Winthrop University Hospital Home Health Agency

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Winthrop University HospitalHome Health Agency

• Strategic Planning
• Acute Care Hospitalization
• 2005-2006

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• Hospital based agency located in Mineola, NY
• Consists of CHHA and LTHHCP
• Active patients 450-500 on CHHA and 150 on
  LTHHCP
• Average number of weekly admissionsgt100

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8th Scope of Practice

• Participated in 2005 Pilot Project
• Goal Reduce Acute Care Hospitalization
• Plan Decrease National average of 27.9
  (12/00-12/04)
• Decrease NY State lt38.8

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Organizational Change

• Utilize PDCA Methodology
• Form a CQI Committee
• Review factors relating to increased ACH rates
• Develop an Action Plan
• Educate our front lineprofessional staff

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OBQI Data on Acute Care Hospitalization
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Communication

• All levels of staff involved
• Introduced at Mandatory Staff meetings
• Follow-up monthly at the team level
• Multi-disciplinary Approach
• New hires educated during orientation

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Communication

• Key to change within the organization
• Effects both the culture and the way we deliver
  care
• Open lines of communication both upwards and
  downwards
• Leadership buy in is essential

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Plan of Action

• Intake coordinators perform a risk assessment
• At SOC RN assesses risk factors for
  rehospitalization
• Appropriate disciplines placed
• Patients educated and provided with Emergency
  care Plan

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Emergency Care Plan

• ?On Call [phone]
• ?RN Name/______________
• ___________________________
• ?Supervisor________________
• CALL the RN if the patient is hospitalized
• Emergency Care Plan
• This plan outlines what to do in case of an
  emergency. Please keep this information where
  you can find it.
• Our agency has nursing staff on call 24 hours a
  day including nights, weekends and holidays.

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Plan of Action

• Educate pt on s/s disease process
• MSW for supportive counseling and planning
• Education of on-call RNs in how to prevent
  re-hospitalization
• Implementation of telemonitoring

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Telehealth

• Implemented in 10/05
• NY State DOH Grant
• Currently 59 patients on program
• All diagnostic groups (mainly cardiac)
• Both CHHA and LTHHCPs
• Participating in IPRO/HCA 2006 Telehealth Demo

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Telehealth Data1/06-7/06
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Quality Monitoring

• Utilization of Clinical Guidelines (10 diagnosis)
• Participate with our hospital in Get with the
  Guidelines
• Focused clinical record reviews
• Track/trend results to share with
  staff/administration/board
• Revise forms/tracking tools accordingly to
  facilitate outcomes

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Quality Monitoring and Education

• Share results of ACH record audits with
  managers/staff
• During monthly team meetings educate staff on
  OBQM data
• Quarterly collaboration with our hospital to
  provide supportive data to prevent
  rehospitalization

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Future Plans

• Expand the telemonitoring program
• Correlate data from telehealth to determine if
  ACH rate decreases
• Mentoring of professional staff to educate
  patients on how to access our on-call system to
  prevent a return to the hospital
• Continued implementation of Best Practices to
  improve all patient outcomes

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Key to Successful Outcomes
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• Ongoing communication with administration/physicia
  ns/staff to improve communication
• Further development of educational tools and
  technology to improve practice
• Strong commitment to involving the entire Team
  in the Quality Improvement Process