The roll-out of healthcare reform, population
health management programs, and accountable care organizations are driving new
innovations between hospitals and home health organizations.
As a result
of their quest to help hospitals provide a more fluid care experience for
patients and prevent readmissions, among other quality goals, home health
organizations are carving out a permanent role on the healthcare continuum.
“We’re really seeing a shift in which ambulatory services are more of the
focus of healthcare today,” says Pam Cowin, clinical administrator for home and
transitional care at Vidant Health in Greenville, NC.
Cowin, with 20
years’ experience in home health, is not the least bit surprised. “In home
health, the goal has always been to keep patients at home and out of the
hospital,” she says. “So, when CMS began enforcing penalties for hospital
readmissions, hospitals really started paying more attention to post-acute
services.”
Home Health Nurses in the Spotlight
These newly
forged collaborations are translating into changes for home health nurses on the
frontline. In fact, home health nurses will play a starring role as hospitals
and home health organizations continue to evolve their relationship. Cowin says
now there is an increased focus on improving the nursing case management model,
care coordination, and system-wide performance improvement work.
“We are
seeing higher expectations and a new level of accountability for nursing-driven
patient outcomes,” says Cowin. “There is a shift occurring in which nurses are
becoming an extension of primary care providers in identifying and helping
address care gaps.”
Cowin says over the last few years, Vidant Home
Health and Hospice has created new processes to bridge gaps in care. One change
has been to ramp up patient contact in the home. In addition to normally
scheduled nurse visits and having an on-call nurse on duty after hours, Vidant
now schedules nurse/patient phone checkups.
Cowin notes, “The
combination of home visits and phone checkups increases our contact with the
patient and family. This improves our oversight of the plan of care and
facilitates early recognition and intervention of problems which may have
resulted in readmission.”
Additionally, Vidant is working closely with
providers to improve transitions when patients leave the hospital. “Now, we send
staff to the hospital prior to the patient being discharged or admitted to
facilitate a seamless transition,” says Cowin. “It’s now become more of a
transfer than a discharge or an admission and gives patients ongoing access to
care.” she points out.
When a hospital readmission does occur, Vidant
and the hospital share information and look for any gaps in care. “That can
range from doing a patient interview on what brought them back to the hospital
to doing a chart review on both sides to identify any opportunities to improve
care,” says Cowin.
Reinforcing the Case Management Model
Home
health’s case management nursing model is ideal when it comes to the type of
improvements hospitals and home health organizations are starting to make. From
the moment the nurse enters the patient’s home, they provide a holistic care
approach, taking into consideration how well the patient is doing from a
physical, psychosocial, environmental, and spiritual standpoint.
“Nurses
in home health are truly the case managers,” says Cowin. “They are looking at
every aspect of that patient’s care in the home. Nurses are on alert to identify
any barriers to a patient’s care and wellness, including safety hazards in the
home, lack of family/caregiver support and medication issues.”
Home
health nurses often work alone and have a high degree of autonomy compared to
nurses in hospitals and other care settings. Critical thinking is highly valued
and nurtured in home health nursing because clinicians are expected to take on
multiple roles. “Often one person wears many hats including areas of quality,
risk management, and infection control, whereas each of these would be a
dedicated department in other healthcare settings,” says Cowin.
Home
health is an attractive work environment for nurses who like having a flexible
schedule and a work-from-home experience. As home health organizations move
toward participation in new payment models and seek to meet new quality and
patient experience expectations, they will need to recruit and develop nurses
who not only have strong critical thinking skills but also those who are
comfortable making decisions that would normally be made by someone else.
Moreover, nurses must have the ability to serve patients in any type of
environment. “Home health nurses really have to exhibit a non-judgmental
attitude because one home may have holes in the floor and infestation issues
while the next visit may be in a million dollar home,” says Cowin.
Long-term success also hinges on helping nurses strike a healthy balance
between home and work to prevent burnout. Because there is more flexibility with
their schedules, home health nurses sometimes blur the line between home and
work.
Their home becomes their office, says Cowin. “We start working
with them on setting boundaries during the interview process by asking them to
focus on what they like to do in their downtime. “We continue the conversation
when they are hired, making sure that they have an adequate orientation time,
and we help them with setting boundaries.”
Nurses are also encouraged to
avoid isolation by committing to routine communication with their peers and
supervisors.
This post
excerpts an article in the Spring 2015 issue of HealthStream's PX Advisor
(), and is used here with permission.
