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Application of OBQI Principles & the Acute Care Hospitalization Improvement Matrix for Plan of Action Development. Part 2 October 27, 2005. Objectives. Review the Areas for Improvement incorporated in the ACH Improvement Matrix

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Application of OBQI Principles & the Acute Care Hospitalization Improvement Matrix for Plan of Action Development

Part 2

October 27, 2005

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  • Review the Areas for Improvement incorporated in the ACH Improvement Matrix

  • Identify evidence-based strategies to reduce avoidable hospitalizations

  • Describe how to incorporate evidence-based strategies and corresponding actions into outcome-based quality improvement (OBQI) process for POA development

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The Challenge

  • Multidimensional issue across provider settings

  • Evidence that hospitalization rates can be decreased

  • Gap between science and practice

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The Mission

  • Implement care delivery systems that prevent deterioration resulting in need for hospitalization and emergent care

    The Goal

  • Reduce avoidable hospitalizations and emergent care for home health patients

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The Solution

  • Multi-dimensional

    • Improve care processes

    • Lead & influence improvements across provider settings

  • Focus improvement on

    • Coordinating care transitions

    • Identifying patients at risk

    • Stabilizing & managing complex/chronic conditions

    • Supporting patient/caregiver self-management

    • Improving communication/collaboration w/physicians

    • Creating systems/using health information technology to support these practices

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The Plan

  • Use OBQI process to systematically identify problems driving agency ACH rate

  • Use strategies and actions identified in the Change Binder to help build POA

  • Engage in a quality improvement community to share lessons learned (HHAs & other providers)

  • Continuously strive to improve quality

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Resources to Assess the ACH Issues

  • Risk-Adjusted Outcome Report (page 3)

  • Agency Case Mix Report

  • Case Mix Analysis Tool

  • Patient Tally Workbook

  • Process of Care Investigation

    • ACH Chart Audit Tool

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Case Mix Analysis Tool

Purpose ― Allows HHAs to obtain a better understanding of the characteristics of their hospitalized patients

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What does it do?

  • Computes case mix values for “hospitalized” and “non-hospitalized” episodes

  • Calculates differences in case mix values between “hospitalized” and “non-hospitalized” episodes

  • Produces a report that shows the differences in case mix values of hospitalized and non-hospitalized patients

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What value does it provide?

  • Extends the review of the Case Mix Report to examine case mix differences between patients who are and are not hospitalized

  • Can help focus process of care investigation to identify true cause(s) for ACH rate

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Patient Tally Report Workbook

  • Excel-based tool

  • Contains raw OASIS data for all of the patients included within your OBQI report

  • Combines your Case Mix Tally and Outcome Tally Reports into one tool

  • Allows you to query your OASIS data to determine case mix & patient outcome information

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Patient Tally Report Workbook

  • Open up Patient Tally Workbook

  • Select 4th option on menu – View existing spreadsheet data

  • At bottom of page select tab labeled Case Mix Query 1 – provides list of the hospitalized patients for your agency

  • At bottom of page select tab labeled Case Mix Query 2 – provides list of the non-hospitalized patients for your agency

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Patient Tally Report Workbook

  • From Case Mix Query 1, select 30 patients to perform a record review utilizing the Audit Tool included in the ACH Planning Packet

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Process of Care Investigation

  • Identify a list of "should be done" care processes

  • Narrow the "should be done" list to the MOST IMPORTANT

  • Utilize the ACH chart audit tool or clinician interview guide

  • Randomly select up to 30 patient care episodes

  • Review the care episodes

  • Summarize findings

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What is a Process-of-Care Investigation?

  • Systematic investigation of care contributing to outcomes

  • Targets Specific Aspects of Care Delivery Contributing to the ACH Outcome Result

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Pitfalls to Avoid

  • Premature closure (jumping to conclusions)

  • Involving only agency management

  • “Blaming” data collection or analysis methods

  • Not focusing on care delivery

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Initial Steps in Investigating Care Provided

  • Identify what should be done in providing care

  • Determine what actually was done

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Agency Decisions

  • Determine the review format

  • Determine who will conduct the review

  • Determine the cases to be reviewed

  • Determine the review time frame

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Drawing Conclusions:

  • Compile team member tally sheets

  • Aggregate results

  • Summarize problem area(s)

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Problem Statements

  • Describes specific aspects of care that demonstrate inadequate care (or excellent care)

  • Contains specific, concrete wording to which clinical staff can relate

  • Address issues within the agency’s control

  • Focuses on patient care delivery instead of documentation

  • Contains a sufficiently narrow focus to keep a plan of action manageable

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  • Change Framework – entire set of change concepts organized into Areas for Improvement and Stages of Care

  • Improvement Matrix – “big picture” of the organization and high-level strategies

  • Strategy – high-level change concept; represents a series of actions designed to achieve a specific objective

  • Action – specific change idea that can be tested and implemented at the agency level

  • Tool – a form, instrument, or manual that can be used as is or modified to support strategies and actions

  • Resource – a reference for more information related to implementing specific strategies and actions

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ACH Improvement Matrix:Areas for Improvement

  • Promoting Patient Self-Management

  • Implementing Evidence-Based Practices & Guidelines

  • Using Systems and Technology to Promote Effectiveness and Efficiency

  • Improving Care Delivery Systems & Mobilizing Community Resources

  • Creating a Culture of Quality

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Promoting Patient Self-Management

  • Focus on problem-solving skills and self efficacy

  • Role of homecare nurse in assessing, motivating, and empowering patient self-management

  • Evidence that effective self-management associated with better outcomes

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Implementing Evidence-Based Practices and Guidelines

  • Strong foundation of evidence-based guidelines and tools exists

  • Demonstrated impact on hospitalization for selected interventions

  • Guidelines and tools need to be adapted for home care

  • Focus on getting clinicians to know and use the evidence base

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Using Systems and Technology to Promote Effectiveness and Efficiency

  • Systems and technology key to supporting and sustaining use of guidelines and tools

  • Systems range from simple to complex

  • Key functions:

    • Identification and tracking

    • Internal/external communication

    • Decision support and “just-in-time” information

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Improving Care Delivery Systems Efficiency& Mobilizing Community Resources

  • Delivery systems problems lead to avoidable hospital admissions

    • Poor planning

    • Poor communication

    • Insufficient information transfer

  • Growing body of research demonstrates effectiveness of better discharge planning and improvements in transitions across settings

  • Effective changes include

    • Collaborative planning with hospitals

    • Use of transition protocols

    • Use of interdisciplinary teams/ APNs

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Creating a Culture of Quality Efficiency

  • Quality improvement is a complex process

  • Requires top-down/bottom-up involvement

  • Commitment of senior leaders key at every stage: launching, implementation, and sustainability

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Using the Change Binder with OBQI Efficiency

  • Comprehensive Framework

    • Represents excellent system of care required to make transformational change

    • Not intended to do everything

    • Add strategies over time

  • Issues not the same in every agency

  • The OBQI process along with some additional diagnostic tools can help HHAs narrow their focus

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Identify Problems/Strengths and Best Practices Efficiency

  • Identify the problem or strength

  • Specific Actions from the Change Framework can be considered for clinical best practices, especially those from

    • Promoting patient self-management

    • Implementing evidence-based practices and guidelines

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Develop Action Plan Efficiency

  • Specific Actions can be considered for intervention activities to implement clinical actions (best practices), especially system changes

    • Using systems and technology

    • Improving care delivery systems

    • Creating a culture of quality

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Intervention Actions Efficiency

  • What is to be Done

  • When it is to be Done

  • Who is Responsible

  • How Action is to Monitored

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Strategy Combinations Efficiency

  • Identifying patients at risk and implementing Actions to address the risk

  • Disease management

  • Transition from hospital to home health care

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Identifying Patients at Risk of Hospitalization Efficiencyand Implementing Actions to Address the Risk Factors

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Implement the Action Plan Efficiency

  • Clinical staff informed

  • Responsible persons carry out intervention activities

  • Specified activities occur as planned

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Monitor the Action Plan Efficiency

  • POA is a dynamic tool

  • Monitor

    • Intervention actions occurred

    • Best practices are used consistently

    • Outcome

  • Measure outcome and process

    • Measurement strategy

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Tips for Internal Monitoring Efficiency

  • Monitor your measures over time

  • Assign responsibilities for data collection

  • Establish a schedule and process for data collection

  • Consider real-time data collection

  • Integrate data collection into ongoing work

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Next Steps Efficiency

  • Discuss with Team

  • Further investigation?

  • Finalize POA

  • Implement POA

  • Conduct Small Tests of Change

  • Measure & Monitor

  • Work Collaboratively with IPRO and other HHAs

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Assistance Efficiency

November Regional Workshops

  • Need to conduct Process of Care Investigation prior to attending

  • Bring problem(s) identified from POCI

  • Will review tools to assist in internal monitoring

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Assistance Efficiency

November Regional Workshops

Afternoon Breakout Sessions

  • Focus on POA development utilizing ACH Improvement Matrix

  • Provide opportunity for LTHHCP & Special Needs agencies to collaborate on issues related to their specific patientpopulation

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Goals Efficiency

  • Leave workshop with POA constructed

  • Return to agency to consult with clinical staff on tool selection

  • Submit final ACH POA to IPRO no later than 12/30/05, for review and comment

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Assistance Efficiency


  • Change Binder

  • Shared learning

  • Collaboration

  • IPRO Home Health Project Team

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Contact Information Efficiency

Sara Butterfield , RN, BSN, CPHQ, CCM / Project Director

Phone: 518-426-3300 ext. 104

Email: [email protected]

Christine Stegel RN, MS / Performance Improvement Coordinator

Phone: 518-426-3300 ext. 113

Email: [email protected]

Susan Hollander MPH, CPHQ / Assistant Director

Phone: 516-326-7767 ext. 241

Email: [email protected]