Application of OBQI Principles & the Acute Care Hospitalization Improvement Matrix for Plan of Action Development

1. Application of OBQI Principles & the Acute Care Hospitalization Improvement Matrix for Plan of Action Development Part 2 October 27, 2005

2. Objectives • Review the Areas for Improvement incorporated in the ACH Improvement Matrix • Identify evidence-based strategies to reduce avoidable hospitalizations • Describe how to incorporate evidence-based strategies and corresponding actions into outcome-based quality improvement (OBQI) process for POA development

3. The Challenge • Multidimensional issue across provider settings • Evidence that hospitalization rates can be decreased • Gap between science and practice

4. The Mission • Implement care delivery systems that prevent deterioration resulting in need for hospitalization and emergent care The Goal • Reduce avoidable hospitalizations and emergent care for home health patients

5. The Solution • Multi-dimensional • Improve care processes • Lead & influence improvements across provider settings • Focus improvement on • Coordinating care transitions • Identifying patients at risk • Stabilizing & managing complex/chronic conditions • Supporting patient/caregiver self-management • Improving communication/collaboration w/physicians • Creating systems/using health information technology to support these practices

6. The Plan • Use OBQI process to systematically identify problems driving agency ACH rate • Use strategies and actions identified in the Change Binder to help build POA • Engage in a quality improvement community to share lessons learned (HHAs & other providers) • Continuously strive to improve quality

7. Resources to Assess the ACH Issues • Risk-Adjusted Outcome Report (page 3) • Agency Case Mix Report • Case Mix Analysis Tool • Patient Tally Workbook • Process of Care Investigation • ACH Chart Audit Tool

8. Case Mix Analysis Tool Purpose ― Allows HHAs to obtain a better understanding of the characteristics of their hospitalized patients

9. What does it do? • Computes case mix values for “hospitalized” and “non-hospitalized” episodes • Calculates differences in case mix values between “hospitalized” and “non-hospitalized” episodes • Produces a report that shows the differences in case mix values of hospitalized and non-hospitalized patients

10. What value does it provide? • Extends the review of the Case Mix Report to examine case mix differences between patients who are and are not hospitalized • Can help focus process of care investigation to identify true cause(s) for ACH rate

14. Patient Tally Report Workbook • Excel-based tool • Contains raw OASIS data for all of the patients included within your OBQI report • Combines your Case Mix Tally and Outcome Tally Reports into one tool • Allows you to query your OASIS data to determine case mix & patient outcome information

16. Patient Tally Report Workbook • Open up Patient Tally Workbook • Select 4th option on menu – View existing spreadsheet data • At bottom of page select tab labeled Case Mix Query 1 – provides list of the hospitalized patients for your agency • At bottom of page select tab labeled Case Mix Query 2 – provides list of the non-hospitalized patients for your agency

17. Patient Tally Report Workbook • From Case Mix Query 1, select 30 patients to perform a record review utilizing the Audit Tool included in the ACH Planning Packet

18. Process of Care Investigation • Identify a list of "should be done" care processes • Narrow the "should be done" list to the MOST IMPORTANT • Utilize the ACH chart audit tool or clinician interview guide • Randomly select up to 30 patient care episodes • Review the care episodes • Summarize findings

19. What is a Process-of-Care Investigation? • Systematic investigation of care contributing to outcomes • Targets Specific Aspects of Care Delivery Contributing to the ACH Outcome Result

20. Pitfalls to Avoid • Premature closure (jumping to conclusions) • Involving only agency management • “Blaming” data collection or analysis methods • Not focusing on care delivery

21. Initial Steps in Investigating Care Provided • Identify what should be done in providing care • Determine what actually was done

22. ACH Clinical Record Review Tool

23. Agency Decisions • Determine the review format • Determine who will conduct the review • Determine the cases to be reviewed • Determine the review time frame

24. Drawing Conclusions: • Compile team member tally sheets • Aggregate results • Summarize problem area(s)

25. Focused Clinical Record Review Grand Tally Sheet

26. Problem Statements • Describes specific aspects of care that demonstrate inadequate care (or excellent care) • Contains specific, concrete wording to which clinical staff can relate • Address issues within the agency’s control • Focuses on patient care delivery instead of documentation • Contains a sufficiently narrow focus to keep a plan of action manageable

27. Change Binder

29. Definitions • Change Framework – entire set of change concepts organized into Areas for Improvement and Stages of Care • Improvement Matrix – “big picture” of the organization and high-level strategies • Strategy – high-level change concept; represents a series of actions designed to achieve a specific objective • Action – specific change idea that can be tested and implemented at the agency level • Tool – a form, instrument, or manual that can be used as is or modified to support strategies and actions • Resource – a reference for more information related to implementing specific strategies and actions

31. ACH Improvement Matrix:Areas for Improvement • Promoting Patient Self-Management • Implementing Evidence-Based Practices & Guidelines • Using Systems and Technology to Promote Effectiveness and Efficiency • Improving Care Delivery Systems & Mobilizing Community Resources • Creating a Culture of Quality

32. Promoting Patient Self-Management • Focus on problem-solving skills and self efficacy • Role of homecare nurse in assessing, motivating, and empowering patient self-management • Evidence that effective self-management associated with better outcomes

33. Implementing Evidence-Based Practices and Guidelines • Strong foundation of evidence-based guidelines and tools exists • Demonstrated impact on hospitalization for selected interventions • Guidelines and tools need to be adapted for home care • Focus on getting clinicians to know and use the evidence base

34. Using Systems and Technology to Promote Effectiveness and Efficiency • Systems and technology key to supporting and sustaining use of guidelines and tools • Systems range from simple to complex • Key functions: • Identification and tracking • Internal/external communication • Decision support and “just-in-time” information

35. Improving Care Delivery Systems& Mobilizing Community Resources • Delivery systems problems lead to avoidable hospital admissions • Poor planning • Poor communication • Insufficient information transfer • Growing body of research demonstrates effectiveness of better discharge planning and improvements in transitions across settings • Effective changes include • Collaborative planning with hospitals • Use of transition protocols • Use of interdisciplinary teams/ APNs

36. Creating a Culture of Quality • Quality improvement is a complex process • Requires top-down/bottom-up involvement • Commitment of senior leaders key at every stage: launching, implementation, and sustainability

40. Using the Change Binder with OBQI • Comprehensive Framework • Represents excellent system of care required to make transformational change • Not intended to do everything • Add strategies over time • Issues not the same in every agency • The OBQI process along with some additional diagnostic tools can help HHAs narrow their focus

41. Identify Problems/Strengths and Best Practices • Identify the problem or strength • Specific Actions from the Change Framework can be considered for clinical best practices, especially those from • Promoting patient self-management • Implementing evidence-based practices and guidelines

42. Develop Action Plan • Specific Actions can be considered for intervention activities to implement clinical actions (best practices), especially system changes • Using systems and technology • Improving care delivery systems • Creating a culture of quality

43. Intervention Actions • What is to be Done • When it is to be Done • Who is Responsible • How Action is to Monitored

44. Strategy Combinations • Identifying patients at risk and implementing Actions to address the risk • Disease management • Transition from hospital to home health care

45. Identifying Patients at Risk of Hospitalization and Implementing Actions to Address the Risk Factors

46. Small Tests of Change

47. Implement the Action Plan • Clinical staff informed • Responsible persons carry out intervention activities • Specified activities occur as planned

48. Monitor the Action Plan • POA is a dynamic tool • Monitor • Intervention actions occurred • Best practices are used consistently • Outcome • Measure outcome and process • Measurement strategy

49. Tips for Internal Monitoring • Monitor your measures over time • Assign responsibilities for data collection • Establish a schedule and process for data collection • Consider real-time data collection • Integrate data collection into ongoing work

50. Next Steps • Discuss with Team • Further investigation? • Finalize POA • Implement POA • Conduct Small Tests of Change • Measure & Monitor • Work Collaboratively with IPRO and other HHAs