Physician Perspective on Home Health Quality Improvement

1
Physician Perspective on Home Health Quality
Improvement

• Stephen Winbery Ph.D., M.D.
• QSource TN QIO

2
Human Factors Tools

• Types of Errors
• Planning
• Execution
• Violation

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Planning Errors

• Plan to fail
• System designed to give results
• insanity

4
Execution Errors

• Timing and timeliness
• Work load
• Memory
• Capability/ Training
• Materials/ Paperwork

5
Violations

• Nurses will do for the patient
• Work a rounds
• Understanding
• Compliance
• Ends and means

6
Diabetic Patient

• A 72 year old diabetic patient has an average BS
  over 2 weeks gt 350. A1C in a physician office
  last week was 11. At 700 PM the patient goes to
  the emergency department with lethargy and
  breathing hard.

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Planning Errors

• Policy for elevated glucose
• Who did the initial assessment?
• What services?
• How do we contact the physician?
• What are the HH criteria?

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Execution Errors

• Who saw the patient?
• Capability and training?
• Work load ?
• Skill set?
• Criteria for non-urgent referral?
• Criteria for urgent referral?
• Communication/ Organization

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Violations

• Timing work load
• Perception
• Understanding
• Compliance
• Ends and means

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Ask the Doctors

• Home heath Medical Directors
• Targeted Physicians
• Hospital Administrators
• ER Doctors

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Doctors Ignorance

• Criteria for level of service
• Valid admit order
• Assessment information and process
• Need to participate
• Contact/ Communication issues
• Goals and limitations

12
Medicare Payment for Home Health

• Not comprehensive
• Types of services
• Shorten hospital stay
• Reasonable expectation to Improve
• Independent
• Care giver assistance

13
Home Health Assessment

• Most valuable service
• Expertise of the assessor
• Payment
• Directing services
• Expectations/ Goals

14
Hospitalization and Emergent Care

• Same issue
• 25 40 of Home Health Patients
• Whats a good number?
• Tends to be high when home health is over
  utilized

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Emergent Care Planning

• Admit criteria/ order
• Assessment
• Physician orientation
• Physician contact
• Guidelines
• Case management

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Emergent Care Execution

• Staff satisfaction
• QI processes (Business case)
• Training/ Capability
• Memory/ Organization
• Case management/ Teams
• Barriers to communication

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Emergent Care Violations

• Paperwork reduction
• Supervision
• Internalize process/ Investment
• Skill set

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Emergent Care Case

• 66 year old patient sent to the ER on Saturday
  because his gastric feeding tube is out. He is
  not febrile and not dehydrated. He receives all
  of his medications and nutrition via his G-tube.

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Emergent Care Case Discussion

• Planning errors
• Execution errors
• Violations
• Opportunities to prevent

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Emergent Care Case 2 Discussion

• A 48 year old ESRD patient goes to the ER for
  elevated BP (235/146). The patient is
  asymptomatic. The patient is not on BP
  medications. The patient has know about her
  hypertension for two weeks and became anxious
  about getting her BP down to normal.

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Emergent Care Case 2 Discussion

• Planning errors
• Execution errors
• Violations
• Opportunities to prevent

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Reasons for Failure in Emergent Care

• Not a candidate for home health
• Failed initial assessment
• Services not ordered
• Communication
• Incomplete information to patient
• Contact information/ Coverage
• Convenience

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Polypharmacy/ Medication Compliance

• Non - Compliance is the rule
• Understanding and Trust
• 5 Medications 100 interaction
• Easy to survey for polypharmacy
• Simplify drug regimens
• Communicating with the physician
• Simplify drug regimen

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Strategies with the Physicians - Planning

• Orientation
• Urgent and non-urgent communication
• Contact preference/ Coverage
• Expectations
• Preferences

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Strategies with Physicians - Execution

• Audit admit orders
• Feedback/ Survey
• QI Physician leaders (rotate)

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Strategies with Physicians - Violations

• Case management help
• Physician to Physician
• QI Physician leaders (rotate)
• Training on discrete issues
• Data and reports

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Discussion and Questions

• Dr. Winbery SWinbery_at_tnqio.sdps.org
• [phone]

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Physician Perspective on Home Health Quality
Improvement
Thank You!

• S. Winbery Ph.D, M.D.

This material was prepared by Qsource of
Tennessee and adapted by gmcf, the Medicare
Quality Improvement Organization for Georgia,
under contract with the Centers for Medicare
Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The
contents presented do not necessarily reflect CMS
policy. Publication No. 7SOW-GA-HH-05-17