As Quality Assurance Director of a large Medicare agency, I have always emphasized the need for correct programming that is related to findings of the OASIS. Currently, we are trying to find a way to emphasize the importance of OBQI scores to our clinical staff as a means of preparing for Pay for Performance. We are hopeful that our outcome scores, though not bad, will improve over time. What steps can we take to obtain OBQI improvement?

Sounds like you’ve already taken the first and most important step towards better scores. The understanding you have that your OBQI results are improvable is more than half the battle. Many Home Health providers and clinicians fall into the habit of “business as usual” in their day to day practice. Certainly the homecare environment offers many challenges that even the most efficient providers find taxing: travel, care concerns, documentation and communication are a few examples that we all encounter. Over the last decade, near-constant fluctuations in the care model (PPS, 2008 New Rule) have combined with a litany of technological developments to define a working experience for homecare clinicians that differs from any other in healthcare. Even though clinicians in other working environments integrate the many healthcare changes that confront their particular workplace (hospitals, SNFs), they also have the nearly constant proximity to co-workers. The Home Health workplace offers less of the support and camaraderie that is common to all other care delivery environments. Consequently, the working structure and support experienced due to these differences cannot be understated as we discuss how to help your staff adapt behaviors that can lead to better outcomes, or OBQI scores.  

The key to OBQI improvement lies in the ability to convey the desire for maximal outcomes with front-line clinical staff; the nurses, therapists, etc., that deliver the agency’s care interventions on a daily basis. The raising of awareness on these items is a crucial step in establishing a clinical management program that will assure improved outcomes. All successful providers in this area employ education as a means of establishing best practice types of care pathways for clinicians to follow and modify on a patient to patient basis. Most agencies understand the importance of education for new clinicians as well as the regular in-service updates they utilize to instruct in new care techniques and Medicare reforms. Nearly all good agencies follow this sort of regime to establish a baseline of clinical expectation for their employees to attain as a means of assuring quality care.  

The area where most of the permanent changes occur is the management-based care co-ordination that is required for meaningful OBQI improvements. The reasons for this are many. Differences in experience and clinical skills, staffing and productivity concerns, and lack of administrative insight into the PPS model are all commonly heard. The initiation of the kind of close management that other care sectors employ leads to a shared sense of responsibility between the agency and the front-line clinician. The regular focus on the clinical challenges that the staff nurse or therapist encounter prompt improvements in subtle and not so subtle ways. 

Nurses are reminded to find and involve caregivers to assist with care tasks. Patient and caregiver education regarding disease processes, medication teaching and management, wound care and patient participation have the numerous simultaneous effects. Patients and families come together as they identify their potential roles as caregivers that can extend the life of the Home Health visits through their participation. Veteran nursing personnel are energized by their new-found ability to effect change through contemporary PPS programming and care models. Score improvements quickly follow.  

In comparison, therapy staffs are even more energized. PTs begin to understand the drivers of transfer and gait improvements; skilled therex, caregiver HEP compliance and participation, gait training through repetition of ideal patterns, etc. OTs can improve the delivery and efficiency of their care interventions to focus on the ADL issues that they affect; bathing, dressing, toileting, or high level ADLs. Duplicated services between PT and OT can be addressed. 

All of these changes have positive results and are nearly un-attainable when the individual clinician is expected to monitor and evolve these areas independently. Home Health agencies need to progress beyond the point where they believe that the only quality improvement solution is to get better clinicians. The best homecare clinicians are those that are created by assertive management and education, and maintained by the constant support of clinical care co-ordination. Staffing you agency with these clinicians, and supporting their on-going growth as they refine their (and your agency’s) skills, will lead to the OBQI improvements you seek.