Health at Home

Presentation Notes

Quality Improvement poster presented at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: Outcome and Assessment Information Set is a patient-specific, standardized assessment used by Medicare in-home health care to determine reimbursement and measure quality. This data set is a comprehensive but complex assessment designed to collect information related to a home care recipient’s demographic information, clinical status, functional status, and service needs. Recent studies have concluded a need to improve care delivery and quality improvement activities are linked to better outcomes (Wang et al., 2017; Shetty et al., 2021).

Local Problem: During standardization of two home care programs, it was found new hires were struggling with learning how to accurately assess and document the patient’s clinical and functional status negatively impacting the development of an appropriate care plan, and quality metrics.

Method: Health at Home completed a re-design of onboarding training called “Admission Series” using a learner-centered multi-factorial approach; technology/innovation, interactive virtual classroom, learn-apply-learn concepts, chunk-and-check knowledge assessments, simulation evaluation, and monitoring. Plan-Do-Study-Act cycle was used to test the effectiveness of the training. Post-evaluation, individual coaching sessions were implemented to ensure proper episode management and successful independent practice.

Results/Conclusions: During the Plan-Do-Study-Act for this project, the following results were noted: comparing the 2020 Cohort (pre-intervention) to 2021 Cohort (post-intervention), the 60-day Hospitalization Rate improved by 1.9% (17.5% vs 15.6%) and Management of Oral Medications improved by 2.3% (80.3% vs 82.6%). Another notable improvement was Overall Risk-Adjusted Roll-up; comparing 2021 Cohort to like-sized agencies, revealed a score of 86.2% vs 85.9% while Health at Home score compared to like-sized agencies showed a score of 88.2% vs 85.9%. In this same category, Health at Home 2020 vs 2021 results were up 88.2% from 87.2%.

Implications for Practice: Accurately assessing and documenting patient presentation is vital to setting up an appropriate and successful plan of care that is tailored to meet patient needs (McNicholas C, Lennox L, Woodcock T, et al, 2019). Plan-Do-Study-Act cycle allowed new hires to apply and integrate the information resulting in improved health outcomes.

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