Promoting smooth transitions from hospitals and nursing homes to outside care—including professional home healthcare—without triggering readmissions is garnering new attention from the Centers for Medicare and Medicaid Services. Twenty new measures endorsed last week by the National Quality Forum (NQF) may be able to further assist healthcare providers in determining if they are delivering quality care to patients in their homes.
More than 7 million Americans receive professional healthcare services annually in their homes after they are discharged from healthcare facilities or because of acute illness, chronic health conditions, disability, or terminal illness, according to the NQF. In 2007, home healthcare annual expenditures were projected to be $57.6 billion. However, improvements in the quality of home healthcare have been small.
"The committee was very mindful of what was meaningful for the public," said Carol Spence, PhD, RN, director of research at the National Hospice and Palliative Care Organization, Alexandria, VA, and co chair of NQF's Home Healthcare Steering Committee. Continuum of care—and the role of professional home healthcare in that process—was another issue on the table during the committee's discussions.
The 20 new measures focus on eight specific areas of home healthcare: timely initiation of care; patient and caregiver education; preventive services; pain intervention and assessment; improvement and assessment of clinical symptoms; improvement in functional status; assessment of need for emergency room or hospital care; and patient experience of care.
Patient experience of care will be measured using the Consumer Assessment of Healthcare Providers and Systems survey, which lets patients and their families provide details about their home healthcare experiences. In addition, other specific measures address areas including: receipt of flu shots, depression screening, improvements in mobility, pain reduction, medication compliance, improvements in the status of surgical wounds and number of pressure ulcers, and the percentage of home healthcare patients who need rehospitalization.
In addition to endorsing new measures, NQF reviewed 15 other previously endorsed home health measures, many of which have been used by CMS' Home Health Compare, an online tool for consumers to compare the quality of care provided by home health agencies across the country.
The endorsement of measure the quality, safety and patient experience of care in the home aligns with goals set out by the National Priorities Partnership, a group of 28 organizations, convened by NQF to address transformation of the healthcare system. The home healthcare measures work was conducted under a contract from CMS.
A study recently published in The New England Journal of Medicine shows that 20% of Medicare patients are readmitted to the hospital from which they were recently discharged within a month. That percentage jumps to 34 when looking at a three month time period. The data, representing Medicare claims collected between 2003 and 2004, show that more and more discharge is becoming a time at which it is crucial to have a good communication plan in place among caregivers and patients. What's more, the presence of a strong continuum of care can lead to lower rehospitalization rates.
"In order to address this issue, we are going to wind up addressing the most profound issues in healthcare today," says Stephen Jencks, MD, MPH, a lead author of the study and independent consultant in healthcare safety and quality. "Issues like a system which has become provider-centered rather than patient- and family-centered. If your concerns stop when the patient goes out the door of the hospital or start when the patient comes in the door of your office, you're not going to provide the care that's necessary to keep people from being rehospitalized."
Saying that rehospitalizations are costly is an understatement. In 2004, $17.4 billion was spent caring for patients readmitted to the hospital; Medicare paid hospitals $102.6 billion in total that year. Med Pac, a commission that advises Congress on Medicare policy, has recommended that instead of rewarding hospitals for the quantity of patients they see, hospitals should receive payment for providing the highest quality of care to patients—including whether their patients are readmitted with select conditions.
Some states are already performing far better than others in terms of rates of rehospitalization. The five states with the highest rates of rehospitalization have rates 45% higher than the 5 states with the lowest rates of rehospitalization. What this shows, is the degree to which the community at large is a player, or what Jencks describes as a two-way street, and not simply the fault of the hospital.
"The way to see this is as a community challenge—to get people, whether they are hospital CEOs, nursing home managers, mayors, or the directors of the health departments—to be thinking about how their role involves bringing people together," says Jencks. "For a hospital, it's a wonderful opportunity for them to take a leadership position which will ultimately benefit them."
So how can hospitals do their best to prevent readmissions?
Ensure that a member of the patient's family, or a caregiver, will be present at discharge and a part of the care planning process. "The patient is rarely going to be able to take this responsibility in the shape that their usually in when they're discharged," says Jencks.
Using the teach-back method, a style which asks patients to repeat back to the explaining caregiver in his or her own words the information exchanged, teach patients and families what they will need to do to care for themselves at their next phase of care, what the risks are that warrants a phone call to a physician, and a phone number that they can call when one of those risks arise.
Prevent the patient from leaving the hospital without a follow-up appointment of some kind. In his study, Jencks and his colleagues found that about 50% of patients who were rehospitalized had not been seen by an interim physician after 30 days. Hospitals often say that they can't make an appointment in that short of a timeframe for a patient's follow-up care, says Jenks. "My answer is, well if you can't get it how do you think the patient's going to get it?"
Create a list of reconciled medications for the patient to take with him or her at discharge that clearly spells out what he or she should be taking upon leaving the hospital. Many patients go home and stare into their medicine cabinets, confused about those medications that they took before being hospitalized.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailinghcomak@hcpro.com.
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