Courage to Improve

1
Courage to Improve

• Presented
• By
• HMI Home Health Agency

2
Incentives for Pilot Participation

• Early notice and understanding of our ever
  changing environment reduces the number of stress
  induces responses.
• Capturing the opportunity to help in the shaping
  of the standards by which our work is judged.
• An opportunity to ensure that all the variables
  that affect quality and outcomes of our work are
  identified.

3
Discovered Challenges

• Delay in early intervention based on the
  agencys intake process.
• Increase awareness of the need for improved
  interdisciplinary communication among the field
  staff.
• Failure to identify high risk patients early
  enough within our episodes.

4
Discovered Best Practices

• Care conferences that were being done with
  detailed documentation had better outcomes
• The Therapy team of the agencys joint visits
  strategy for assessment and ongoing intervention
  promoted more positive outcomes and developed a
  greater team spirit within the organization

5
Chosen Strategies

• An initial assessment will be done by the
  Staffing Coordinator to determine the potential
  risk of emergent care and acute care
  hospitalization prior to the SOC/ROC utilizing
  the HMI Intake and risk assessment form and
  priority status (Admission within 24 hours) be
  given to this admission.
• The case manager will notify the Clinical.
  Manager of all patients found to have 3 or more
  risk factors during their risk assessment on the
  same day as the SOC/ROC and flag the patients as
  a medical risk.

6
Chosen Strategies

• A multi-disciplinary case conference to identify
  interventions specific to each patient, based on
  their specific risk factors, within 72 hours
  of patients SOC/ROC.
• The field case manager will implement an
  individualized care management plan for each
  patient found to be at risk for emergent care
  or acute care hospitalization within 5 days of
  SOC/ROC.

7
The Pilot Framework Design Impact

• The friendly and available staff from The
  Delmarva Foundation made participation and
  understanding of the pilot process easy.
• The support materials were designed in a manner
  that made it easy to locate the needed
  information and make any needed modifications for
  your agency

8
Successes

• The greatest success experiences was that for
  individual patients our intervention reduced
  their re-hospitalization by 25-35.
• Our staff learned to work more cohesively as a
  unit for the improvement of our patients
  outcomes
• Administratively we were able to make needed
  internal changes in an environment of support for
  the change.

9
Challenges

• As an agency we were faced with the many factors
  that also affect the patients re-hospitalization
  that were outside our scope of control
• Poverty
• Illegal Drug use
• Poor familial support systems
• Patient need for increased care due to
  deteriorating health conditions
• Patients lack of compliance with plan of care.

10
Next Steps

• Continue to work on improvement of our intake
  assessment processes as the driver for early
  assessment and intervention for high risk
  patients.
• Continue to foster and improve communication
  between our field staff workers as collective
  team.
• Continue to work with other community based
  resources to minimize the impact of factors
  directly outside of span of control.