.
• Program participation linked to outcomes.

Slide 53

Registered Participants

• 10,865 Medicare Home Health Agencies (HCIS, 2010).
• By 5/31/2011, 4,721 (43%) had registered for the campaign.
• Of those, 3,075 had ≥10 discharges/month (1/1/2010-6/30/2011) and were included in analysis.
• Potentially impacted about 3 million patients.

Slide 54

BPIP User Feedback

• E-mail inquiry (Zoomerang) sent to agencies downloading BPIP.
• BPIP-specific questions, but similar structure:
  • Use of relevant campaign materials.
  • Taking recommended actions.
  • Self-assessed impact.
• 4 BPIPs evaluated.

Slide 55

Recommended Tool Use

Image of bar chart with the following data:

Slide 56

Actions Taken or Planned After Downloading BPIP

Slide 57

Posting Tables and Graphs Showing Medication Management Performance

Image: A pie chart shows Posting Tables and Graphs Showing Medication Management Performance.

Time relative to BPIP download:
After (9)
Plan to (14)
Before (45)
Not Done (31)
Other (1)

Slide 58

Self-Reported BPIP Impact

Slide 59

Outcomes

• Quality measures generally improved.
• Quality performance was better in groups of agencies with more intense participation in the campaign.
• OASIS-B to OASIS-C transition appears to have impacted the medication management improvement measure.

Slide 60

Agencies grouped by participation

• "Nonparticipants" did not sign up for the HHQI National Campaign.
• "Participants" signed up for the campaign, but did not download related campaign materials.
• "Downloaders" signed up and downloaded materials related to the BPIP.
• "Respondents" responded to the user evaluation related to a BPIP.

Slide 61

Acute Care Hospitalization Rate

Image: A line graph shows the acute care hospitalization rates from Jan. 2009 to Oct. 2010.

Legend:
Respondents (n=422)
Downloaders (n=430)
Participants (n=2,225)
Non-Participants (n=1,357)

Slide 62

Medication Management Improvement

A graph shows the rate of medication management improvement from June 2006 to December 2012.

Legend:
Respondents (n=103)
Downloaders (n=190)
Participants (n=1,180)
Non-Participants (n=595)

Slide 63

Impact Assessment

• ACH outcome only.
• Using item response theory, developed composite score for ACH evaluation responses.
• Divided composite score into quartiles, which we believe represented increasing levels of intensity of participation in campaign.

Slide 64

Changes in ACH and ALOS by Participation Intensity Quartile

Image: A bar chart shows changes in ACH and ALOS by participation intensity quartile.

* Average length of service for home health patients in agency.

Slide 65

Cost implications

A flowchart showing the cost implications for BPIP. Project cost $1.4 million; and the average Medicare hospital admission cost $11,000. Both lead to a project cost equivalent to 127 admissions. 195 HHAs in top 2 participation quartiles averaged 1,600 episodes/year; and these HHAs reduced hospital admissions 0.5% more than lower groups. Both lead to 1,560 fewer readmissions than expected.

Slide 66

Limitations

• Observational study (pre-post).
• Small sample size.
• Missing data.
• Confounding ACH with ALOS.
• Externalities.

Slide 67

Conclusions

• Campaign was successful, engaging nearly 5,000 home health agencies.
• Agencies used campaign materials and many adopted recommended practices.
• Quality of care measures:
  • Acute care hospitalization.
  • Medication self-management.
• Participation intensity linked with improvement.

Slide 68

Future Challenges

• Understanding and addressing disparities.
• Reaching smaller agencies.
• Accelerating improvement.

Slide 69

Questions? Comments?

Thank you for coming to this presentation

Presenter e-mail: cschade@wvmi.org
or visit our Web site: http://www.HomeHealthQuality.org