Improving the delivery of care for diabetes patients with a collaborative model

A diverse group of home care agencies participated in a national Home Health Diabetes Learning Collaborative focused on developing the skills of practitioners to implement process-of-care changes among their diabetes populations. Through face-to-face meetings, conference calls, and "listserv" communications, these agencies worked together to plan, test, and spread best practice change concepts. Early evaluation results suggest the collaborative was an effective mechanism for achieving rapid quality improvements in the home care setting.     

Redesigning for success: managing the prospective payment system

Managed care and the new Medicare prospective pay system are dramatically changing the way home health agencies conduct their business. Agencies are busy downsizing, streamlining, and looking for creative ways to do more with less. Many industries have found success with process reengineering, the concepts of which are outlined in this article so that agencies may adapt them to "recreate" themselves. Practical measures are demonstrated through the steps one large home health agency has taken to address these issues.     

Using nurse practitioners in home care. A report of two pilot projects

Currently, nurse practitioners are not being employed by home care agencies due to problems related to reimbursement by third party payors, physician reluctance, and scope of practice concerns. This research describes client conditions and advanced practice services that home care nurses have identified as useful for the delivery of quality care.     

Co-optation and Cooperation Between Home Health Agencies and Hospices

This study explores the emerging conflict and cooperation between two types of organizations providing home health care to chronically ill and terminal patients—the hospice and the home health agency. Exploratory results suggest that the variables of size (terminal patient load), and competition (the number of other home health agencies in an area) influence relationships between home health agencies and hospices. It is also suggested that recent Medicare regulations may encourage mergers between agencies and hospices in addition to the existing modes of cooperation and referrals.     

Co-optation and cooperation between home health agencies and hospices

This study explores the emerging conflict and cooperation between two types of organizations providing home health care to chronically ill and terminal patients--the hospice and the home health agency. Exploratory results suggest that the variables of size (terminal patient load), and competition (the number of other home health agencies in an area) influence relationships between home health agencies and hospices. It is also suggested that recent Medicare regulations may encourage mergers between agencies and hospices in addition to the existing modes of cooperation and referrals.     

Communication between continuing care organizations

Communication between health care providing organizations is fundamental to discharge planning and continuity of care, but has been reported to be inadequate. Using a classic communication model, the content of communication between hospitals and home health agencies was examined in 300 closed home care records and compared to referral content desired by practitioners. Discharge planners sent about half of the referral information recommended by the literature. Referrals consisted primarily of background data, some medical data, even less nursing care data, and almost no psychosocial data. No referral form was used by the hospital in over one third of the cases. Discrepancies existed between what client care data practitioners identified as important or desirable and the data they actually received. As responsibility for providing health care is decentralized and shared by multiple organizations, communication between providers will play a greater role in ensuring continuity of care. The findings suggest that adoption of standardized, written referral forms might facilitate clear and complete communication. ©1995 John Wiley & Sons, Inc.     

An agency-university research partnership: focus on late-life depression

Does anyone working in home care have the time to do one more thing? We would think most clinicians, administrators, educators, and quality improvement coordinators would answer "NO." This article provides a current example of what happened when three Medicare-certified home health agencies answered "YES" to a research partnership dedicated to addressing the unique challenges of enhancing late-life depression treatment and outcomes in the home care setting. The development of an ongoing home care agency-university partnership is described to stimulate other agencies to consider this type of research collaboration.     

Accuracy in the Outcomes and Assessment Information Set (OASIS): results of a video simulation

There is little information regarding the accuracy of the Outcomes and Assessment Information Set (OASIS), the patient assessment tool mandated for use in Medicare-funded home health care. The purposes of this study were to evaluate the accuracy of OASIS completion by home health nurses and rehabilitation therapists, to compare responses of nurses and therapists, and to determine whether dispersion of answers would affect the home health resource group (HHRG) to which patients were assigned for Medicare home health care payments to agencies. Using a video simulation of admission and discharge visits, 436 clinicians from 29 Ohio home health care agencies scored selected OASIS items. Although the majority of the items were rated accurately, discrepancies were found between clinician responses and the "correct" answer on several items. Nurses and therapists provided similar ratings on most items studied, but for most cases in which discrepancies were found, nurses were more likely to agree with the "correct" answer. Discrepancies most often led to patients being assigned to lower-payment HHRGs. Continued monitoring of OASIS data collection accuracy is recommended to maximize the value of the OASIS instrument in home health care research, practice, and policy.     

Emergency preparedness

The Boy Scout motto is "be prepared," but can your home health agency abide by this standard? The post-9/11 days of 2001 and the natural disasters that have threatened people and plagued our home and countries abroad illustrate the heightened level of awareness and preparedness home healthcare agencies must achieve to satisfactorily meet emergency preparedness standards. Community-based nurses often are on the front line of response to a man-made, biological, or naturally occurring event. You may have been assigned to work on a plan for your agency's response or have had questions asked about preparedness by your clients and family members. Here are six Web sites to get you started on the answers to those questions and concerns.     

Disaster preparedness for vulnerable persons receiving in-home, long-term care in South Carolina

PURPOSE: The purpose of this study was to examine how agencies in South Carolina that provide in-home health care and personal care services help older and/or disabled clients to prepare for disasters. The study also examines how agencies safeguard clients' records, train staff, and how they could improve their preparedness. METHODS: The relevant research and practice literature was reviewed. Nine public officials responsible for preparedness for in-home health care and personal care services in South Carolina were interviewed. A telephone survey instrument was developed that was based on these interviews and the literature review. Administrators from 16 agencies that provide in-home personal care to 2,147 clients, and five agencies that provide in-home health care to 2,180 clients, were interviewed. Grounded theory analysis identified major themes in the resulting qualitative data; thematic analysis organized the content. RESULTS: Federal regulations require preparedness for agencies providing in-home health care ("home health"). No analogous regulations were found for in-home personal care. The degree of preparedness varied substantially among personal care agencies. Most personal care agencies were categorized as "less" prepared or "moderately" prepared. The findings for agencies in both categories generally suggest lack of preparedness in: (1) identifying clients at high risk and assisting them in planning; (2) providing written materials and/or recommendations; (3) protecting records; (4) educating staff and clients; and (5) coordinating disaster planning and response across agencies. Home health agencies were better prepared than were personal care agencies. However, some home health administrators commented that they were unsure how well their plans would work during a disaster, given a lack of training. The majority of home health agency administrators spoke of a need for better coordination and/or more preparedness training. CONCLUSIONS: Agencies providing personal care and home health services would benefit from developing stronger linkages with their local preparedness systems. The findings support incorporating disaster planning in the certification requirements for home health agencies, and developing additional educational resources for administrators and staff of personal care agencies and their clients.     

The role of the Medicare fiscal intermediary and the Regional Home Health Intermediary, Part 1.

The Medicare fiscal intermediaries (FIs) are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims. There are two primary functions for the FI--reimbursement review and medical coverage review. Hospital-based home health agencies relate to the hospital's FI for reimbursement purposes. All home health agencies are assigned to a special FI, the Regional Home Health Intermediary (RHHI), for medical review issues. The same or a different FI may audit the hospital's cost report. Freestanding home health agencies deal with separate reimbursement and medical review divisions within a single RHHI's office. The author reviews the role of the Medicare FI and the RHHI and their relationship to home health agencies. Part 2 will appear in the July/August issue.     

Factors influencing use of home care and nursing homes

AIM: This paper reports a study comparing the characteristics of patients who use home care services and those who are cared for in nursing homes, and identifying the factors that influence the use of these care settings. BACKGROUND: The increase in the functionally dependent older population has led to an increase in the number of nursing homes and home care agencies. It has become clear that, rather than disputing which is the better of these options, it would be better to determine the characteristics of patients who use the two long-term care services. Gaining an understanding of the unique characteristics of patients who are cared for by home care agencies and those who are cared for in nursing homes will be imperative for reforming and developing long-term care systems. METHOD: The research model was based on the Anderson Model of Health Services Utilization. Interviews were conducted with 99 stroke survivors from two home care agencies and four nursing homes, and their family members, between May and December 2001. RESULTS: The patient characteristics that predicted greater use of home care rather than nursing home services were: being married, poor physical function, impaired cognitive function, higher rates of comorbidity, various medical complications, and/or number of catheters (e.g. urinary catheter, naso-gastric tube). CONCLUSION: Contrary to the findings of previous studies conducted in countries with ageing populations, our findings indicate that in South Korea home care agencies, rather than nursing homes, provide care for severely impaired patients. This may be due to differences between countries in their long-term care systems and cultural attitudes toward end-of-life care. Our results will contribute to the development or reformation of long-term care systems in countries with ageing populations, and to the development of strategies for increasing access to these services.     

The role of the Medicare fiscal intermediary and the regional home health intermediary, Part 2.

The Medicare fiscal intermediaries (FIs) are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims. There are two primary functions of the FI--reimbursement review and medical coverage review. Hospital-based home health agencies relate to the hospital's FI for reimbursement purposes. All home health agencies are assigned to a special FI, the Regional Home Health Intermediary (RHHI), for medical review issues. This may be the same FI or a different one than that audits the hospital's cost report. Freestanding home health agencies deal with separate reimbursement and medical review divisions within a single RHHI's office. The author reviews the role of the Medicare FI and the RHHI and their relationship to home health agencies. Part 1 was featured in the June issue.     

A unique opportunity for students: long-term therapeutic relationships with chronically ill clients

Because of a number of factors, fewer opportunities are available today for students to have independent clinical experiences with home care agencies. At York College of Pennsylvania, community health nursing faculty designed a home health clinical experience with chronically ill clients that would be meaningful to students, fill unmet client needs, and establish or strengthen the relationship between the nursing department and community/home health agencies. In addition to achieving the stated goals, these clinical experiences offered additional unanticipated benefits that resulted from the long-term nature of these client-student interactions.     

The need for evidence-based guidelines in home care

There is a lack of condition-specific evidence-based guidelines in the home care field. A recent article by Peterson (2004) suggests that the home care industry must now address this on several fronts, including: 1. adopting guidelines for specific conditions from other settings, 2. implementing selected "best practices" developed by within home care agencies (that are usually consensus-based), and 3. collecting outcomes data with the purpose of creating a home care specific evidence base.This column summarizes Peterson's (2004) recent work on the importance of creating an evidence base for the home care field.     

Explaining area variation in the use of Medicare home health services.

This study examines the determinants of area-level variation in Medicare home health use in 1985 for the entire United States, using data from Medicare Home Health Bills, the Medicare/Medicaid Automated Certification System, the Medicare Provider Analysis and Review Files, and other sources. Weighted two-stage least squares regression was used to analyze variation in the number of home health users per 1,000 enrollees and the average number of visits received per user. The data were aggregated to the Metropolitan Statistical Area and the rural part of the state, resulting in 343 units of analysis. According to the study's results, higher proportions of Medicare enrollees use home health services in areas with fewer nursing home beds per enrollee, higher hospital discharge rates, and shorter mean lengths of stay, higher Medicare reimbursement ceilings for skilled nursing home health visits, and more home health agencies per enrollee. Other things being equal, beneficiaries in New England are 40% more likely to use home health services than their counterparts in other regions with similar climates. The average number of visits received by home health users appears to be higher in areas where there are more agencies per enrollee and a higher share of agencies that are proprietary. There also appear to be large regional differences in the number of visits received per user. Our results imply that constrained access to nursing home beds is leading to higher levels of Medicare home health use and that there may be further savings from the substitution of home health services for hospital days. The study shows that Medicare reimbursement ceilings may constrain use and that access may be a problem for beneficiaries in areas with fewer agencies per enrollee. This study also points to significant regional variation in the proportion of beneficiaries who use home health services, even with controls for many different explanatory variables. Overall, our results suggest the possibility of serious limitations in access to Medicare home health services.     

Comparison of home health care outcomes and service use for patients with wound/skin diagnoses

The purpose of this comparative study was to evaluate patient outcomes for wound healing and home health care service use for patients whose care was paid for by the traditional Medicare program versus a Medicare managed care organization (MCO). Results showed that there were no differences between the groups in wound healing at discharge, functional ability at discharge, or the numbers of home visits. Changes in the Medicare reimbursement system for home health care may have provided an equalizing effect between Medicare MCO and traditional Medicare patients with wound/skin diagnoses in home health care agencies in the Midwest.     

New Horizons for Home Health Care: Responses to Prospective Payment

The implementation of hospital reimbursement on the basis of diagnosis-related groups and on its effect on home health care is explored. The issue is examined in relation to the types of services now being requested of home health care agencies and how agencies have responded. Implications of a diagnosis-related group system of reimbursement for home health care services, are also considered.     

Evaluations of neonatal nurse practitioners: How accurately do they reflect current practice?

Today, neonatal nurse practitioners (NNPs) practice in a variety of settings. Tertiary and secondary nurseries are still the largest employer of NNPs. Follow-up clinics and home care agencies employ NNPs as well. In each of these arenas a performance evaluation is necessary. Standardization of role expectations, agreed-on competencies, and expected outcomes is lacking. Yet NNPs are evaluated each day on a set of criteria that is often institutionally derived. The evolution of the NNP role and the need for standardized evaluation measures are addressed in this report. Strategies for accomplishing this task are presented. Copyright © 2001 by W.B. Saunders Company