High-Performing Agencies

Effective patient care begins with having systems in place to support delivery, measurement, and improvement for performance. A high performing home-based care organization uses robust data to inform practice, recruits and trains staff for consistent, reliable high performance, and recognizes the value of high performance. Customer service - in other words, a drive to maximize patient experience - is embedded in all aspects of home based care.
The Institute for Healthcare Improvement defined the Triple Aim, which was expanded to include combatting staff burnout as the forth essential element of a ‘Quadruple Aim.’  The four Aims are:
  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations
  • Reducing the per capita cost of health care
  • ‚ÄčImproving staff and clinician satisfaction

As home-based care becomes more competitive and more accountable, every agency must strive to achieve the Quadruple Aim. In this module we examine characteristics of home health and hospice organizations that perform highly on standardized measures of quality and patient experience. Other Blueprint for Excellence modules focus on improving outcomes for specific conditions, adding value (for example, by reducing readmissions) and developing community partnerships to improve population health. Home based care organizations will capitalize on achieving success on the four by communicating this value to payers, patients and referring organizations.
Use these links to navigate ElevatingHome’s Best Practice Recommendations for a high performing home-based care organization.

Use a Quality Improvement Model
Staff and Team Training and Recognition
Improve Patient Experience (see Blueprint Module)
Collect and Use Data Strategically
Develop Community Partnerships
Demonstrate and Communicate Value
Ensure Safety of Your Team 

Use a Quality Improvement Model
Home health organizations need to first identify and adopt a formal quality improvement model that guides assessment and improvement activities in a systematic framework. Table 1 below is adapted from the Institute for Healthcare Improvement Plan-Do-Study-Act-Sustain model (PDSA) and could be one approach used by home based care organizations. See Blueprint for Excellence Resources for links to other Quality Improvement models. Accreditation standards such as the Joint Commission and Community Health Accreditation Program (CHAP) also offer guidelines for developing effective quality improvement programs.
Table 1: Institute for Health Care Improvement Performance Improvement Approach 
Plan-Do-Study-Act (adapted for Home Health)
The PDSA model is a rapid cycle approach to quality improvement that can be used to quickly test and assess changes to drive performance improvements. Use PDSAs to conduct small scale tests of solutions – and drive ongoing performance improvements
  • Start with highest frequency problem area identified. Use both data and front line staff input to identify trends, issues, and possible process changes to test
  • Develop a flow chart for current process to help identify gaps, redundancies, inefficiencies.
  • Identify all staff involved in the workflow and their roles
  • What process steps are in place and that could be modified to improved outcomes or efficiency?
  • Determine what documentation is required?  Who obtains information?
  • Identify resources lacking in agency: staffing, communication modalities, contract issues, etc.
  • Convene diverse PDSA workgroup: different disciplines, representative of different hierarchical levels within the group and potentially, patient/family representatives
  • Empower the workgroup with ownership of the whole process from processes through audit. Ensure common understanding of goals, applicable regulatory requirements, desired outcomes
  • Plan a new process that clearly defines roles and responsibilities for each discipline/department involved
  • Define quality and other measures to determine impact on improvement goal and compliance with process change
  • Standardize and simplify and eliminate unnecessary redundancies
  • Develop prompts in required documentation to assure new process is followed
  • Develop strategy to integrate redesign into existing workflow        
  • Identify resources required within the organization to meet improvement goals.
  • Determine length of time the test intervention will be piloted before evaluation
  • Identify and implement training requirements for the test process
  • Pilot test the new process
  • Implement structures that need to be in place to support staff during the pilot period
  • IT changes
  • Staffing
  • Supervisor availability
  • Identify mechanism to give and receive feedback from frontline staff during the pilot
  • Make sure staff involved are engaged and bought into the process change
  • Solicit feedback from all participants in the test change: frontline staff will be able to provide additional insight into how intuitive the new design is. Depending on agency size – focus groups of clinicians and/or patients can be used to obtain feedback
  • As the pilot progresses, identify additional areas for improvement
  • Continuously monitor pre-determined measures to assess impact on improvement goal and compliance with process change
  • Continue to refine, support, evaluate and sustain the program: a successful pilot does not always lead to successful large scale implementation
  • Develop problem specific audit tools to review the impact
  • Begin audits immediately after implementation. Auditing can be done electronically or manually, retrospectively or prospectively, looking at process or outcomes. (Electronic reports are easy, efficient method to assess adherence to process.  Sample size can be up to 100% of patients.)
  • Retrospective audits are time consuming but can be used to track the quality as well as quantity of process compliance, i.e. quality of documentation, any patient safety issues.  Sample size depends on time and resources available.
  • Prospective (concurrent) audits – allows for more timely feedback.  Reviewer can intervene on any missed opportunities and high-risk areas can be targeted for evaluation.  Effective way to improve compliance.
  • Audit should include all staff in the process. Examine overall compliance as well as individual department compliance. Identify department specific issues that need to be addressed.
  • Audit report should contain (1) Issue; (2) how compliance is defined; (3) current (actual) performance and goal; and (4) action plan if gap between the actual compliance percentage and the goal
  • Analyze audit results.  For example, an analysis of number of patients (or %) not admitted on time might analyze the following factors as possible QI targets: Referral source / Program staff not available / Unable to meet treatment needs / High risk for re-hospitalization / Staffing availability / Insurance verification / Inaccurate documentation—MD delayed admission documentation not current / Length of time it takes for admission visit
  • Assure adequate resources, timely staff communication and team training
  • Build the interventions into electronic tools, staff performance expectations
  • Elevating Home Best Practices:  Remember that many crosscutting QI activities influence performance on all Star Measures. Use these techniques to facilitate improvement across your organization. 
  • Offer staff training on the importance of measures and on improvement specific to measures
  • Provide OASIS training and auditing
  • Match staff to patient need
  • Use patient-defined goal setting
  • Use 'Always events' to improve reliability on high priority performance areas
  • Have staff and clinicians at all levels review data and discuss accountability 

Recommended Resources: Health Resources and Services Administration Quality Improvement Methodology Toolkit.  
Home Health Quality Improvement University - Modules address QAPI and Performance Improvement Projects (PIPs) on a variety of topics. 

Staff and Team Training and Recognition
A successful home health agency will be able to reliably execute necessary clinical and interpersonal interactions with patients, families, and referral sources to achieve and maintain performance. Consistency is crucial. This requires establishing expectations, offering ongoing training, identifying weaknesses through measurement and auditing, and correcting any performance gaps.

Top Tip: Provide annual training and testing for all staff on skills related to Quality Measures, regardless of performance, and track individual performance on Star Metrics monthly

Best Practice: Offer Reliability Training
  • Adopt agency-level procedure manual for all staff
  • 100% record audit
  • Provide annual training and testing for all staff on critical assessments and indicators
  • Use individual monthly scorecards or reports on clinicians (use quantitative data as well as qualitative supervisor reviews to identify strengths and weaknesses)
  • Promote joint initial visits with therapy and nursing
  • Implement interdisciplinary “shadow” program for new staff
  • Use scenario training for applying codes to specific case scenarios
  • Adopt inter-rater reliability training to ensure coding consistency
Best Practice:  Ensure buy in of staff for the agency’s quality agenda
Best Practice Interventions:
  • Create an agency-level Nurse Council to develop or endorse standards of care including “always” events such as pain assessment, front loading, touch points, teleheath, emergency plan, pulse ox
  • Develop a monthly or quarterly “recognition” program such as ‘clinician of the month’ to acknowledge high performance
  • For agencies with multiple sites, consider recognizing the highest performing site
  • Adopt a ‘care excellence’ blue ribbon, pin or other designation to recognize staff consistently meeting criteria
  • Educate patients and families on the meaning of the “care excellence’ designation
Best Practice: Help clinical managers manage strategically for quality
Best Practice Interventions:
  • Make star ratings, quality improvement and key indicators the priority for managers
  • Designate operational responsibility to supervisors, not managers
  • Require monthly review of key indicators: ER use, readmission, poor CAHPS results
  • Train management on financial implications of case mix
Best Practice: Consistent application of assessments, tools and documentation
Best Practice Interventions:
  • Prioritize OASIS questions to ensure high priority questions are addressed in visit 1.  For example, focus on assessing areas most likely to lead to readmission, ER visits, etc.
  • OASIS training (see next section)
Best Practice: Bring new hires up to capacity efficiently and retain them after training
Best Practice Interventions:
  • Centralize orientation to ensure consistent transmission of critical information
  • Use clinical scorecards to identify strengths and weaknesses of new hires (and periodically, of veteran staff as well)
  • Emphasize simulations and scenarios as part of training – have peers demonstrate skills to others as part of training
  • Incorporate skills needed to manage patient experience as well as clinical skills in the training curriculum
  • Promote mentoring relationships or team-building to support new hires
Best Practice Example: Public Recognition of High Performers. Advanced Home Care developed a recognition program to encourage staff to compete on quality. Each clinician is rated on HHCAPHS scores and wound care as part of an agency-level “care excellence” program. The highest performing employees each month get certificate, a ribbon to wear on their name badge, and incentive funds to use at agency store. High performing staff are recognized in meetings and in a ‘hall of fame’ on the wall. AHC believes that the Care Excellence program drives ‘healthy competition’ among clinicians. Clinicians now have more ownership of their outcomes data. Staff also appreciates the recognition they get when they wear their ribbons into the patient homes. This signals to the patients that they are getting a high-quality nurse. For details see Case Example: Advanced Home Care orientation and training program

Best Practice: Identify 1-2 patient-centered goals and promote them through consistent behaviors of staff
Best Practice Interventions:
  • Adopt checklists for key functions such as start of care, discharge, and other transitions
  • Develop clear protocol for patient engagement at each visit, for every staff member, including a script if appropriate
  • Use information technology to ensure consistent practice, for example, by embedding Always Event fields in the EMR
Best Practice Example: Use an “always event” strategy to reliably align clinical practice, documentation, and measurement according to patient-centered goals. Case Example: The Sutter Center for Integrated Care (SCIC) - Always Event
Collect and Use Data Strategically
Home -based care organizations seeking that 5-star rating need to have tools to capture and aggregate data strategically. Data should be used to assess and improve all aspects of agency performance: clinical quality, efficiency, resource allocation, training, and improving patient experience. Accurate and reliable OASIS data is the foundation for evaluation of all home health activities.

Best Practice: Review agency data monthly, analyzing data by site, by measure, and by clinician to quickly identify and resolve deficiencies.
  • Review ED / readmission data real time.
  • Work with your data or data vendor to determine which measures are having the greatest impact on individual performance and the agency’s Star Ratings.
  • Target performance improvement and agency wide performance improvement projects (PIPs) on closing performance gaps that will most impact Star Ratings. See for example Case Example: Porchlight VNA Data Management for Success
Best Practice: Make clinical and process data readily available to drive quality improvement
Best Practice Interventions:
  • Program electronic ‘alerts’ to clinicians reminding them of high priority activities associated with performance measures
  • Have management review trends and evaluate use of alerts regularly to identify weaknesses
  • Develop performance targets for specific star rating measures and review performance against goals monthly with staff
  • Develop scorecards for staff or use the clinician scorecard feature in Strategic Healthcare Programs (SHP) or EMR tools
  • Benchmark agency data against regional competitors, statewide performance, and national performance
  • Understand which measures are driving the agency’s Star Ratings ranking.  Focus improvement on measures in which achievable gains will put the agency over the threshold into the next performance tier
  • Incorporate CMS risk adjustment in benchmarking for national and state comparisons
  • Use predictive alerts to flag patients at risk for ED use or readmission
  • Use a performance data management tool that can provide real time reports
  • Look for patterns in ED and readmission data (such as correlation with staffing, day of the week, or clinical conditions that can drive PIP interventions
  • Build the data reports into daily, monthly and quarterly quality monitoring processes, and ensure that all staff have information on the agency’s performance
Best Practice: Ensure consistent application of OASIS coding
Best Practice Interventions:
  • Staff each agency location with at least one certified OASIS coder
  • Have the same staff member perform the start of care and discharge assessments whenever possible
  • Create incentives for staff to achieve OASIS certification
  • Offer OASIS training for consistent assessment and documentation by all providers
  • Conduct admission OASIS review for accuracy on functional sections
  • Use OASIS ‘tip of the month’ as refresher
  • Use a tool linking key OASIS indicators to Star Rating Measures to demonstrate the connection between accurate coding and performance.
  • Calculate ROI for investing in coding training: assess reimbursement differences when case mix is accurately reflected as a result of improved coding
Best Practice Example: Use rotating training and testing case coding scenarios for all staff to ensure cases are being coded with correct and consistent acuity levels. See Case Example: VNA Health Group - 5 Star Agency Practice - Ensuring Accuracy of OASIS

Best Practice: Consistent OASIS assessment processes and findings
Best Practice Interventions:
  • Joint visits between Start of Care RN and Rehab to improve OASIS validity
  • Use designated standardized, validated assessment tools
  • Develop assessment protocols that require use of designated tool and objective verification of patient report
  • Educate clinicians on functional status assessment skills, including use of interdisciplinary expertise such as PT and OT
  • Use scenario training to improve inter-rater reliability of processes
  • Use inter-rater reliability testing and training to ensure consistent interpretations
  • Staff cases with consistent caregivers and clinical staff
  • Use supervisory and management staff strategically to promote quality goals (rather than having them focus on direct clinical responsibilities)
  • Develop automated scorecards for staff or use the clinician scorecard feature in SHP / other EMR
  • Implement process for auditing OASIS on admission and discharge
  • Use QA audits as performance improvement projects
  • Use the 5-day window prior to locking to collaborate on OASIS scoring
Develop Community Partnerships
Home-based care organizations are trusted members of the communities and have the opportunity to build on this recognition. Improve population health, create a smoother path to discharge to the community, and increase awareness of the home-based care organization by developing community partnerships.

We recommend users review the Blueprint for Excellence modules on Improving the Palliative Care Continuum and Preventing Readmissions /Maintaining Discharge to the Community for specific best practice interventions on developing partnerships with hospitals, clinical groups, and community based organizations to improve palliative care and community stay. Identify community based organizations willing to partner with the HHA on nutrition, caregiving assistance, transportation, and other resources that can help prevention readmissions during and after the home health episode. Examples include:
  • Alzheimer’s Association and Local Chapters of Heart, Lung or other Associations
  • Community Health Centers
  • Food Pantries / Meals on Wheels
  • Housing Organizations
  • Transportation (crucial for clinical follow up)
  • Medication assistance programs - both for financing and picking up medications
  • Protective Services
  • Local Health Department or Office of Aging
  • State Health Insurance Programs
  • Senior Centers and Adult Day Care
  • Volunteer Organizations - respite, peer support, other direct support
  • YMCAs - many offer depression and falls prevention services
Best Practice Example: VNA of Boston uses Community Resource Specialists (CRS) to access community services.  VNA of Boston has 3 CRS employees to patient needs. These individuals are highly skilled non-clinicians who utilize excellent communication skills, mostly by phone and in some cases home visits, to assist the clinician/manager upon request in seeking and securing such resources as Personal Care Assistance, heavy chore service, assistance with IADLs such as homemaking and rides, Lifeline, prefilled medication systems, assistance with Payor applications, and/or specific disease support services. The norm is that the clinician identifies the specific need(s) and makes a referral to the CRS. VNA of Boston reports that the system has been in place for 18 years and has been very, very helpful.

Demonstrate and Communicate Value
Payers and other partners need to know that your organization is a trusted partner that can deliver on the Quadruple Aims. 

Best Practice: Use data to show value of home-based care in competitive marketplace
Best Practice Interventions:
  • Benchmark your agency data against local competitors, regional agencies, and nationally. Note that local performance may drive ACO and VBP partnerships
  • Develop ‘programs’ to attract specific types of referrals using data from HHA and competitors to show outcome and efficiency differentiate the organization 
Ensure Safety of Your Team 
In 2019 ElevatingHome/VNAA is releasing two new chapters of the Blueprint for Excellence to improve the home care workforce. See chapters under the "High Performing Agency" table for more information.  We encourage home-based care leaders to review ElevatingHome's past and upcoming Home Health and Hospice Education Programs for the latest training and information.
Page Updated August 2019