Initiate Safe Care
What happens during the first few days a patient is admitted for home-based care has tremendous impact on the patient’s outcome and the likelihood of readmission. Here we discuss best practices for initiating home-based care - including timely initiation, general risk assessment, falls risk, and flu/pneumonia shots. Best Practice recommendations promote the highest quality of care as well as high performance on home health performance ratings.
The Start of Care (SOC) period is critical for building trust between clients and the agency. Initial visits influence patients' experience with care and how they respond to agency interventions. Patients should be evaluated soon after admission to home health to ensure safe, timely, efficient, effective care and to prevent hospitalization or re-hospitalization. During this time, home health professionals conduct assessments, intervene on clinical issues, and schedule follow ups. This is the time to put into place systems to support the patient and caregiver at home, to prevent readmission and ensure successful stay in the community.
Use the links here to navigate to best practice information on elements of care that should be addressed for every patient in the initial visits:
Timely Initiation of Care
Falls Risk Assessment and Prevention
Delivering Flu and Pneumonia Shots
Relevant Measures for Home Health:
- How often the home health team began their patients’ care in a timely manner
Timely initiation of care is important to patient experience, and may also help home health agencies prevent gaps in care that lead to exacerbations and potentially, readmissions. This section includes Best Practice recommendations for improving timeliness of admission while meeting patient expectations.
Timely Admission Top Tip: Consider admissions team where geographically feasible, or dedicated liaisons to ensure consistent admissions processesRecommended Goal: admit and correctly document admissions within 24-48 hours of referral
- Agency scheduling of staff not consistent with admission volume
- Patients refuse admit on same day
- Challenges reaching and changing start of care (SOC) date with MD
- High risk patients: cognitive impairment, low health literacy, high risk patient
- Referral source issues
- Lack of decision-making clarity regarding who gets admitted and when
- Program staff not available
- Agency unable to meet patient treatment needs
- Insurance verification delays
- Inaccurate documentation (e.g. incorrect information, inability to find patient)
- Length of time it takes for admission visit
- How prioritize “high risk” versus “acuity” versus “treatments required”
- Create a Liaison Team to the hospital that will initially be responsible for patient scheduling and use central scheduling
- Use dedicated liaisons with specific referral sources
- Use admission projections to schedule admission team staffing
- Establish agency-wide goal to open cases to service within 24 hours
- Streamline admissions administration
- Develop clinical algorithms to guide intake, including HHA recommendations for services and rehabilitation
- Develop and document clear accountability for admissions to promote consistency:
- Who initiates intake
- What documentation is needed
- Who obtains documentation
- How to document changes in SOC date
- Identify high risk clients at time of referral or admission
- Improve authorizations process: Work with insurance payers to develop contract language to allow initial visit pre-approval to avoid delays or non-payment. Meet with payers regularly. Make sure weekends are pre-approved.
- Proactively plan for equipment and supplies. Work with referral sources to modify care plan such as (1) changing wound care orders to a dressing that isn’t changed daily (2) change IV med dosing to allow flexibility in admission time (3) Give IV dose just prior to hospital discharge (4) contract with infusion company to do first IV dose at home.
- Delay facility discharge if patients need equipment that can’t get into the home immediately
- Audit and monitor compliance with report back to clinical and admission team staff. Develop quality query for patients not admitted within 24 hours to understand factors contributing to the delay
- Use fax or electronic SBAR communications to engage physicians in a timely manner
- Provide OASIS training/ audits on accurate coding admissions and to check the referral and discharge dates for accuracy
- Consider reserving the OASIS assessment for second visit so the patient is not as tired. The agency will need to consider completion of OASIS per their individual policy.
Best Practice Model: Admission Team
- Team manages new admits for 3- 5 visits to establish accurate care plan. After that patient handed off to the case manager.
- Admission teams based on a 7-days a week model (since 70% of admits are done on the weekends). HHAs need to schedule staff for when admissions occur, which is the weekends. Make sure productivity model reflects varying levels of effort by case managers and admissions team.
- Admission teams are salaried employees, no differentials, no overtime, but are paid at a higher level.
- Clinicians initiate care within 24-48 hours
- For some less acute or lower risk patients contact physician for approval of a change in the start of care date after talking with patient/family to assure concurrence and arrange for admission when staffing is available
- Adopt process for calling MD for new verbal order for new SOC date if delayed
- Create initiation visit for high risk for readmission patients – this visit requires seeing the patient within 24 hours of hospital discharge
- Start telehealth on the first visit (when indicated)
A standard risk assessment tool helps target those patients at risk of hospitalization so that organizations can identify and stratify patients at certain levels of risk for hospitalization. The risk assessment tool supports an early identification of patients at risk. ElevatingHome recommends tools from the Institute for Healthcare Improvement for their simplicity. There are no risk assessment tools with validity and reliability specifically targeted to the home care setting.
Goal: Tailor intensity of visits and interventions to the risk level of the patient, and measure impact through patient experience, readmissions, and ED use
Best Practice Interventions:
- Adopt and use a standard tool at the initial admission evaluation to determine risk of hospitalization. Evaluate if the patient needs a second visit based on moderate to high risk of hospitalization. Patients identified as high risk should also receive a second visit within 48 hours of discharge from the hospital. High risk patients are those at risk for hospitalization, including heart failure and COPD patients, as well as those patients on high risk medications.
- On the first or second visit, determine if the patient needs frontloading of nursing visits in the first two to three weeks.
- Document visit frequency on the patient plan of care.
- Determine if the patient would benefit from telemonitoring (if available) based on diagnosis and incorporate into plan of care.
- Determine organizational barriers to frontloading during the first two visits and for the first two to three weeks for identified patients. Include staffing needs in this determination.
- Educate all staff on use of risk stratification tools, confidence ruler, zone tools and high risk medications.
- Educate all staff about the importance of this practice to get staff buy-in for the practice to be implemented successfully.
- Monitor plans of care, track results (readmission rates) and communicate outcomes to all staff.
- Measure productivity in such a way as to allow the same clinical team to see patient over the first two weeks.
Strategies to Manage Risk
Goal: Connect patients and caregivers to follow up care, and ensure they have information and a plan to access this care
Best Practice Interventions:
- Implement a process to identify responsibility for making an appointment and communicating information to patient, family and staff.
- During the first visit, address the need to make an appointment with the physician for follow-up.
- Discuss barriers to making a follow-up appointment
- Ask patient / caregiver to explain how they will get to the appointment, and connect to social work or transportation resources if needed
- Discuss the use of a personal health record as a tool to help patients engage in their own health care.
- Use coaching as an approach with patient/caregiver during visits subsequent to follow-up to make an appointment with the MD' or other clinician, asking them to 'teach-back' reasons for the appointment and their plan
- Implement a process for patients that were referred from an MD/clinician office (that have not been in hospital).
- Incorporate changes in the medical record.
Table 1 below summarizes Initial Interventions in Home Health Episodes
|Table 1: Initial Interventions in Home Health Episodes|
|Complete Admission Requirements|
|Conduct Risk Assessment|
|Implement Risk Management Strategies|
|Develop Collaborative Clinical Intervention Plan|
|Assess Patient and Caregiver Knowledge While Setting Expectations for Patient Experience|
Relevant Measures - Home Health:
- How often the home health team checked patients’ risk of falling
- IMPACT ACT: Incidence of Major Falls
Table 2 summarizes home health and hospice interventions to prevent falls.
Best Practice Strategies
Goal: standardized fall risk assessment on every home health and hospice patient, with a falls prevention plan implemented for patients at high risk.
Best Practice Interventions:
- A falls risk assessment is completed as part of the initial assessment by team members of the IDT.
- Build assessment tools into electronic records
- Use prompts to ensure any findings are acted on
- Develop protocols for referring patient to PCP or specialty care if at high falls risk
- Implement an agency-specific process is in place for accurate/reliable occurrence reporting, auditing, tracking and trending of falls metrics
- Collaborate with community based organizations that can support falls prevention interventions
See Blueprint Module Maximize Function for more details
|Table 2: Addressing Risk Factors for Falls at Home|
|Risk Factors for Fall||Preventive Interventions|
|Incontinence||Full RN assessment including type of incontinence, medication implications, teaching opportunities, e.g., Kegel exercises|
|Visual impairment||OT referral for environmental modifications|
|Impaired functional mobility||PT, OT, RN, MSW assessments based on specific dysfunction and need for personal care support|
|Environmental hazards||OT, PT referrals and room-to-room recommendations|
|Poly pharmacy||RN medication management with MD and pharmacy consultation focused on high risk medications, duplicative therapy, and clarification of current prescriptions and timing of doses to help reduce risks|
|Pain affecting level of function||RN for complete pain assessment with non-pharmacological interventions and pharmacological interventions if needed|
|Cognitive impairment||Referral to speech therapy if indicated. These patients often need the assistance of home health aides to help family caregivers. Medical Social Work intervention should be focused on identifying volunteer or paid home health aide services to help prevent falls by providing safe assistance with all ADLs.|
|Pain||Pain is a falls risk factor since it has a negative effect on a patient’s level of function. Non-pharmacological interventions are preferred from a falls risk perspective but pharmacological interventions should be used with caution if necessary.|
- Preventing Falls Among Older Adults-Centers for Disease Control and Prevention (CDC)
- Preventing Falls: A Guide to Implementing Effective Community-Based Fall Prevention Programs -CDC
- CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults, 3rd Edition
- CMS Partnership for Patients – Falls Resources
- National Council on Aging – Falls Prevention Resources
- Stop Falls – Falls Prevention Center of Excellence for patients, families, providers and researchers
Relevant Measures - Home Health:
How often the home health team made sure that their patients have received a flu shot for the current flu season
How often the home health team made sure that their patients have received a pneumococcal vaccine (pneumonia shot)
Delivery of flu and pneumonia shots is an important safety and prevention strategy. Pneumonia is deadly and preventable. There were approximately 50,000 deaths from pneumonia in the U.S. in 2010, and there are 1.2 million hospitalizations for pneumonia each year. However, only 62 percent of those 65 years of age and older had received a pneumonia vaccination (CDC, 2013). In addition, home health agencies are accountable for ensuring eligible patients receive a flu shot each flu season. The Home Health Compare measure, "How often the home health team made sure that their patients have received a flu shot for the current flu season," is used in calculation of Home Health Star Ratings.
ElevatingHome Best Practice: As part of an admission evaluation, all patients will be assessed for flu and pneumonia vaccination status. Use the 'ASSESS ACCESS AND ADMINISTER' agency assessment form to assure that protocols are in place for procedures for administration, storage, safe transport, standing orders, patient refusals, and monitoring of program.
Goal: documentation of flu shot (and pneumococcal) at transition and intake and increase vaccine access
- Lack of coordination of care between PCP, hospitalist and specialty physicians
- State scope of practice barriers
- Clinicians do not understand the question and the definition of “episode of care” in relation to this question.
- Difficulty locating documentation of vaccines or lack of documentation
- Challenges for patients to visit PCP or clinic to obtain vaccine
- Ensure buy in from the CEO & the board stressing the importance of flu/PNE immunizations
- Obtain standing orders in August for flu vaccine (in states that permit it)
- Include mandatory date of flu shot field on referral and intake forms
- Make flu/pneumonia part of initial assessment, recertification and discharge
- Incorporate information into EMR or designate centralized easy to locate place to document last flu vaccine date
- Develop protocol to get order for vaccine if not provided and develop referral arrangements to assist the patient in getting a vaccine from the PCP, retail clinic, public health clinic or other site
- Implement a designated 'vaccine day' with a dedicated nurse providing vaccines to all homebound patients in a service region in need of flu or pneumonia vaccines. Obtain orders and consent as needed in advance. Having designated day and staff will simplify documentation and vaccine transportation.
- Adopt routine data query to identify patients who have not received the flu vaccine
- Designate a staff member to call MD and ask if patient has had flu vaccine if patient does not remember date of last flu shot
- Use the state vaccine registry and take the vaccine to current patients as part of their visit
- Educate clinicians on meaning of the flu vaccine OASIS question and meaning of “episode”
- Routinely assess OASIS accuracy documenting the immunization in the history screen and accurate coding of the M question on TIF and discharge
- Patient lack of knowledge on need for shot
- Staff not understanding the importance of patients receiving the flu shot
- Patients refusing-“it made me sick”
- Patient does not recall when they had the flu shot.
- Clinician’s personal beliefs of the efficacy of flu and other immunizations.
- Provide on-going staff education on compliance and importance of the annual flu vaccine (for patients and for staff)
- Educate staff on the different types of immunizations with a focus on Flu/PNE including risks associated with vaccination compared to risk for non-vaccinators
- Offer web-enabled refresher education for all staff on flu/pneumonia in late fall
- Offer competition or incentives for staff vaccinations so staff can be role models for patients
- Create or use FAQ handout for patients addressing common vaccination concerns
- Develop policies for staff requirements for flu and pneumonia vaccination, and monitor staff compliance during the flu season
Centers for Disease Control and Prevention: Key Facts About Seasonal Flu Vaccine
Influenza Vaccination Information for Health Care Workers
|Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.|
|By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.|
|Educate payers on opportunity to improve outcomes by more effectively caring for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.|
|Support clinicians and staff to practice in teams and at the top of their licenses, train for excellence, and recognize achievement.|