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VNAA BLUEPRINT FOR EXCELLENCE
FIVE STAR STRATEGIES:
OPERATIONAL BEST PRACTICES
TO IMPROVE HOME HEALTH QUALITY MEASURES
Why 5-Star Best Practices?
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Home Health Compare
Star Ratings
Value Based Purchasing
Meeting patient needs
Reimbursement
For Live Links, Case Studies, Resources
and More Information
VNAA Blueprint for Excellent
5-Star Best Practices
http://vnaablueprint.org/5-star-best-practices/5-starbest-practices-HH.html
(Members only)
Groups of Measures
9 measures are used in CMS Star Ratings, in 5 of 6 measure categories
Managing daily activities
• Improvement in Ambulation
• Improvement in Bed Transferring
• Improvement in Bathing
Managing pain and treating symptoms
• Improvement in Pain Interfering With Activity
• Improvement in Shortness of Breath
Treating wounds and preventing pressure sores (no measures apply to Star Ratings)
Preventing harm
• Timely Initiation of Care
• Drug Education on all Medications Provided to Patient/Caregiver
• Influenza Immunization Received for Current Flu Season
Preventing unplanned hospital care
• Acute Care Hospitalization
Improving patient experience as reported in CAHPS survey (publicly reported January 2016)
• The star rating reflects performance on composite measures addressing care of patients,
communication between providers and patients, and specific care issues
What is the Blueprint?
• Expert recommendations from VNAA member Work Group
• Based on evidence, but evidence is not available on every
topic
• Work in progress – knowledge continues to evolve
• Identifies multiple options for improvement
• Blueprint ideas are used in conjunction with Clinical
Pathways, accreditation, electronic tools, regulatory
compliance and other requirements for home health
agencies
• Users identify strategies that work in their organization,
given size, workforce availability, caseload, customer needs
Thank you
VNAA Operational Best Practices
Work Group
How To Improve Quality
Cross-cutting strategies that influence all Star Rating
Measures:
1) Adopt a quality improvement model
2) Use your data strategically
3) Educate and train staff to improve reliability
4) Ensure accurate OASIS assessment and
documentation
Quality Improvement Models
Institute for Healthcare Improvement
• Plan-Do-Study-Act-Sustain
• Improve consistency of practices
• Make the right thing to do the easy thing to do – build the
processes into tools and documentation systems
• Evaluate new programs to ensure the achieve desired goals
Other programs and models available from HRSA, AHRQ, HHQI
Best Practice Tip
Adopt cross cutting quality steps to improve all measures:
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Staff training specific to the measure
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OASIS training and auditing
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Matching staff to patient need
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Patient-defined goal setting
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Always events to improve reliability
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Data review and accountability at all clinician and
management levels
Use Data Strategically
Best practices:
• Use electronic alerts for gaps in care or documentation
• Use predictive alerts for patients at risk of care gaps
• Routine review of data trends; daily review of readmissions and
ED data
• Performance targets specific to star ratings measures
• Benchmark agency data to risk adjusted state and national data
• Partner with a data analytics vendor if needed
• If you’ve got it, flaunt it! Make sure your customers know you
can deliver high performance in the areas they care about
Measurement and Evaluation
Best practice tip: Generate measurement reports weekly
or at minimum, monthly to be reviewed by team
members, including clinicians. Develop criteria for
improvement directly related to Home Health Compare
and Star Ratings. Understand which measures are driving
your Star Ratings, and address them first in quality
improvement.
Educate and Train Staff
Consistency is the goal!
• Train specific to Star Measures and the ‘big picture’
• Use simulations and scenarios to help adult learners make
the connections
• Reinforce OASIS skills with regular updates and tips
• Recognize high performing staff
• Teach skills needed to manage patient experience
• Use mentors and preceptors
• Recognize different education needs for nursing and therapy
• Provide monthly and quarterly scorecard and feedback on
staff performance specific to metrics
Accurate OASIS Assessment and Documentation
• Train staff on big picture links between assessment,
patient care, documentation, and reimbursement
• For functional status, observation is key
• Conduct 100% review before submitting OASIS
• Assign same clinician at SOC and discharge
• Train for inter-rater reliability of assessments and
documentation
• Support continuing OASIS education and certification of
staff
Strategies to Improve Performance on
Star Rating Measures
Managing Daily Activities
Managing Daily Activities (** Measures Used in Star Ratings )
How often patients got better at walking or moving around**
How often patients got better at getting in and out of bed**
How often patients got better at bathing**
Managing Daily Activities
Barriers to high performance:
• Patient depression
• Patient cognitive impairment
• Not all staff engaged in care plan goals
• Rehabilitation staff not involved (shortages, lack of MD
referral)
• Some patients have limited improvement opportunity
Managing Daily Activities
Best Practice Recommendations
• Screen all patients for cognitive problems and depression
• Involve therapists early – Occupational therapy (OT)
• Develop plan of care with emphasis on functional status
• Improve consistency of care plan implementation - assign
agency staff with knowledge of patient’s plan (POC)
• Educate referral sources on need for rehab services
• Develop sources for supplemental rehab staff, and processes
to ensure they practice according to agency performance
standards
Managing Pain and Treating Symptoms
Managing Pain and Treating Symptoms (Measures Used in Star Ratings ** )
How often the home health team checked patients for pain
How often the home health team treated their patients’ pain **
How often patients had less pain when moving around
How often the home health team treated heart failure (weakening of the heart)
patients’ symptoms
How often patients’ breathing improved **
18
Managing Pain and Treating Symptoms
Barriers to High Performance
• Inconsistent assessment and documentation
• Inconsistent physician prescribing and responsiveness
• Patient factors (fear, non-adherence, home
environment)
• Lack of access to / use of palliative care specialists
Managing Pain and Treating Symptoms
Best Practice Recommendations
• Agency level Nurse Council develops, endorses and oversees use of
agency specific pathways for pain and dyspnea management
• Pain and dyspnea standardized assessment conducted with vital signs
• Adopt pain management ‘always event’
• Consistent use of clinical pathways with numeric thresholds for
contacting physician
• Develop and use relationships with palliative care nurse consultants
• Adopt SBAR communications
• Adopt symptom management checklists in EMR
• Enhance clinician training with ELNEC or other targeted information
• Educate referral sources on need for pain, dyspnea protocols and need to
involve rehab staff
Managing Pain and Treating Symptoms
Best Practice Case Example:
• Re-educate all clinical teams on pain screening and pain
assessment in cognitively impaired patients
• Increase referrals to PT to manage pain and dyspnea with
movement
• Review SHP data and hospitalization data on regular basis
• Implement High Risk protocol (frontloading visits, etc.)
• Standardize patient education materials with hospital
• Implement Better Breathing program overseen by PT
Treating Wounds And Preventing Pressure Sores
Treating Wounds and Preventing Pressure Sores (No Measures Used in Star
Ratings)
How often patients’ wounds improved or healed after an operation
How often the home health team checked patients for the risk of
developing pressure sores (bed sores)
How often the home health team included treatments to prevent pressure
sores (bed sores) in the plan
How often the home health team took doctor-ordered action to prevent
pressure sores (bed sores)
Treating Wounds And Preventing Pressure Sores
Barriers to Best Practice:
• Patient factors – cognitive or mobility impairment,
caregiver capacity
• Burdensome documentation systems for wound
assessment and management
• Understaffed for certified wound care staff
• Lack of continuity of staffing
• Lack of coordination of care
Treating Wounds And Preventing Pressure Sores
Best Practice Recommendations:
• Skin risk assessment every visit
• Skin protection care plan
• Assertive incontinence management
• Referral to community resources for additional in-home support
• Increase number of wound certified clinical specialists (incentives,
education, etc)
• Provide wound consults when healing does not meet milestones
• Provide staff in-services on skin care and documentation
• Use online or electronic wound assessment program with
photography
Preventing Harm – Timely Admission
Preventing Harm – Administration (Measures Used in Star Ratings ** )
How often the home health team began their patients’ care in a timely
manner**
Preventing Harm – Timely Admission
Barriers to Best Practice:
• Staff scheduling / availability
• Patient related challenges: high needs, cognitive
impairment, refusal
• Referral source issues: lack of information, lack of
follow through, insurance verification challenge
• Inaccurate documentation
Preventing Harm – Timely Admission
Best Practice Recommendations:
• Designate accountable staff for admissions – e.g. dedicated
Admissions Team or admission nurse
• Streamline admissions administration and identify critical
information or actions for admissions process
• Adopt clinical algorithms that guide agency
recommendations for intensity of services and equipment
• Create liaison team with hospitals and key referral sources,
to plan for efficient referral and follow up processes
• Develop payer relationships as part of value-based
contracting arrangements
• Establish agency-level goal for timeliness of admissions, with
audit and QI processes to ensure goals are met
Preventing Harm – Clinical Care
Preventing Harm – Clinical Care (Measures Used in Star Ratings ** )
How often the home health team taught patients (or their family
caregivers) about their drugs **
How often patients got better at taking their drugs correctly by
mouth
How often the home health team checked patients’ risk of falling
How often the home health team checked patients for
depression
Preventing Harm – Clinical Care*
Barriers to Best Practices for Medication Reconciliation:
• Variable practices across nursing and rehabilitation
specialties
• Increasing number of therapy-only cases
• Professional practice / licensure barriers
• High complexity of patient medication regimens
• Challenges reaching prescribers
• Multiple prescribers
*recommendations target the Star Ratings Measure
Preventing Harm – Clinical Care
• Create agency-level Nurse Council to develop medication
reconciliation and education templates
• Cross train nursing and rehabilitation staff, with scripting if
needed
• Provide advanced training on patient education, with focus on
low literacy, adult learning, teach back, and patient engagement
• Implement protocols for requesting Skilled Nursing visit for
patient with complex regimens and therapy-only
• Implement geriatric medication consults
• Use SBAR for prescriber interactions
• Develop partnerships with pharmacists for consults, education
• Program EMR to alert for high risk regimens
Preventing Harm - Interventions
Preventing Harm – Interventions (Measures Used in Star Ratings ** )
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)
For patients with diabetes, how often the home health team got
doctor’s orders, gave foot care, and taught patients about foot care
Preventing Harm - Interventions
Barriers to Best Practices – Flu Shot
• Lack of coordination with other practitioners
• Lack of documentation or difficulty locating records
• Lack of clarity regarding the ‘current flu season’ and HH
episode
• Patient refusal
• Provider’s not prioritizing
*recommendations target the Star Ratings Measure
Preventing Harm - Interventions
Best Practice Recommendations – Flu Shot
• Include flu shot status in referral info and/or initial assessment
• Incorporate into health record as mandatory field
• Develop protocols for follow up where shot is missing – may be
standing orders, referral to PCP, referral to other site
• Obtain standing orders in states where allowed
• Designate specific staff to follow up with providers and/or query for
missing data
• Educate staff on agency protocols and annual initiatives
• Tap into Centers for Disease Control and Prevention resources for
patient and provider information
Preventing Unplanned Hospital Care
Preventing Unplanned Hospital Care (Measures Used in Star Ratings **)
How often home health patients had to be admitted to the hospital **
How often patients receiving home health care needed any urgent,
unplanned care in the hospital emergency room – without being
admitted to the hospital
How often home health patients, who have had a recent hospital stay,
had to be re-admitted to the hospital
How often home health patients, who have had a recent hospital stay,
received care in the hospital emergency room without being re-admitted
to the hospital
Preventing Unplanned Hospital Care
Barriers to Best Practices – Preventable
readmissions:
• Early hospital discharge without adequate
planning
• High risk patients needing additional intensity
• Physical referral to the emergency department
• Lack of access to outpatient urgent care
• Patient / caregiver lack of knowledge or fear
Preventing Unplanned Hospital Care
Best Practice Recommendations – preventing readmissions
• More effective identification of high risk patients
• Offer intensive home health services for high risk patients, including
frontloaded visits, link with private duty
• Arrangements with physician or nurse practitioner for home visits
• Improve relationships with hospitals – liaison teams, participation
on discharge planning team
• Using SBAR communications for more rapid response
• Track, monitor ED and admission data, and develop targeted
interventions
• Develop transition of care protocols
• Improve planning and education with patients on what to do in
emergencies. “Call me first” education tools.
• Use technology to monitor, engage with patients
Improving Patient Experience
Patient Experience Reports from CAHPS (Measures Used in Star Ratings **)
Care of patients (composite of questions 9, 16, 19, 24) **
Communication between providers and patients (composite of
questions 2, 15, 17, 18, 22, 23) **
Patient Experience Reports from CAHPS (Measures Used in Star Ratings **)
Specific care issues (composite of questions 3, 4, 5, 10, 12, 13, 14) **
Overall rating of care provided by the home health agency (question
20) **
Improving Patient Experience
Barriers to Best Practice:
• Lack of consistent practice
• Lack of customer service perspective
• High demands
• Cognitive barriers
Improving Patient Experience
Best Practice Recommendations:
• Create an ‘always event’ practice to ask patients about their goals
• Understand customer needs more effectively: routine outbound call
at 1 week and after any complaint
• Designate agency leader for customer service
• Implement customer service QI in areas of frequent complaints:
scheduling, return calls, staff turnover
• Develop formal process for effective handoffs when there are staff
turnovers
• Offer customer service training for all employees with scripting, roll
playing
• Document patient goals in the home, use them for discussion with
patients and refer to them when discussing progress
Improving Patient Experience
Top Tip: Make it an ‘always event’ to ask about the
patient’s personal goal for each specific visit: “what can I
do for you today?”
Improving Patient Experience
Best Practice Tip to Enhance Home Care Customer Experience /
Satisfaction Measures
 Staff education and training about patient experience, reports and
influencers of satisfaction
 Telephone calls to each new patient 24 hours before start of care
 Telephone check in with patient within the first 2 weeks of care, to
ensure satisfaction with quality of care
 Agency-specific calendar that case manager writes the visit schedule
for each discipline and posts it on the refrigerator
 Telephone call before visiting
 Weekly/monthly measurement reports: team/clinician measures
reviewed with supervisors “critical for improvement”
 Spotlight positive stories
 Recognize the very low margin for error in home care
From the Visiting Nurse Associations of New England (VNANE)
Measurement and Evaluation
Why it Matters: Quality measures are tied to
reimbursement and market share:
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Home Health Star Ratings
Home Health Compare
Home Health Value Based Purchasing
CMS Comprehensive Care for Joint Replacement
• See also: VNAA's VBP e-Toolkit
More Details
See VNAA’s Blueprint for Excellence
5-Star Best Practices module
VNAABlueprint.org
for links to training, education, references,
resources
Contact
Quality and Performance Improvement
Visiting Nurse Associations of America
2121 Crystal Drive, Suite 750, Arlington, VA 22202
[email protected] | www.VNAA.org