"Connecting the Dots": A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients.

BACKGROUND: In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination. OBJECTIVE: To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients. DESIGN/PARTICIPANTS: We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method. KEY RESULTS: HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability-hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication-enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals-liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management-HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety-HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC. CONCLUSIONS: In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

Delineation of self-care and associated concepts.

PURPOSE: The purpose of this paper is to delineate five concepts that are often used synonymously in the nursing and related literature: self-care, self-management, self-monitoring, symptom management, and self-efficacy for self-care. METHOD: Concepts were delineated based on a review of literature, identification of relationships, and examination of commonalities and differences. FINDINGS: More commonalities than differences exist among self-care, self-management, and self-monitoring. Symptom management extends beyond the self-care concepts to include healthcare provider activities. Self-efficacy can mediate or moderate the four other concepts. Relationships among the concepts are depicted in a model. CONCLUSIONS: A clearer understanding of the overlap, differences, and relationships among the five concepts can provide clarity, direction and specificity to nurse researchers, policy makers, and clinicians in addressing their goals for health delivery. CLINICAL RELEVANCE: Concept clarity enables nurses to use evidence that targets specific interventions to individualize care toward achieving the most relevant goals.

Psychometric Testing of the Sidani and Doran Therapeutic Self-Care Scale in a Home Health Care Population.

BACKGROUND AND PURPOSE: Self-care is a central goal of home health (HH) nursing care. The study purpose was to assess psychometric performance of the Therapeutic Self-Care Scale (TSCS) in a U.S. HH population. METHODS: TSCS reliability was assessed with Cronbach's alpha and test-retest analyses ( n = 59). Convergent validity testing and principal components analysis (PCA) were performed. RESULTS: After elimination of 2 items, internal consistency reliability was acceptable (α = .804) and test-retest reliability was high (intraclass correlation = .94; p < .001). Convergent validity analyses were inconclusive. PCA found 2 underlying dimensions consistent with a conceptual difference between self-care and self-management. CONCLUSIONS: A valid, reliable measure of self-care/management would be useful for measurement of HH nursing outcomes. The TSCS holds promise but needs further refinement before it can serve this purpose.

Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement.

OBJECTIVES: To evaluate effects on patient outcomes of Outcome-Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC). DESIGN: A quasi-experimental design with prospective pre/post and study/control components within two multiyear demonstration trials (occurring from 1995 to 2000) in which 73 home health agencies implemented OBQI, receiving several annual cycles of outcome reports to evaluate and enhance patient outcomes. SETTING: New York and 27 other states. PARTICIPANTS: The study involved 157,548 predominantly older adult patients admitted over 3 years to 54 OBQI agencies from 27 states in the National Demonstration Trial, 105,917 patients admitted over 4 years to 19 OBQI agencies in the New York State Trial, and 248,621 patients admitted over 3 years to non-OBQI control agencies in the 27 demonstration states. INTERVENTION: As a clinical management and administrative intervention, OBQI involves collecting, encoding, and transmitting patient-level health status data to a central source that provides each OBQI agency with a risk-adjusted outcome report comparing the agency's patient outcomes with those from a reference population and with its own outcomes from the prior period. Target outcomes are selected and focused plans of action implemented to change care behaviors. Outcome changes are evaluated through the next report cycle. MEASUREMENTS: Outcome measures include hospitalization rates and improvement and stabilization outcome rates in functional, physiological, emotional/behavioral, and cognitive health. RESULTS: For the National and New York State Demonstration Trials, the risk-adjusted relative rates of decline in hospitalization of 22% and 26%, respectively, for OBQI patients over the 3-year and 4-year demonstration periods were significant (P <.001) and unparalleled by considerably smaller rates of decline for the non-OBQI patients in the 27 states. The risk-adjusted rates of improvement in OBQI target outcome measures of health status averaged 5% to 7% per year in both demonstration trials and were significantly greater (P <.05) than analogous improvement rates for nontarget comparison outcomes, which averaged about 1% per year. CONCLUSION: It is feasible to integrate the programmatic, data collection, data transmission, and outcome enhancement components of OBQI into the day-to-day operations of home health agencies. The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients. OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare settings.

A Study of Reliability and Burden of Home Health Assessment Using OASIS.

The Outcome and Assessment Information Set (OASIS) is used for outcome reporting, quality improvement, and case mix adjustment of per-episode payment for home health care. The research described here addresses interrater reliability of OASIS items and compares clinician time required to complete patient assessment with and without OASIS. Interrater reliability for OASIS data items was estimated using independent assessments by two clinicians for a sample of 66 patients. Incremental assessment time due to OASIS was estimated using interview data from two agency-matched groups of clinical care providers-one group who used OASIS in the assessment and a second group whose assessment did not include OASIS items. Interrater reliability is excellent (kappa > .80) for many OASIS items and substantial (kappa > 0.60) for most items. The reported time required to complete an assessment with OASIS did not differ from the time required for a comparable assessment without OASIS. The results of this study are being used to guide developmental efforts to improve OASIS items. They can also be informative to home health care agencies when interpreting OASIS-based outcome and case mix reports.

A basic and practical overview of the six steps of outcome-based quality improvement. Interpreting outcome reports: the basics.

Analysis of OASIS data produces several types of agency-level (aggregate) reports. This article describes the components of the risk-adjusted and descriptive outcome report.

A basic and practical overview of the six steps of outcome-based quality improvement. Selecting target outcomes: the basics.

After obtaining the risk-adjusted and descriptive outcome report, the first activity of outcome enhancement involves selecting one or two target outcomes. This article outlines the criteria for target outcomes selection and features a suggested timeline.

New tool to use with patient tally reports.

A new tool is available for agencies to use with their patient tally reports derived from OASIS data. By using queries submitted to the outcome and case mix tally reports, agencies can select a group of care episodes for follow-up in the process-of-care investigation portion of their outcome enhancement activities. An example of how an agency used the tool to select care episodes for review is provided.

The process-of-care investigation. The basics.

The risk-adjusted and descriptive outcome report provides a foundation for Outcome-Based Quality Improvement (OBQI). This article describes the steps of the process-of-care investigation that will begin once target outcomes are selected.

Developing and implementing a plan of action to improve care. The basics.

Once agencies have completed a process-of-care investigation, the next step of OBQI is the development and implementation of a plan of action to improve care. In this article, the authors share strategies for developing, implementing, and monitoring a successful plan of action and describe how pilot agencies developed their own action plan.

Performance benchmarking. Part 1: What it is & how to use it.

Benchmarking provides data necessary to evaluate an organization against norms for various administrative and clinical purposes. There are many different types of statistical comparisons used to benchmark one organization against others, or against itself over time. Careful selection of benchmarking strategies can give an organization confidence in the results, thereby maximizing the usefulness of the data for decision making and performance improvement.

Performance benchmarking. Part 2: Trends in home health care & what's in store for the future.

The need to change will catch up with an organization whether it overtly incorporates a change and evolution program or, less desirably, has to inefficiently react to and recover from change forced from the outside. The latter approach can be devastating in terms of staff morale, patient well-being, cost and revenues, staff retention, and organizational pride. It is far wiser to embrace, learn about, and efficiently incorporate the new practices and approaches in home health care that will result from progressively more emphasis on benchmarking, understanding and using the valuable benchmark information internally, and by virtue of understanding and using such information, contribute constructively to the evolution of home health care both externally and internally.

Implementation of electronic surveillance of catheter use and catheter-associated urinary tract infection at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals.

BACKGROUND: Manual surveillance of indwelling urinary catheters (IUCs) and catheter-associated urinary tract infections (CAUTIs) is resource intense. METHODS: We implemented electronic surveillance in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Capacity was created centrally to analyze data collected electronically or manually at each site. We measured the average IUC duration and proportion of patients with IUC duration <3 days. CAUTIs were identified using a validated algorithm based on the Centers for Disease Control and Prevention definition and used to calculate rates and standardized incidence ratios (SIRs). RESULTS: Electronic surveillance was implemented in 25 units at 20 NICHE hospitals. Full automation was achieved at 15 of 16 sites with electronic health records (EHRs). Electronic surveillance challenges included EHR data element formats and IUC documentation. Study units reported on 4,574 patients for 16,105 IUC days over a 6-month period. The mean of the unit-level average IUC duration was 3.2 ± 2.6 days, mean proportion of patients with IUC duration <3 days was 52.4% ± 50%, and mean CAUTI SIR was 0.14 ± 0.31. CONCLUSION: A centralized electronic surveillance strategy for CAUTI is feasible and sustainable. Baseline performance of participating sites was exemplary, with very low SIRs at baseline.

A Trial of electronic surveillance feedback for quality improvement at Nurses Improving Care for Healthsystem Elders (NICHE) hospitals.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) risk is directly related to duration of indwelling urinary catheters (IUCs), rising beyond 2 days of catheterization. METHODS: We conducted a cluster randomized study in nonintensive care units of Nurses Improving Care for Healthsystem Elders (NICHE) hospitals. Electronic surveillance data were used in an audit and feedback intervention for frontline nurses to reduce IUC duration. Multivariable methods were used to identify the difference in average IUC duration and proportion of patients with IUC duration <3 days between patients in an early intervention group and a delayed intervention group, adjusting for patient, unit, and hospital characteristics. RESULTS: A total of 24 units at 19 NICHE hospitals reported 13,499 adult patients with IUCs over 18 months. Early and delayed intervention groups had important baseline differences in IUC utilization. Use of evidence-based CAUTI prevention measures increased during study participation. In multivariable analysis, the average IUC duration and proportion of patients with IUC duration <3 days were not improved in the early intervention group compared with the delayed intervention group. CONCLUSION: The impact of the audit and feedback intervention was not significant despite the uptake of evidence-based CAUTI prevention practices.

Chief nursing officers' perspectives on Medicare's hospital-acquired conditions non-payment policy: implications for policy design and implementation.

BACKGROUND: Preventable adverse events from hospital care are a common patient safety problem, often resulting in medical complications and additional costs. In 2008, Center for Medicare and Medicaid Services (CMS) implemented a policy, mandated by the Deficit Reduction Act of 2005, targeting a list of these 'reasonably' preventable hospital-acquired conditions (HACs) for reduced reimbursement. Extensive debate ensued about the potential adverse effects of the policy, but there was little discussion of its impact on hospitals' quality improvement (QI) activities. This study's goals were to understand organizational responses to the HAC policy, including internal and external influences that moderated the success or failure of QI efforts. METHODS: We employed a qualitative descriptive design. Representatives from 14 Nurses Improving Care of Health System Elders (NICHE) hospitals participated in semi-structured interviews addressing the impact of the HAC policy generally, and for two indicator conditions: central-line associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Within-case analysis identified the key components of each institution's response to the policy; across-case analysis identified themes. Exemplar cases were used to explicate findings. RESULTS: Interviewees reported that the HAC policy is one of many internal and external factors motivating hospitals to address HACs. They agreed the policy focused attention on prevention of HACs that had previously received fewer dedicated resources. The impact of the policy on prevention activities, barriers, and facilitators was condition-specific. CLABSI efforts were in place prior to the policy, whereas CAUTI efforts were less mature. Nearly all respondents noted that pressure ulcer detection and documentation became a larger focus stemming from the policy change. A major challenge was the determination of which conditions were 'hospital-acquired.' One opportunity arising from the policy has been the focus on nursing leadership in patient safety efforts. CONCLUSIONS: While the CMS's HAC policy was just one of many factors influencing QI efforts, it may have served the important role of drawing attention and resources to the targeted conditions-particularly those not previously in the spotlight. The translational research paradigm is helpful in the interpretation of the findings, illustrating how the policy can advance prevention efforts for HACs at earlier phases of research translation as well as pitfalls associated with earlier phase implementation. To maximize their impact, such policies should consider condition-specific contextual factors influencing policy uptake and provide condition-specific implementation support.

Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals.

BACKGROUND: Indwelling urinary catheters (IUCs) are commonly used in hospitalized patients, especially elders. Catheter-associated urinary tract infections (CAUTIs) account for 34% of all health care associated infections in the United States, associated with excess morbidity and health care costs. Adherence to CAUTI prevention practices has not been well described. METHODS: This study used an electronic survey to examine IUC care practices for CAUTI prevention in 3 areas-(1) equipment and alternatives and insertion and maintenance techniques; (2) personnel, policies, training, and education; and (3) documentation, surveillance, and removal reminders-at 75 acute care hospitals in the Nurses Improving the Care of Healthsystem Elders (NICHE) system. RESULTS: CAUTI prevention practices commonly followed included wearing gloves (97%), handwashing (89%), maintaining a sterile barrier (81%), and using a no-touch insertion technique (73%). Silver-coated catheters were used to varying degrees in 59% of the hospitals; 4% reported never using a catheter-securing device. Urethral meatal care was provided daily by 43% of hospitals and more frequently that that by 41% of hospitals. Nurses were the most frequently reported IUC inserters. Training in aseptic technique and CAUTI prevention at the time of initial nursing hire was provided by 64% of hospitals; however, only 47% annually validated competency in IUC insertion. Systems for IUC removal were implemented in 56% of hospitals. IUC documentation and routine CAUTI surveillance practices varied widely. CONCLUSIONS: Although many CAUTI prevention practices at NICHE hospitals are in alignment with evidence-based guidelines, there is room for improvement. Further research is needed to identify the effect of enhanced compliance with CAUTI prevention practices on the prevalence of CAUTI in NICHE hospitals.

OASIS-C: development, testing, and release. An overview for home healthcare clinicians, administrators, and policy makers.

The Outcomes and ASsessment Information Set Version C (OASIS-C) is the most comprehensive update to OASIS since its inception. This article describes the background and rationale for the changes, the testing process, an overview of the changes, and a description of the quality measures that will be generated from the use of OASIS-C.