Quality Management in Home Care Services

In the last decade, the home healthcare industry has expanded significantly. The multiple groups, systems, and agencies involved in home health services and the nature of home care delivery itself, can all present special challenges in the design and implementation of quality management activities.

It is important to focus performance measurement activities on areas of high volume or high risk. These areas will vary among agencies. That's why the first step must be to identify your agency's scope of service. Shown below is an example of how a hospital-based home health care program described their scope of service:

This Home Care Program is an active, hospital-based program that provides home health services, restorative care, and personal care services to patients of all ages within a radius of 50 miles of Memorial Hospital. Services are provided 24 hours a day, seven days a week. All services are provided in patients' homes and are managed through a central office located on the hospital grounds. Medical care is prescribed by physicians who are credentialed members of the hospital medical staff. The professional staff include registered and licensed nurses, speech therapists, registered dietitians, medical social workers and home health aides. Key customer groups include patients, patients' families, attending physicians, payer groups, social services agencies, mental health clinics, pharmacies, and other home care service groups.

Most common conditions treated include, but are not limited to, the following:

Diabetes
CVA
COPD
Fractures
Postoperative patients

Congestive heart failure
Decubiti
Degenerative joint disease
Nutritional deficiencies

Treatments and services provided include, but are not limited to, the following:

wound care
catheter changes
ostomy care
IM/SQ injections
vital signs
equipment checks

IV therapy
venipuncture
tracheostomy care
passive/active ROM
DDST

Clinical functions performed by the professional staff include but are not limited to the following:

Assessment
Planning
Intervention
Evaluation
Discharge planning

Thermo-regulation
Counseling
Maintenance of skin integrity
Maintenance of nutrition

Once the home health agency's scope of service is defined, the next step is to identify the important aspects of care which will be routinely evaluated. Important aspects of care are selected by program management and staff personnel on the basis of whether the areas are high volume, high risk, and/or problem prone. Aspects of care will generally be oriented toward clinical conditions, clinical functions, processes, and specific interventions. Shown below are examples of important aspects of home care.

Examples of Important Aspects of Care:

Wound Care

Management of Diabetic Patients

Tube Changes

Management of Post Total Hip Replacement Patients

Management of Post Knee Replacement Patients

IV Therapy

Ventilator Care

Patient/Family Satisfaction

Adequacy of Documentation

For each important aspect of care under review, measures of performance should be identified. Sources for performance measures may include nursing and other professional standards of care, standards of practice, procedures, and current literature. Measures should be established, as appropriate, for all professional disciplines involved in the aspects of care. Shown below are examples of performance measures for nursing management of patients on home IV therapy.

Important Aspect of Care: Nursing Management of patient on home IV therapy

Examples of Performance Measures

1. 100% of patients on home IV therapy will meet all suitability requirements; threshold.

Willing and able caregiver

Electricity in the home

Availability of telephone

Environmental safety and cleanliness

Refrigerator

2. 100% of patient assessments will address the following:

Previous reactions to IV therapy

Client knowledge of IV therapy

Fluid requirements

Nutritional status

3. 100% of patients will be weighed at the same time, on same scale, in similar weight clothing.

4. 100% of charts will show evidence that patients were examined for signs and symptoms of complications of home IV therapy.

Infiltration (swelling, pain, redness, and thrombophlebitis)

Fluid overload (edema, weight gain, pulmonary rales)

Pyrogenic reaction (increased temperature, headache, nausea, vomiting)

Equipment failures/faulty equipment

5. 100% of patients/families will have adequate instruction in the care of the IV site.

Education on discontinuation

Education on dressing care

Education on signs and symptoms to be reported

Performance measurement data should be periodically reported and evaluated. If performance levels are outside expectations, the aspect of care should undergo further analysis to determine whether a problem or opportunity to improve exists. Such in-depth evaluations should be performed by the Director and staff involved in the aspect of care to determine the scope of the problem, systems and agencies involved, responsible staff, and causes (e.g., systems, procedures, staff knowledge, staff performance). When other agencies or services are involved, cross-functional groups should be appointed to evaluate the actual or potential problems. Don't overlook involvement, as necessary, of durable medical equipment providers and home care pharmacy services.

Based on problems identified in the evaluation process, the staff and Director will determine corrective actions that should be taken. Actions will specify what is to be done and what changes are to be made, what groups or individuals are to take the actions, when changes are to be instituted and when improvement may be expected. Follow-up on the effectiveness of actions taken should take place as soon as a reasonable time has passed. If, after follow-up, data shows no improvement or deterioration, the Program Director and staff will determine whether further evaluation is required to identify all causes of the problem, or to determine whether additional or alternate actions should be taken.

To Learn More: Patrice L. Spath is available for inhouse presentations on this topic and other health care quality and resource management topics. Plus, training manuals are available for purchase. For further details, visit the Brown-Spath & Associates' web page at http://www.brownspath.com Address comments or correspondence to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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