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Enhancing Homecare: Strategies to Reduce Avoidable Hospitalizations

The "Move to Improve" program, led by Gina Mazza, RN, BSN, and Jim Culhane, MSW, MBA, focuses on identifying best practices to decrease avoidable hospitalizations among home care patients. This collaboration involved 76 agencies analyzing data, implementing new tracking systems, and refining practices based on real-time audits and training. Preliminary findings suggest significant improvements in hospitalization rates through accountability, targeted interventions, and a commitment to data-driven decision-making.

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Enhancing Homecare: Strategies to Reduce Avoidable Hospitalizations

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  1. Gina Mazza RN, BSN Partner, Fazzi Associates Jim Culhane. MSW, MBA Director of Homecare and Personal Services VNA of Manchester and S NH Move to Improve Program Process and Results February 2013

  2. Objective • To identify best practice strategies for reducing avoidable hospitalizations of the home care patient. 2

  3. Move To Improve Project Statistics • 76 Agencies • Size of agencies by Average Daily Census: • Mean: 230 • Median: 157 • # agencies less than 100: 19 • # between 100 and 300: 39 • # agencies greater that 300: 20 3

  4. Move To Improve Project Statistics • For comparative analysis, agencies were divided into three categories: 4

  5. The Program… • Initiated collection of baseline OASIS data • Agency practice survey • Focus Group • Developed Tracker and Hospitalization Management Dashboard • Training 5

  6. Revised Structure • Audit tool revised • Dashboard revised • Monthly Accountability/Planning Meeting

  7. SafeSide™ Structure

  8. Fazzi’s SafeSide Outcomes Model The Outcome Oriented Change Model Process Improvements Data Monitoring and Tracking Project Leader Planning and Improvement Meeting Practice Refinements Real-Time Audits Education and Competency New Strategies

  9. Leadership of Program 9

  10. Frequency of Monitoring Hospitalization Rates 10

  11. Results of Agencies Performing Audits 11

  12. Overall Results 12

  13. Recommendations • Audit charts of hospitalized patients • Critical to identifying core issues related to hospitalization • Create teachable moments • Set clear and measureable goals and share with team • Set stretch goals and publicize and celebrate wins 13

  14. Recommendations 3. Accountability • Have a leader that has authority, accountability and respect of clinicians. 4. Develop a plan for change and operationalize • Plan, Do, Check, Act • Don’t let daily fires distract from the focus. 14

  15. SafeSide Hospitalization Study 2012: Key Findings 1. This patient was identified as high risk for ACH. 2. Interventions were implemented for the ACH risks identified. 15

  16. Final Thoughts • Act with purpose • Make decisions based on data • Set clear goals • Have clear outcomes 16

  17. Gina L. Mazza RN, BSN413- 584-5300 17

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