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2012 Welcome Webinar transcript

Shanen: Hello, and thank you for joining Moving Forward, the 2012 HHQI National Campaign Welcome Webinar. We are so pleased that so many of you have logged in to learn about more the exciting enhancements to the HHQI National Campaign as we formally launch our third phase of improving home health quality today, September 18, 2012.

Now to welcome everyone to today’s webinar, I am pleased to introduce Cynthia Pamon, who is the HHQI National Campaign Government Task Leader for the Centers of Medicare and Medicaid Services.

Cynthia: Hello, everyone, and welcome to the kick off webinar for phase 3 of the Home Health Quality Improvement National Campaign. We here at CMS are so glad you joined us today on the webinar. And in phase 3, we are striving to create a campaign that is both clinically and operationally relevant and effective.  We hope that the resources and tools provided through the campaign will assist you with providing quality care to your patients. We also look forward to your active involvement and engagement in today’s webinar and in all of the campaign activities in the near future. With me today is Jean Moody-Williams, Director of the Quality Improvement Group and the Center for Clinical Standards and Quality here at CMS. In addition to being a published author, Jean is a registered nurse and champion for health care quality in all health care settings including home health. I will turn the mic over to Jean to say a few words to you.

Jean: Thank you, Cynthia, and I would like to thank all of you for joining this call this afternoon. This work is very important, and I think that you are going to really enjoy the webinar as you hear from those in the field who are actually experiencing the benefits from prior campaigns and know how important it is that, working together, we collaboratively will improve the care of patients. The thing that I really wanted to point out is that your work is so important to really achieving some very significant national goals. You’re probably very familiar that the Secretary of the Department of Health and Human Services has charged us all to improve the safety of patients, to reduce the number of health care acquired conditions, and much of the work that will be done through this initiative – such as reducing unnecessary hospitalizations or working on the management of oral medications –  really are fully focused on improving the care that patients receive and improving the experience that their families have as they go though the care processes with them.

We are also very much concerned about matters of prevention as we look at flu and pneumonia, and eventually looking into other areas of population health that we know you all can have a definite impact on, and of course, the reduction of health care disparities is key as we do all of our work. More recently, we have had a focus on patient and family engagement, and we consider that you’re in the homes interacting with families on a daily basis, and we can actually learn a lot from you on how we can best go about improving and activating patients as they try to navigate their way through the care system. So I am going stop because I know the program that is ahead of you, and I want you to be able to jump right into that, and I encourage you to fully participate and ask lots of questions. We are just here to support you and the work that you do to improve patient care. And I will turn it back to Cynthia.
Cynthia: Thanks, Jean. With that, we are going to get going and get started, and we look forward to hearing more from you in the future. And I will turn it back over to Shanen.
Shanen: Thank you, Cynthia, and thank you, Jean. We really really appreciate both of your comments. It’s a great way to kick off a very exciting live webinar broadcast session today. As you all mentioned, we want this to be as interactive as possible, so please, if anyone participating today has any questions or comments for any of the presenters that you are about to hear, please  send them via email to at any time. You don’t have to wait until the end of the session. As soon as that question pops in your head, go ahead and open up your email function and hit send, and we will get to as many questions as we can at the end of today’s session as time allows. Also, handouts from today’s presenters will be posted on line at by the end of this week, alongside of a recording of today’s session. So if you like what you’re hearing and would like to share it with others or even hear a replay of it, you’ll have that opportunity by the end of this week, and we will notify everyone via email of the ability of both the recording and the handouts from today’s session. Next up on the HHQI Welcome Webinar, we will be discussing the evidence-based resources that the campaign provides free of cost to all participants. Here to tell us all about it is Lead RN Project Coordinator Eve Esslinger.
Eve:  Thanks, Shanen. Hello everyone. I am going to be sharing with you the schedule and plans for the Home Health Quality Improvement phase 3 educational resources. We’re going to continue with the Best Practice Intervention Packages, or the BPIPs. The packages have truly been a good resource for many, starting with home health providers and now used by other providers as well. In fact for the phase 2 BPIPs, there were over 150,000 BPIP downloads. That is pretty amazing. We know the BPIPs are being used, but we are going to make some format changes to meet the needs of more agencies for phase 3. The first thing I would like to do is a brief review of the past two campaign packages I do see in phase 1. For those of you who were active in that campaign, you’ll remember we had 12 packages and they were monthly. And then for phase 2 which started which started in January 2010, we had 6 quarterly packages, and we posted those up through April 2011. Now for phase 3. As you see, we have 8 packages planned. Now, what we know is the best practices continue to be the best practices. The best practices haven’t changed. For example, we know that fall prevention, improved medication management and better disease management – those are just examples of best practices – all prevent hospitalization. We also know the work of implementing of BPIPs is ongoing, and we need to get the best practice tools and resources into clinicians' hands so they are used. What we decided to do for phase 3 was to develop an abbreviated or what we called “Focused BPIP” for the topics of Patient Self-Management, Medication Management, Disease Management (2 parts), Fall Prevention and Cross-Setting Care. The release dates are on this screen, and as you see the first of these, Patient Self-Management, will be published on November 1, 2012. The packages will be about 15 pages in length and even contain most of the tools. The topics are not new, so you will see some tools that you may have seen or even used before. However, I caution you. They are not the same tools. They have been updated. We have looked at them from health literacy concerns and also updated them. There will also be at least 1 new tool in each package, so kind of something for everyone even if you used a lot of the resources. The Focus BPIPs are ready to be turned over to the hands of clinicians. They are short, attractive and contain information for just about everyone. I think you will all like them and appreciate the new format. The previous BPIPs from the previous campaign are also still available, and I am going to show you where you can find them in just a moment. Most of the information is still current. In fact, I would say probably 99% of it. So if you are looking for more information than you are going to find in the Focus BPIPs, consider going back to one of the previous BPIPs. There’s tons and tons of information in those BPIPs. We will reference and link to these BPIPs from the Focus BPIPs when it is appropriate also. We will have two additional BPIPs for this campaign that are not “Focus.” These are more traditional, and we are going to call them “Primary.” You’ll see packages and release dates for Dual-Eligible Providers and Immunization. Dual-Eligible Providers is a topic that Misty Kevech will discuss later on in the conference.

Now, we get lots and lots of questions about implementing the packages, and I would like to spend about five minutes giving you some tips and information on implementing BPIPs. To begin, the best practices are evidence-based. And our goal is to put the evidence in the hands of the clinicians in the form of practical guidance and turnkey resources. We want to work with our participants to make the resources adaptable, dependent on their patient preferences and values. You know we always appreciate your input and suggestions. They’re great, and please understand that you can take our tools and adapt them and change them. You can add your logo; you can even add something more specific to your agency or specific to your patient population, and you certainly can add directions for your staff on completing the tool. Use them, and make them your own. Now just a few minutes on some absolutes on improving. Your staff needs your organization to commit to quality. Quality is not a once and done; it’s an ongoing 24/7 and 52 weeks a year [process]. Keeping quality at the center of all agency processes and making sure quality is actively reflected in your mission is so important. You need to have the type of culture that promotes quality. One that learns from errors or potential errors and focuses on improving processes. What I would like you to do is to ask yourself when you have a patient hospitalized, what happens? It should be a team effort to look and see if there were perhaps missed opportunities, and note that I said “missed opportunities,” not mistakes or errors. We have to see them as missed opportunities. Are there things that you could do different next time, all of you? It is import to see also if your agency has the processes to make it easy for the staff to work on avoiding unnecessary hospitalizations. It was interesting that a recent publication called The Delta Study to Reduce Hospitalization, a national study to reduce hospitalization through home care, was shared last year at the National Association of Home Care Conference in October, and it was also posted or published around January of this year. This study found that agency awareness and support was the second most frequently used strategy to prevent hospitalization. The report states that “agency awareness support is making sure everyone in the agency knows that preventing hospitalizations is important and knows the ways in which the agency is trying to address the problem.” That is so, so important, and truly it is an organizational commitment. I also have listed ongoing staff education. I urge you take advantage to learn with your staff and share in their successes. Use our resources here at HHQI; use our data; use our information. A lot of this takes practice, and it is ongoing. And also communication a lot of communication. Speaking of communication, keeping communication lines open between disciplines, between other providers and especially with the patient caregiver and family. These are all keys to being successful, and you know it is so easy for me to set here and for us all to talk about improving communication, but it is not so easy to practice at it. Sometimes we have to break old habits, but we really do need to work on it, to practice, to make it better.

Now what I am going to do is go through some slides from our updated web site and share with you how to find the BPIPs. I bet most of you know, but I just wanted to go over a couple things that may be helpful to you. Number 1: make sure you are registered and logged in; Shanen will go over that later. But then when you are on, go under Education in the tool bar. If you click right on BPIPs, I will show you where you will end up on the next slide, but before that, if you have a specific BPIP you know that you are going for, I can just go and pick the BPIP I want and go straight there, but if you are going to click on the BPIP link, what you would see on this screen is all the BPIPs listed. All the BPIPs will be housed in the same area, so when we start releasing the new BPIPs as of November of this year, you will see them here also. Then what you will do is peruse and see what you want to use. If you click down at the bottom Fall Prevention BPIP, we’ll go to the next screen. This has the BPIP and all the resources associated with the BPIP, and down at the bottom is the Fall Risk Assessment with Algorithm and our guest speaker uses that form, and she will tell you about that.

So speaking of our guest speaker, we have with us, Gail Batson. She is a Nurse Quality Coordinator at Harmony Home Health in Natchitoches, Louisiana. I would like to tell you a little bit about Gail. What Gail is going to be doing is sharing with us  how she found the BPIPs and how she applies them. Gail graduated from a nursing diploma program in 1969. Gail has worked many years in many multiple provider settings, serving has hospital nurse, OB/GYN clinic nurse, nursing administration and long term care, hospice staff nurse, hospital supervisor, and since 2010, she has been the Quality Coordinator at Harmony Home Health. Gail furthered her education by earning her BSN and MSN while working full time. Gail is married to her high school sweetheart, has one son, a wonderful daughter-in-law and is the proud grandmother of two lovely granddaughters ages 13-going-on-30 and 9. Gail’s favorite place in the world is her home town, and I am going to share with you a little bit about that on the screen. Her home town was the setting for Steel Magnolias, The Horse Soldiers and The Man in the Moon. When Gail isn’t working or in her home, she is relaxing in Panama City Beach, Florida, her second favorite place in the world where she rests, relaxes and recuperates. So I have a picture of Gail for you on the screen and a very interesting picture of yes, snow in Louisiana. I didn’t think that was possible, but it is. Rare occurrence. So I would really enjoy and appreciate introducing Gail to you now.
Gail: Hello, everyone. It’s a pleasure to be here today, and I just really wanted to let you know that I was honored to be asked to participate in this webinar. It is just a real fun thing to do and any time you can educate is a good day for me. Yes, it does snow in Louisiana, and this is a view from a window in our office. It was a beautiful, one-day snow, and then it went away, so that is about all we get every couple of years.
What was going on here at Harmony Home Health when I came was a lack of quality programs. They did have a utilization review and audit system, but there was very little in the way of processes improvement. It was a lot of numbers, as Ria will allude to later. There were numbers, but there was really nothing to progress from having these numbers, so as it was a new position, the administrator told me that I would be developing and evolving this program, so actually I was starting from scratch. Once I got familiar with the systems here at Harmony and the people and generally what had been processing here, I thought, “What am I going to do next?” I said, well, do like everybody else in the 21st century; you Google it. So I typed in “quality improvement and home health” into the browser, and guess what the first thing that pops up on the list was. It was HHQI.

So that is how I found HHQI. And I said, this is right up my alley, so I clicked on that and found that it was very easy to register. The site was very easy to navigate, user-friendly, easy to browse through all the different aspects of the HHQI programs. What I didn’t really believe at first was that it was free. I said, “What’s the catch?” So I registered and signed up, and I was looking around in the site for what it was going to cost, but it doesn’t cost anything. It’s a wonderful service, and as Eve also said, we are all here together to improve the quality and the access to care.

The BPIPs were just what I needed. I was browsing through the site, and I saw some of the packages, and I started a little late after the actual phase 2 had started and found a couple of tools that I thought would be good to help improve our systems here. The Fall Risk Assessment Form was the first thing I saw, and it was a really concise, clear, very detailed Fall Risk Assessment which our assessment had been rather vague and really didn’t give as much information as I thought it should give to make decisions about how to prevent these falls. So I really enjoyed the Fall Risk Assessment. The exciting thing was when I found it, I flipped it over and there was the algorithm on the back. So you have all this information and now what do you do with it? So there was the algorithm, and if your patient has certain difficulties, mobility issues, incontinence and that sort of thing, then you can just look at your little box and follow the algorithm and get your physical therapist involved, your social services involved and whoever you need to get involved in this fall risk prevention. So I said this is really handy, and it helped us plan and activate a good program for fall prevention. The staff nurses where actually given the Fall Risk Assessment Form to look at and to read over and give us input about how they would like to change it if they would like to change it, and they did. They made a few changes in the assessment and what would they do differently or what would they add to it, so you need your staff input as Eve also said. It is invaluable to get staff buy-in to go along with the changes.

Then we were concerned about medication management. That was sort of an issue; we had a paper system at the time. There is a section in the Skilled Nursing Track in the Medication Management that gives you a checklist of how to properly do the medication reconciliation. I gave this to the nurses and said you really need to be doing 99.9 % of the things that are on this check list because if we’re not, we are really not managing the medications very well, and as everyone knows medication management, most of our patients are poly-pharmacy, have multiple medications and go to the hospital or go to the doctor to get meds changed. So you really have to keep on top of the medication management. I passed that out to the staff in our weekly staff conference. I try to pass a few things out as often as I can. I don’t want to overload them, but they seem to enjoy the fact that they have something to refer to, to be sure they were getting all their bases covered and they were doing their medication reconciliation.

Also, I really, really like the Emergency Care Plan, and that is in your section over here, but the Emergency Medication Plan was really something I thought our patients could utilize and our nurses could utilize for our patients. Sometimes we have low literacy patients, and they have hard time following just written instructions – a black and white piece of paper you give them to do this, do that. When I printed these out and showed them to the nurses, it actually has a little illustration there like “I hurt” or “I’m have trouble breathing” and has little bullet points which really focus in on what the patient problem is and first is when to call your home health agency and then when to call 911. That helps the patient and the nurse decide exactly how they are going to proceed with patient and keeping them out of hospital. We talked about hospitalization a little bit earlier too. So the Emergency Plan is something we started using, and I really do recommend that for everybody, and you can download it, put your agency name in there, put your patient’s name in it. Go to the section your interested in, , for instance, “Fever Above.” A lot of patients think 99.2 is a fever, so you could put “a fever above 100.4, call us” and “fever above 101, call 911.” So that helps the patient understand when they need to call us and when they need to call 911.

So those where just invaluable tools, and I only have three of them that I really focused on because you don’t want to overload your staff. You don’t want to overload yourself. You can’t throw a lot at people all at once and expect you to have a good job. Some people pick five or six things they want to work on, and that is just way too much. You are going to frustrate yourself. It’s like teaching a pig how to fly. You frustrate the pig, and you can’t do it, so don’t overload your staff or yourself, and you’ll be much happier with your system. Just a few practical tips that I found.

I have a little philosophy, and I call it my marketing philosophy, actually. Of course most agencies have marketing and handouts and things they like to do to attract patients and have doctors and providers refer to them, but I think “if you build it, they will come.” So in other words, if you build in the quality to your agency, the patients will come to you and the doctors will refer to you, like the Field of Dreams. That is what I like to think that we are doing here at Harmony Home Health. We are building in the quality, and they will come. And of course, it is always a team effort. You have to work closely with your administrator, the director of nursing, and the assistant director of nursing so they are all on board, and we work together with these projects. You have to make an effort to coordinate. It isn’t necessarily easy, but it is necessary. Coordination is key. You have to be sure everyone is on the same page and everybody has the same philosophies and the general idea of what you are trying to accomplish, for instance, coordination with the hospital. Now, we only have one hospital here in Natchitoches. It is a smallish town. It is a University town, but we have one hospital, and I called and spoke to the Quality Coordinator there which I had already known before she was the Quality Coordinator, and we spoke several times and emailed back and forth. She was very interested in some co-ventures in-services and asked me to come over and give an in-service about what we were doing and how this would benefit both the hospital and home health agencies. We shared some tools. There is another good organization called H2H, or Hospital to Home. We shared these things, and how we can better serve the patients that are our patients. They’re not my patients; they’re not her patients; they’re our patients. We see them in the home, and they see them in the hospital situation, so we wanted to coordinate our efforts, and sometimes it’s not easy, especially if you don’t know the people, but you really do have to reach out because if you are sitting there waiting for somebody to get in touch with you, you may be sitting there for awhile. Louisiana has one of the highest hospitalization rates in the country, so we have to coordinate with our other providers to overcome our high rate, and that is one of the things I am really working on here at Harmony Home Health. I have a little program where I try to review the transfer forms from the visit before the transfer, the visit after the patient gets out of the hospital, and of course, the hospitalization records to see, as Eve said, if I can glimpse an opportunity that we might have missed. You don’t want to call them an error or mistake because retrospectively, it’s always easier to see what you may have missed. And share this information with the staff, so hopefully that is a little education that will benefit not only the patients but the staff as well, so they can get more confident. When they say, this is a little different or that is a little different but it’s really not that bad, but it may be that bad for that patient. You have to individualize your assessment to coincide with what’s been the routine findings in your patients. As I said, Louisiana has one of the highest hospitalization rates in the country, so we really need to start working on getting it down. Also, we sneak in a little education during our staff meeting or our case conference meetings. Nurses, especially home health nurses, are busy, busy, busy, busy, and they don’t want to sit still long. They have places to go and people to see, so instead of trying to present some long (boring) PowerPoint presentation, I try to just give them a little bit here, a little bit there in our staff conferences. I call it baby steps. Give them some handouts; give them some of the tools to read and get back to me with any opportunity or changes that they think may be beneficial to the system here. So they don’t sit still long, and you have to know this and plan appropriately. If you tell them they have an hour-long presentation tomorrow at 2:00, they go “Ohhh… I’ve got patients to see… I’ve got this to do… I’ve got that to do.” You also need to be reasonable about the number of tools that you throw at them and the changes you make at one time because resistant is futile. You have to know that you may meet resistance if you make too many changes at one time; you need to take that in baby steps. You have to encourage and solicit feedback that you are going to get from the staff and tell them that anything they want to tell you, we will write that down, we’ll put it in the list of things to do. See if that works for you and works for us, and we can use those suggestions. You have to really be open for all of that because staff input – not just administrative support but staff input – is essential for progressing in your program here. For instance, we did circulate that Fall Risk Assessment and got the staff feedback, and that’s how we came up with our final tool. So as I said, be open, be honest, don’t give in because if you do, you are destined to fail, and the only time you don’t succeed is when you quit. There is a “Don’t Quit” poem you might want to look up online. I don’t have it right here in front of me, but I used that  while I was getting my master’s degree. So in other words, as Henry Ford would say, “If you always do what you’ve always done, you’ll always get what you’ve always got.” So you have plow on. Keep going, and don’t give up. You can do it.

So those are just a couple of little tips from the folks that are in the real world here, and if you don’t do it right the first time, it’s okay. You can just scratch that out and do it again, and see if it works a little bit better the second time. So like I said, I am really happy to be here. It’s a nice cool day in Louisiana for a change. It’s going to be a lovely afternoon, so I hope you have enjoyed this part of the webinar, and there is a lot more good stuff to come, so you all stay tuned and don’t go away. You’ll want to hear the rest of this, and I really appreciate again being asked to be here. So send in any questions you may have, and we will be glad to answer them for you. 

Eve: Thanks so much Gail. That was a wonderful presentation. We here at HHQI appreciate what you’ve had to say so much, and I know that our participants do to, so thank you. Thank you so much.

Gail: You’re welcome. Thank you.

Eve: I do want to tell participants, if you are interested in the resources that Gail went over, I did put the location of those on slide 16, or email me, and we will help you find those.
At this time, I would like to turn things over to Cindy Sun, one of the nurses here, a Nurse Project Coordinator at HHQI.

Cindy: Thanks, Eve, and hello everyone. So now we will move into the data portion, and talking about first, what data reports HHQI has available to you. First of all, they are 12-month rolling reports, and the data comes from the OASIS data that you transmit to CMS, so this is not risk adjusted. It’s untreated and is not the same as Home Health Compare. Where Home Health Compare is risk-adjusted data, this data is raw, and for this reason, there are some security issues involved, and we will talk about those in just a few minutes. Currently, the two particular focused reports that we have are ACH (Acute Care Hospitalization) and the Oral Medication Improvement Rate. As I mentioned, it dates back to 2009, and these are update the third week of every month. Now, this just means that if your agency was a CMS reporting agency in 2009, you probably just have reports just waiting for you. All you need to do is access them. As with everything else on HHQI, everything is free of cost, and it’s free of obligation. To access those reports, just go to the HHQI web site and click on the Data tab, and it will take you into the data portal. Once you’re here, you will notice in the center of the page are the registration and login links. If you have an access, that’s fine, and if you don’t you can create one. The big thing to remember is this login and registration is completely separate and unique from the general access login and registration which you were just told about through Eve and Gail’s information. So there’s one where you can access best practice packages, tools and resources, and this is a separate one. It’s import to know this so you don’t get them mixed up, but it is for the security of your reports.

The first report we are going to talk about is the ACH report. I’m just going to take a second or two to run through it. I just want you to have an idea of what is available on the site for those of you who haven’t accessed it before. You notice on the first report, this is the ACH report, the title is there as well as date it was actually published. At the beginning of each table in the report (it is about 7 pages long), you will notice the hospitalization versus transfer/discharges. The information of where this data was collected is listed at the top. You will notice on this one, it’s “excluding planned hospitalizations.” For those of you that are interested in historical trends over the past few years dating back to before the implementation of the OASIS C, the ACH calculations including the planned hospitalizations are available at the end of this report. Like I said, it’s for historical trends.

The information I want to share with you now is just to let you know this is different from the 30-day readmission rate. We’re asked about the 30-day readmission rate because that is what the facilities and other health care providers in your neighborhood and your communities are probably asking about right now. The ACH rate is calculated based on any time an episode of care ends in a hospitalization. So it is different than what the facilities are talking about, and I just wanted to make that clarification to help when you are discussing and dialoging with your facilities. So in addition to hospitalizations, transfers, and discharge calculations on this particular table, you will also find that the state and national ACH rates are there for comparison purposes. So in our fictitious agency, we can see that this agency started the year with an ACH rate of 30.9% and then improved over the next 12 months and brought their ACH rate down to 24.9%. The last column on the right shows that it’s a 26.3% ACH rate for the year. Now as I mentioned, these is 12-month rolling reports, so you can see this is the June data. Just a couple days ago, July data was posted, so it is available for you now. Another report that you might find helpful is Hospitalizations by Days of the Week. Was there a certain day of the week where your patients had more hospitalizations, or was there a day of the week where there were fewer hospitalizations? If there were fewer hospitalizations on a certain day treading throughout the year, what is going on on that day, and can those variables and factors be moved to the other days of the week?

The next report is my favorite report, looking at Reasons for Hospitalizations. You will notice this information is coming from M2430, and this where you can really drill down and see if there is a particular disease process that is causing your patients to go back to the hospital. This might be an area where you want to focus your improvements. I just wanted to point out the “Other than Above” category on this particular question, and this is a table where you can watch it on a monthly basis. All of your efforts going into reducing that “Other than Above” option will be displayed on this table. This is the graphic visual in case you want to share your monthly information with your staff, but you don’t want to put the raw data out on the bulletin board. This is a nice visual that you can cut out and post to keep everybody informed of what is going on with your actual rate. The other tables included in ACH report are Age, Race and Ethnicity, Payment Source, and Fall Prevention Interventions. The real question is, did any of these play a role in the rate in which your patients  were hospitalized?

Now, let’s take a second and look at the Oral Medication Management Report because we all know that oral medication mismanagement is a frequent cause of hospitalization. The first table looks at the overall improvement rate of how your patients improve while in the care of your agency. Looking again at the discharges and how many of the discharges did show improvement (that is how to calculate the rate), and then also as with ACH rate, we are looking at state and national averages as well to give you something to compare it to. Again on the fictitious agency, we can see they started the year with a 47.5 % of their patients leaving the agency showing improvement in the management of their medications while under the care of the agency. Over the next 12 months, we can see the agency increased to 51.3% of their patients improving in the management of their medications. With the state and national rates, we can compare and see that this agency did a little bit better than the national rate, but then a little bit lower than the state’s rate. Other tables that are included in the Oral Medication Improvement Rates include the Medication Follow-Up , High Risk Drug Education, Race and Ethnicity, and Age. The question is, did they impact it positively or negatively? The data is just to help focus your efforts on that. Coming soon, we are going to include risk-adjusted data as well as a brand new report looking at Immunization Rates.

The data reports are here simply to provide evidence of where you may want to focus your improvement process, but only you at the agency and in the patient’s home can actually decide the true picture. HHQI offers different areas of support to help answer not only your questions on interpreting these report, but also what steps you should take next. If you go back to the main page of the data portal where you originally logged in or registered, you will notice in the upper right corner, there is a link for questions. Here you will find guides and webinars to help you with the interpretation of the reports as well as a few next steps. Another good link is on the left-hand side. The FAQs are found there and may have some answers to your questions. And finally if everything else fails, please feel free to contact us through either of these two links. We will be happy to either provide answers via email, or if you prefer, we will be happy to arrange a phone call and go over the individual reports with you. As it has been mentioned here before, we’re here to help. All we need to know is what we can do to help you with this. We know that these reports are not going to do any good if they are not being used. So let us know what we can help you with. The final link I wanted to show you on this page is a resource. It’s for Access Plus. This is a system developed for those wishing to access the reports of more than 11 agencies every month. The idea is this system will help you not have to log in to all 11 reports every month. If this is something that sounds of interest to you, contact us, and we’ll be glad to walk you through steps.

Now I am very pleased to introduce Ria Rodriguez who will speak to how her agency has utilized the HHQI data reports. Ria was born and raised in the Philippines in the capital of Manila. She shares that her name came from the acronym of her parents’ names – R for Rudolpho, I for Isabel, and A for Always. She received her BSN in 1991 in her homeland, and then came to the United States in 1995. Ria has provided care in the Chicago area hospitals, rehabs and long-term care facilities for 15 years in the capacity of supervisor, Director of Nursing, and Corporate Consultant before moving east in 2010 and joining the VNA of Maryland as the Associate Director of Quality Improvement and Education. Recently, Ria was recognized as one of the 2012, 100 extraordinary nurses by the Honor Society of Nursing, Gamma Beta Chapter of Sigma Theta Tau International. Please welcome Ria Rodriguez.
Ria: Hi. Good afternoon, and thank you so much. It is my pleasure to be part of this campaign.

I would like to share with you a little bit about the VNA. The VNA Home Health of Maryland has been serving our community since 1895. We are dedicated to meeting the needs of individuals and families by providing compassionate, innovative, and comprehensive home health care services.  The next slide will show you some of our different programs and the rest of our staff. We have RNs, PTs, OTs. All the staff you could probably think of, we have it.

I would like to share with you how HHQI plays a role in quality improvement in our agency.  There are several reports  from HHQI, but I only focus my attention on reports that would make sense to me.  The following are some of the reports that I looked into every month – The Monthly Hospitalizations, Hospitalizations by Day of the Week, Reason for Hospitalizations, and Improvement in Management of Oral Medication. I’m not saying the rest of the reports are not important. I just think that this is what I need to drive a lot of quality improvement in our program.

First of all, just like a lot of you, I am anxious to see the hospitalization rate monthly, and of course, I would always say “Oh no!” with my boss. He was happy or he would ask me to go double-check the results to make sure it was correct. This is really what everybody wants to know. What is your hospitalization rate? In the medical field, this is what your preferred providers and doctors want to know. So if you are just like us, we are a preferred provider for a lot of hospitals here, and they are very in tune to hospitalization rates, and actually this part of what we share when we give them information on a monthly basis. But of course as we know, this is not yet risk adjusted, and I say not yet because I’m pretty sure they are working on it. So getting back to the hospitalization rate, this report will drive different avenues for improvement processes. There have been different improvement processes that have been made in our agency because of these numbers. So for example, what did we do about this number? You don’t just look at the number. You want to plan on what you can do to improve these numbers. So one of the things we have done is front loading visits. Follow-up visits within 24 to 48 hours is very essential, especially if your start of care is on a Thursday or a Friday. You know what happens during the weekend. Your patient will just blackout, and think you probably don’t have nurses on the weekend, or their nurse is not working on the weekend. So it is very important to have a follow-up visit to know and to see if your patient is okay. This is done especially for our acute patients and those patients who are new to insulin, new to a lot of medications, and the chronic diseases. We concentrate on our heart failure, our COPD, our diabetes patients, so a lot is being done. The first thing I would do after I see my hospitalization rate is to look into one of my audits. We have a lot of audits that we do in the facility, one of which is the Transferring Patient Facility Audit. What I am looking for in this audit is whether there were any signs of infection three days before? Did the patient report anything like feeling sick or not wanting physical therapy because they didn’t feel good. Those are queues, so that is what I am looking for. If the provider or the nurse, whoever is on the case, did they write that down? What did you do? That’s the next step. Was the physician made aware at all points that this patient was saying they weren’t feeling well before the patient went to the hospital? Another thing is, did they call us? In the real world, we all know that not all of our patients have their PCP. Who’s their PCP? It’s the ER. So they all just go to the ER. We must educate our patients to call us. This is a very big drive in a lot of our agencies. In our admission packet, we have this luminous paper that says, “Call us first,” and I would look into the data to see if the patient is actually calling us first. We revised our admission process and our documentation. We have added in the system, “Did you instruct the patient when to call the VNA versus 911 and the MD?” These are some of the changes you will actually do, because you want to improve every time. You want the level not to be just stagnate. You want it to be higher every time. If you see your hospitalization rate trending up, look at your audits. Look at your Utilization Review Audit. If you’re an agency that has your own staff for physical therapy, one of the audits we have here is called the Add-On Discipline Audit. We are looking to see if we are compliant within 48 hours, and we are. You’ll see that. You’ll share that with your staff. The SOC, The Start of Care Discipline: Are you within 24 hours of starting the care? These are important factors that actually were driven because of looking at your monthly hospitalization rate. There are a lot of factors; here are a lot of improvements you can do just by looking at one number. You don’t just look at the number, and then sit down and wait for the next month, and maybe your number will go down. What did you do about that number before that next month? Also, because of our agency’s hospitalization rate, more than 90% of our staff is a Certified Integrated Chronic Care Specialist, and I think that’s something a lot of you should think about because it would really help your patients to help themselves to manage their disease.. So that’s that for the Monthly Hospitalization. As you noticed, I have already talked a lot about the Monthly Hospitalization because there is really a lot of things you can do just by looking at your numbers. There are a lot of things that be driven by this number to improve the quality of care of your patients.

The next report I would like to share that I use is the Hospitalizations by Day of the Week. I use this for two reasons. First, I just really want to see if my patients are trending. Are they going out to the hospital more on weekends, or every Monday, or every Friday? So I would look into that. Why are they going out? Why is this day so trending? The other reason for using this data is for educational purposes for my providers. When I say “provider,” that is everybody that is taking care of our patients out in the field. So, I share this. We have monthly in-services for nurses, and our team meeting minutes say every discipline has to come to the office and one of the things that they share is these results. So they see the graph and the wonderful colors. They all see that green bar is way up there about every Monday or every Sunday, so they will wonder because these are actual numbers. I didn’t make these up. This is what you want to share with your providers; these numbers are real. I didn’t wake up one day and say, “Oh, maybe I’ll put this in.” No. It really is coming from HHQI. So when I was reviewing this report, I did a check during the weekend. Thank God our weekend is really low. What I am finding out is Mondays and Tuesdays. So you need to look into why. You need to look into when the last visit was done. So again, this will generate a lot of quality improvement that you can do for your agency. Look into the last two or three visits. When was that? So then you can adjust. Maybe you need to review your Utilization Review Audit. So that’s how I use it. Also, part of an audit that I do is, did they call us first or no? Or did they call us at one point and say, I am not really feeling well? What did we do about it? What did the triage nurse do? We’re open 24 hours. Our patient can access and talk to a live person. They’re actually their own nurses they are talking to. So that’s really important they know they can call us any time, any day. So you want to throw this out to your staff: What else should we do to lower rates, particularly on Monday?  Maybe they will suggest to give them a call or visit on Friday. We want to make sure. One very important thing is to educate them to call us first.

The next report I look into is Reasons for Hospitalization. This is a search for the real reason for hospitalization. This is another educational tool for the disciplines, for them to get as much information as they can. We’re electronic so you can just click on the reason for a patient going to the hospital. Again, if I show them the graph, there is going to be this red or yellow bar way up that is going to say “Other than Above”. “Other than Above” is usually way up there. The last meeting that I had with the providers, they were like, “Oh! That is really high. What are we doing wrong, Ria?” They will ask you because, again, these are real numbers. I didn’t make these up. You have to really know the reason why they went to the hospital. We don’t approve orders here that just say “Hospital Hold, Patient in the Hospital” unless it is complete. It has to have a reason. It has to the date when the patient went. So our providers are calling the hospitals themselves. What is the admitting diagnosis? And that is the only way they can submit their tests.

The last report I usually look at on the monthly basis is Improvement in Management of Oral Medications. This is very interesting because this information is given to the disciplines or to the provider. It’s an educational opportunity to instruct them or an opportunity to say kudos to you because the rate is really very good; the patients are really improving. How patients improve in the management of oral medications is how they educate the patient, so really they are going to see this. This is what you do every single day or every time that you visit your patient. It’s education. It’s educating them about the medication, the purpose, the side effects… all those things. I show them the results so they know, and again, I usually on throw them the question, “How do you think we can improve on this aspect?” Or if the result is really good, how do we keep it up? It’s a never-ending process. I believe quality improvement should never end. We should always try for quality improvement every single day, and that’s what we do here at the VNA.

Anytime that you have questions, I always email Cindy or I call her, and they will respond to you. They are very supportive, and they will give you the information that you need, especially if you’re new. It is very helpful to start using the reports that HHQI has. Thank you.

Cindy: That was a great presentation, and I am sure everyone can take something from what you’ve shared because you covered quite a lot of information, so that was fantastic.

I’m also sure that there are many out there today with the same feelings of anticipation, concern, and a little anxiety of opening your own data report. Ria has shared some ideas of how to let the data guide your quality improvement process, but if you have other questions we can help you with, just let us know.
Now, I will turn it over to Shanen Wright, the HHQI National Campaign Director.
Shanen: Thank you so much, Cindy, and thank you to all of our presenters and attendees who are still with us today and attending the 2012 HHQI National Campaign Welcome Webinar.

To tie things together, I just wanted to provide a quick live demonstration of the HHQI web site. I know that Cindy and Eve have provided some screen shots, but I thought it might be helpful – especially since we just launched this brand new web site just a few days ago –to quickly show you some of the frequently accessed functions on the web site, so you can make sure that you jump in and start enjoying these great free resources right after today’s presentation or first thing tomorrow morning.

The first thing I wanted to highlight, for those who are not already registered participants in the home health campaign, there is a simple button for registration. You just click on it, and it takes you to a simple form that you can fill out. It asks for information. If you’re in a home health agency, we do need your CMS certification number, so we can adequately track that you are a participant in the campaign and that you are utilizing our resources. If you’re not in a home health agency – maybe you’re a stakeholder, allied partner, or in another setting that is not home health – and you would like to adapt some of our tools, you simply click on the “No” button here and still register for instantaneous access to all the Home Health Quality Improvement National Campaign has to offer. For those of you who are already registered participants from one of our previous phases, there is no need to re-register. Our brand new web site does remember your username and password. So if you have already been participating, all you have to do is click on “Log In” at the top of every single page on the web site, as you see it here in the upper right hand corner. Then when you log in to the web site, there is a great new feature called “Remember Me,” and that way, you don’t have to try to keep track of both your data access and campaign web site information. The campaign web site will keep you logged in. You can see here in the upper right hand corner -- “Welcome Shanen B Wright” -- that means I’m logged in. So now I can enjoy access to all the Best Practice Intervention Packages that Eve talked about. If you click on the Education tab at the top of the web site, it will take you to a page where we list the upcoming schedule of Best Practice Intervention Package releases, as Eve has detailed. Additionally, you can scroll down to the BPIPs and see all of our phase 2 archived resources… all here for you to access, but you must be registered to be able to view. So if you are not yet registered for the campaign, as soon as this webinar is over, please go to,  click on registration, and you can start enjoying these great resources. If you ever need help accessing the web site, navigating it or with anything else, you can always reach out to us at, and we will be happy to assist you as well.

So in phase 3, as we are formally launching today with this Welcome Webinar, we not only have a brand new web site, we also have the new Best Practice Intervention Packages and educational resources that Eve mentioned. We have new data report enhancements that will be coming soon that Cindy detailed, and another really exciting and groundbreaking component of the campaign, which is a key emphasis on small non-profit, publicly funded agencies and/or those that serve a high proportion of dual-eligible patients. Here to tell us all about this exciting new initiative of the HHQI National Campaign is RN Project Coordinator Misty Kevech.
Misty: Thank you, Shanen, so much. I hope that you all are excited about the campaign as we are. As health care industry, we continue to strive nationally toward better outcomes such as ACH, medication management, and immunizations. We still have persistent and well-documented health disparities that are closely linked with social, economic, and environmental disadvantages. And on this slide, you can see some of the key differences that agencies find for some of their patients: gender, age, race, and ethnic status. There are also language barriers, sexual orientation, gender identity, and religious differences. There are also validated differences related to geography, such as urban versus rural, or even frontier. And there are specific regions in the United States where disparities are even greater. Poverty and low socio-economic statuses directly impact health status, access to care, and many other health care needs. In the United States, we still have disparities related to lack of insurance, mental health, disabilities, health literacy, education levels, and even decreased quality of health care for this underserved population. The statistics are astounding. Over significant differences for these factors related to risk factors, hospitalizations, and even mortality rates. The Department of Health and Human Services is working collaboratively across governmental departments of HHS, as well as leading Quality Organization toward a goal: A nation free of disparities in health and health care.

So how do health disparities and the third phase of this campaign connect? We are going to be working on developing materials that focus on the issues for that special population of Medicare patients. We are very excited in this phase of the campaign to be addressing health disparities with an emphasis on special populations in relationship with ACH, medication management, and immunizations. We will be focusing tools and resources toward many of the health disparities that I discussed in the last slide. Notice the circles on this slide. They overlap, and in many cases, so do these special populations. Many agencies care for patients who are termed “Dual-Eligible” because they qualify for both Medicare and Medicaid services related to their income levels and health status. This population offers a different set of challenges for home health as well as other providers to improve patient care and outcome. Many of you are leaders at your agency, and you see statistics come across your computer or your desk every month. Are you able to break down the statistics and determine measures or best practices to overcome and improve outcomes for your diverse populations? As we have seen in different health care settings, many times Dual-Eligibles receive care from a variety of providers and even different services from both payers. Minimal coordination may occur. Fortunately, we are now seeing changes to a more coordinated, patient-centered care for this special population in many states. Each state has different programs or expansions of programs to meet and begin to tackle this ever-growing problem. Some examples include CMS’s Innovation Dual–Eligible Integration Project, CMS’s Medicare Special Needs Plan, health home option with Medicaid managed care organizations, PACE (Program of All-Inclusive Care for the Elderly), PDA waiver programs, and there are more. Also across the country, there are home health agencies that are located in underserved areas that find improving ACH, medication management, and even immunizations very challenging related to some of those factors that we saw on the previous slide. Urban areas have a unique set of problems versus the very remote areas in this country. In this campaign, we are going to focus resources and opportunities to share innovation and ideas for improvement and strategies geared for the underserved areas. Another special group is those small, non-profit home health agencies. They have limited resources and find it difficult to implement the tools and resources at their agency level. Phase 3 of the campaign is going to allow us to work closely with those agencies, provide more one-on-one assistance in creating plans to overcome the barriers or issues that they encounter and that are preventing them from being successful in implementing the campaign materials.

Over the next few slides, I am going to give you a glimpse of different ways we are going to be able to assist the agencies that see these special population patients. With that being said, that is actually every agency on this call. Each agency will have their own unique special population issues. But they are simpler to either other agencies down the road or agencies across the country. The campaign materials being developed are for the Medicare population, but they will work for any of your payer sources, not just Medicare patients. So let’s start to look at some of those key ways that you are going to be able to receive education and support. The Dual-Eligible BPIP, which will be released February 1, 2013, will be a full BPIP package, a much larger version than the Focused BPIPs that Eve mentioned earlier. The SPAN BPIP, which is the Special Population Assistance Network BPIP, is going to include many tools and resources for agencies used to improve awareness, knowledge, and solutions for issues that you find with your special population. Additionally, we are going to explore different models of care or demonstration projects focused on those dual-eligible patients and strategies to advocate and be proactive for our patient outcomes. We will be providing ideas of how your agency can work effectively with these types of organizations to improve coordination of care and maximize patient resources to reach those patients. Additionally, there will be information, tools, tips, or other resources that will be beneficial to the special populations in every BPIP that will be focused on those special topics. We are reviewing all patient tools or handouts for health literacy, plain language – and that’s removing the unnecessary medical jargon. We’re looking at reading levels, etc. You may even see slight differences in tools from previous BPIPs with minor but significant modifications to improve readability and understanding for the patients. Learning how to use available data is another way the campaign will be assisting agencies. Consistent disparity data is very difficult to obtain in many of the social, economic and environmental areas. But we will be sharing as much data or data resources that may assist agencies from a national, state, and/or even a county level for some of the disparity areas. Of course, the HHQI data reports include race groups that Cindy showed you earlier, and we are going to try to provide you with some additional data for this special population as we progress. We will be sharing inventions and strategies on how to use this data and determine the agency’s areas of need and assist them with their quality improvement plans.

Here is a sample of the data that is already included in the HHQI campaign reports for ACH. This breaks this down by race groups for your agency based upon the OASIS item M140, Race and Ethnicity. We will be providing strategies to use reports and additional national, state, county data for quality improvement efforts. A new feature for this phase of the campaign is the SPAN network. We are going to be establishing different SPAN groups related to different disparity issues or concerns. Now, these networks are going to allow anyone who wants to join them to share barriers as well as successes or knowledge. These groups will provide feedback related to tools or resources that will be offered to assist agencies to improve care and outcomes with this special population. You are going to be hearing more about the SPAN groups over the next few months and how to join. In the meantime, if you have a specific issue or solutions that you may want to share with us now, please contact us at and mention SPAN or Dual-Eligible in the email, and I would be very happy to contact you.

I hope that I have given you just a taste of what’s to come with the Special Population Assistance Network. Watch out for more information through our electronic communications. Once again, I hope that you are just as excited as we are as we kick off phase 3 of the campaign. Now, I am going to turn the presentation back over to Shanen.
Shanen: Thank you so much, Misty. Now we have time for a few questions for our presenters.
The first question is for me and asks, “When can we sign up for phase 3?” The answer to that is a simple one. You can sign up right now. We have continued open enrollment for the campaign throughout its duration, so if you’re not yet signed up to participate, please log on to, and we will get you registered instantaneously.

The next question asks, “Have you been able to demonstrate improvement in ACH rates at any of the organizations based on their use of the BPIPs, specifically cross-setting BPIPs related to transitions of care?” That is an excellent question, and I can answer that yes, we have been able to demonstrate clinical quality improvement through agencies with a high level of engagement in the campaign and utilizing campaign resources. We have a very compressive final report that details that information, and that information will be peer-reviewed published soon. Once we have that publication identified and that information out there, we will make sure to let everyone know so you can learn more about the demonstrated clinical quality improvement that Home Health Quality Improvement National Campaign participating home health agencies have shown.

Our next question is for Eve, and this question is from Tiffany in Nebraska who asks, “One of the speakers talked about organizational culture. Do you have resources on improving culture? It seems like most of the information on health care culture is for larger organizations such as hospitals.”

Eve: Tiffany, that’s a good question. We do, and I do agree with you most of the literature about culture change is geared towards hospitals. I will tell you that most of that can be adapted to home care. In at least three or four of the BPIPs from phase 2, you will find a 1 or 2-pager specific to organizational culture. We introduce culture change such as just culture, human factors. Those are very specific to home care, and if you have trouble finding them, email us, and we will definitely get those out to you. That’s a good place to start, and I would also look at the literature that is out there and definitely use that as it applies to home care as well.

Shanen: We have another question for you, Eve. This one is from Shelia in Washington state. “Our agency has been sold, and there was so much turmoil for a while that we didn’t work on anything. Our data has gotten much worse. I guess my question is where should we start?”

Eve: Well, that is a tough one, but it’s kind of a good opportunity too. I think I would go back to where you were. Look at your tools, see what was working. Talk to your staff, and I would use those tips from Gail. Gail started in 2010 in a new quality position at her agency. Do what Gail did; look for those resources. I think it is good to define what your problem areas are. I would get ahold of those data reports from HHQI as soon as possible. Get registered; look at those reports,  and try to drill down your problem areas too because you may, based on those reports, see where you have a problem, and if you don’t based on the reports, then you need to get the staff to get the data to you better. Get the reasons they are being hospitalized. But, great opportunity there. I know it’s tough to start again.

Shanen: Next up, we hear from Josie in Oregon who has a question for Gail. She says, “Hi Gail. Thanks for your story and your tips. My question is that you talked about not overloading, just to do a few things at a time. How many changes do you make at once -- one tool a week, a month? What would be general rule of thumb?”

Gail: A general rule of thumb would be to play it by ear. I know that sounds rather vague, but sometimes you just have to feel out the goings-on there in the home health agency. Some weeks are busier than others. I had a really good, brief presentation – I don’t usually go more than 10- 15 minutes with my presentations – but it was really an usually busy week. Everybody was running around like chickens with their heads cut off, so I just skipped it. I didn’t do it that week but decided we would do it the next week or even the week after that. Sometimes just being sensitive to what’s going on in your agency is important. You can always have something planned. Keep it in the back pocket, and if everything is going well and it’s been a good week, just bring it out and present it to your staff. Usually the reception is better when they’re not hurried or running behind schedule.

Shanen: Sounds great, and thank you so much, Gail. Our next question is from Sheila in Oregon. This is for Cindy. Sheila says, “I am having trouble finding my data. What do I do? I think I registered, but I can’t find my user name and password. Is this a different web site than the BPIPs? If so, what is it?”

Cindy: Hi, and thank you for asking that. That is a question we get quite frequently in HHQI Info. To access your data, it is a completely unique and different registration system than the one you created to access your BPIPs. So once you click into the data site, you are basically in the data portal which is completely separate from the HHQI site. It’s all because of security. Once you are here, you must create a different user account. It is a little bit more difficult to get through because of security aspects of it, but once you are through it, you are done. You never have to go though those questions again. So I encourage everyone. It really only takes 30 to 60 seconds to register for it. It does require information from your CASPER reporting. The steps are on the application itself; it’s very simple. Once you click “verify,” it takes about 2 maybe 3 seconds max to get verified, and you’re in.  If you have difficulties with it at all, and this goes for everyone, please just contact us at HHQI Info, and I will be glad to walk you through the steps to see where you are getting held up and if you are having any difficulties.

Shanen: Our next question is for Ria. This question says, “Do you have any suggestions or lessons learned to help someone who has just started to introduce data results to our staff?”

Ria: That is a very good question. I would share with them 1 or 2 results from HHQI. I would choose the Hospitalization Rate, and I would share with them that this is not from me this is from HHQI, and what do you think we should do to improve the result? That is where I would start.

Shanen: We have another question for Ria. This one is from Lorain, and she asks, “How does one become an Integrated Chronic Care Specialist?”

Ria: At our company, we attended the Chronic Care Specialist course which was given by Pinta Health. Pinta Health is from Little Rock, Arkansas, and I can give you their web site. It’s So you attend the course, and you get certified after you pass the online exam. That is how we got certified.

Shanen: Thank you. We have time for one last question before we wrap things up. This question is for Misty. This person writes, “We are a small agency and don’t have many resources. I do think our issues are different than other larger agencies. Will the Dual-Eligible BPIP be more specific to us? If so, how? We really need things that can be implemented on a small budget. Should we just use that BPIP and not the others since we have limited time?”

Misty: Absolutely not. What we are going to do is create those SPAN network calls, so what you are going to want to do is join one of the SPAN networks that are going to specifically for those small, non-profit organizations. We know you have limited time, but we are going to be able to give you some one-on-one guidance to say, here’s the Best Practice Package on Patient Self-Management. Have you read through it? Let’s talk about what you are doing and how we are able to implement (even it is implementing 1 or 2 ideas), and how you can do it on the limited resources and time that you might have. So we are going to be able to help you individualize key content – maybe not large in scope of using the whole package but will be large to impact what you are doing at your agency. So watch for those SPAN networks because one will be specifically for small agencies.

Shanen: Alright that is all the time we have for questions today. Now with some closing remarks is Cynthia Pamon of the Centers for Medicare and Medicaid Services.

Cynthia: Thank you all again for joining us today. As we move forward, I really want to hear your feedback on what we are providing through the campaign. We actually use the feedback to improve what we do and to design future work. As a former home care nurse, I understand time is short. Consequently, we really are committed to providing you with efficient and effective tools and resources staff may actually use. Be on the lookout for upcoming webinars on various topics and join us again. Please spread the word, so all home health agencies across the country may benefit from the campaign. Take care everyone, and now I return the mic back over to Shanen Wright for final closing remarks.

Shanen: Thanks you so much, Cynthia, and thank you all so much for joining us on Moving Forward, the 2012 HHQI National Campaign Welcome Webinar. Please visit our website at, or contact us anytime at for more information and to provide your feedback. Have a great day.