February 2008 e-Bulletin
 

Resources are Still Available as Campaign Comes to a Close

"I have found the HHQI Campaign initiative to be a wonderful resource and motivator. As a small agency, we do not have the resources for a staff educator and/or multiple educational materials. It is enabling us to keep up with the "big guys" so to speak. We can compare our operations with everyone else in the nation and learn what is going on in the field without costly membership fees! You keep us abreast of educational offerings and Medicare happenings. You do research for us. Thanks so much, your service has been invaluable!!! I hope it continues. It has raised everyone's consciousness."
- Agency Comment from the January 2008 HHQI Evaluation Summary

Believe it or not a year has passed, and the Home Health Quality Improvement (HHQI) National Campaign is coming to a close. The campaign has been an immense success with over 5,500 participating home health agencies. Agencies now have access to a multitude of resources and information. National stakeholders have supported and promoted the campaign, while Local Area Networks for Excellence (LANEs) (QIOs and state associations) have coordinated the campaign work in each state. The campaign will end February 29, 2008. Please see the ‘Spotlight on HHQI Campaign Champions’ section below for guidance on how to locate resources now and when the campaign is complete.

An HHQI Evaluation Survey was conducted this month with participating agencies. A summary of the results is now available on the HHQI Web site. The HHQI Agency of the Campaign was selected from survey participants and we are pleased to announce that Carondelet Home Health Services of Overland Park, Kan. has been named the HHQI Agency of the Campaign.

Additionally the participating HHQI agencies will receive one final CD. Please remember that the information on the CD is not unique—it comes from the podcasts that were posted with each Best Practice Intervention Package (BPIP). The final CD includes the remaining clinician and home health aide podcasts (audio recordings) for the yearlong campaign. The tracks are as follows.

• Track 1: Disease management for clinicians
• Track 2: Disease Management for Home Health Aides
• Track 3: Transitional Care Coordination for Clinicians
• Track 4: Transitional Care Coordination for Medical Social Workers and Home Health Aides

All of the podcasts from the 12 BPIPs can be downloaded from the HHQI Campaign Web site, www.homehealthquality.org. Each clinician podcast is approximately 15 minutes in length, and each home health aide podcast is approximately 10 minutes in length.
 
NOTE:  All continuing education for the Best Practice Intervention Packages will come to a close as of February 29, 2008. Visit the continuing education Web site on www.homehealthquality.org for available packages and links for evaluations/post-tests.

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Best Practice Intervention Package:  Transitional Care Coordination

Transitional Care Coordination is the final Best Practice Intervention Package (BPIP) for the HHQI National Campaign and will be available January 31, 2008. The campaign has produced monthly packages that focused on 12 best practices to reduce avoidable acute care hospitalizations. Home care agencies can download and use any part of the packages, tools and resources. Many of the tools are posted on the Web site www.homehealthquality.org in a modifiable format so they can be personalized and/or changed by agencies.

Transitional Care Coordination is also the final package in the 'Building Upon the Basics' series, which guides agencies to build upon basic interventions that have already been implemented to reduce acute care hospitalizations. The primary goal for improved care transitions is to provide patients with tools and support that promote knowledge and self-management as they transition from one setting to another. Home care can play a significant role in improving transitional care coordination by helping to coordinate handoffs/handovers across health care settings, as well as promoting patient self-management.

This package explores the concepts of care transitions and care coordination and how they have helped formulate transitional care coordination. The package highlights current transitional care work by The Care Transitions Program at the University of Colorado, under the guidance of Dr. Eric Coleman, and application of the concepts for home care. Care transition coaches are pivotal to the care transition model and this package will explain how home health agencies can act as the patient coach.

The Four Pillars of Care Transitions from the Care Transitions Program include four key areas:

1. Medication self-management
2. Patient-centered record
3. Follow-up (with physicians)
4. Red flags

The primary tool for this BPIP identifies the four key areas and potential home health activities. Additional tools highlighted from the Care Transitions Program include the Personal Health Record and Medication Reconciliation form.

The BPIP contains a Leadership, Nursing, Therapy, Medical Social Worker and Home Health Aide Track. Podcasts are available for clinicians (nurses and therapists), medical social workers and home health aides. The podcasts discuss transitional care coordination and application to home care, and reviews previous BPIPs importance in reducing avoidable acute care hospitalizations.

Please Note:  Continuing education will ONLY be available for Transitional Care Coordination and all previous BPIPs until February 29, 2008!  To view a table with available continuing education and links to the appropriate BPIPs and continuing education evaluations/post-tests please visit:  www.homehealthquality.org/hh/hha/contacthours/cne.aspx

If you have not received a certificate from a previous test, please contact Kati Bennett at kbennett@wvmi.org.

The campaign has been a success with almost 5, 600 home care agencies participating in this yearlong campaign. The 12 Best Practice Intervention Packages and their associated resources will continue to be available at www.homehealthquality.org and will soon be available on www.medqic.org.

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Previous Best Practice Intervention Packages

January - Disease Management
December - Patient Self-Management
November - Fall Prevention
October - Physician Relationships
September - Immunizations
August - Telemonitoring
July - Teletriage
June - Phone Monitoring and Frontloading Visits
May - Medication Management
April - Emergency Care Planning
March - Hospitalization Risk Assessment

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Home Health Agency of the Campaign

Carondelet Home Care Services
Overland Park, KS

“Carondelet Home Care Services (CHCS) is honored to be recognized as the Agency
of the Campaign. CHCS has implemented several tools during this project
including the ACH risk assessment tools and emergency patient education
tools. By participating in this project our published ACH outcome has
fallen from 25 percent to 21 percent risk adjusted.” – Cynthia Clark RN, MBA, Quality Manager

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Spotlight on HHQI Campaign Champions

As we complete the work of the campaign, the Home Health QIOSC team would like to extend very big THANK YOU to every HHQI participating home health agency. Obviously, there would not have been a campaign unless home care agencies across the country were willing to step up and commit time and resources to reducing acute care hospitalization rates in home care. Thank you all for your endurance, perseverance and commitment to improving the lives of our patients. Truly, every participating home heath agency is an HHQI Campaign Champion! 

Below are some ‘next steps’ to guide your agency in continuing to work on quality improvement.

Twelve monthly Best Practice Intervention Packages (BPIPs) were provided for agencies in the Home Health Quality Improvement (HHQI) National Campaign to assist agency leadership with implementing and optimizing the top 12 best practices for reducing hospitalizations.

Even though this yearlong campaign is concluding, the resources will remain available and continue to be pertinent. The BPIPs and associated resources will remain available on www.homehealthquality.org through July 31, 2008 and will also be available in early February 2008 on www.medqic.org (under Home Health). There was a significant amount of information in each BPIP that agencies can continue to use for ongoing quality improvement activities. Some suggestions on evaluating future activities: 

• Take time to reflect on the interventions and changes that have already been implemented to assist with reducing ACH
• Evaluate compliance and consistency with interventions and changes that have already been initiated
• Evaluate the BPIP topics that have been identified as a focus area and review the package again, selecting additional action items
• Review the full BPIPs if only the Fast Track was previously used
• Incorporate BPIP action items into the annual quality improvement plan
  • Use the Care Tracks for orientation and staff competencies
  • Develop a competency fair using the resources from the packages
  • Collect all packages together in a resource binder

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View the January Tips of the Week.
View the December Tips of the Week.
View the November Tips of the Week.
View the October Tips of the Week.

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