Exacerbation of Condition VNAA Best Practice for Home Health
Learning Objectives The participant will be able to: Discuss two reasons why it is important to help a patient identify changes in their condition Identify two tools available to help patients/caregivers manage changes in their diseases Identify three steps that are helpful in initiating a Red Flag intervention in home health 2
Why is this important? Key to prevention o Coleman s Care Transition Intervention SM Essential part of self-management Part of comprehensive plan of care o Teach back o Health literacy-sbar for patients/families 3
Research to support importance of managing exacerbation of condition or red flags Evdokimoff, M., (2011) found that implementation of the Four Pillars of the Coleman Care Transitions Model resulted in a 12 percentage point decrease over a 12 month time period. (Red Flags is one of the interventions) Coleman, et.al., (2006) found in a randomized control study that those patients who received the Four Pillars through encouraging patients/caregivers to assert a more active role and fostering care coordination through the use of the personal health record and visits and calls by transitional coach had significantly lower readmission rate than the control group at 30 and 90 days. 4
WHAT S OUT THERE? 5
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http://www.homehealthquality.org/education/bpips/fundamentals-of-reducing- Acute-Care-Hospitalizatio.aspx 7
Stoplight tools 8
Emergency care plan 9
SBAR for staff 10
How to create a useful red flag intervention Make it easy to do the right thing! Embed in your processes Provide all necessary tools Plan for and measure success 11
Make it easy to do the right thing! Embed red flags in admission packet Make part of personal health record Place disease-specific teaching tools into the admission packet 12
Barriers to implementation Inconsistent processes Lack of training materials Staff reluctance Patient reluctance Limited health literacy 13
Embed in your processes Staff input- those closest to the issue What s in it for me? Do I have to? Recruit champions Use best practices, gold standards Identify measurements of success Provide education Don t go for perfection as the goal 14
Create a process map (sample) Review Med List with Patient/Family Understanding (Slide 10) All consistent Discrepancies Noted Provide updated list to patient (agency policy, include in PHR if utilized) Clinically Significant-Contact MD within 1 calendar day Other Issues to Resolve Able to reach MD and resolve Unable to reach MD Unable to Obtain Meds Patient/Family Contact other MD associated with pt. Lack of Money Agency Policy: Program in place Social Work Referral Emergency Funds available in community Contact Hospitalist/DC MD Contact MD Director of Home Care Agency Cannot Physically Obtain Meds Taxi voucher to have delivered Use of pharmacy that delivers Community Programs Program with hospital to send home with x days supply 15
Sample process map 16
Process map/helpful hints 1. Start with patient in mind 2. Identify ROI actions 3. Include not only direct provider of action, but any dept. or individual that has contact with desired outcome, any barriers, supplies needed 4. Include all hand-offs 5. Inputs must be included 6. Who are the decision makers, what do people need to do their jobs? 7. What is your goal and how will you measure it? 8. Accept variations in agency 17
Provide all necessary tools Tools for staff: Hospital discharge information Red flags document Access to disease-specific information Zone tools and spotlight forms Emergency care plan 18
Staff reluctance Collect success stories early in testing Tape record patient testimony (with permission) Provide current research Provide access to benchmarking tools: Home Health Compare Agency software company HHQI Incorporate in competency and evaluations 19
Provide all Necessary Tools Tools for Patient/care partner Red flags document Applicable health literacy appropriate teaching guides/booklets Zone tools and spotlight forms SBAR for patient/family Emergency plan 20
Health literacy Understands Red Flags-appropriate reading level How to Access Appropriate Assistance Who to Call When to Call What information to give-sbar 21
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Clinician role Emergency plan Include parameters in orders If gains lbs in days, increase Lasix to 60mg x 3 days If pain is not relieved to a 4 or below, add (pain medication) If BS is above 250, provide additional 3 units regular insulin Use teach back to assure understanding-who and when to call Post in obvious place (refrigerator) - Family, home health aide can use Provide place for recording vs, weight, BS (calendar, vital sign record; telehealth) Share plans with patient/family Assurance calling you will not necessarily result in trip to ER Reinforce plan when call 23
Plan and measure for success Small tests of change: PDSA 24
Plan Assemble your team State aim of your test Predict what you expect to happen Develop change action 25
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Do Carry out your plan Identify barriers, unexpected findings Analyze data Start small: 1 nurse, 1 patient 27
Study Study your findings: Were they what you expected? What did you learn? 28
Act Make change plans based on what you learned Plan next do : increase numbers involved 29
Where would you start? What is my aim/desired outcome? Where are your champions? Where most likely to meet success? Who else is interested in this? How will I measure success? 30
Measurement Percent of patients who have symptom exacerbation/red flags document completed (choose which document for review in patient chart) Review could be of Red Flags Worksheet, Emergency Plan or Zone Tools/Spotlight Tools 31