Featured Case Study:
A New Mission for Kaiser Home Care
With 19 home health agencies providing three quarters of a million annual patient visits across the continental West and Hawaii, Kaiser Permanente is one of the nation's larger providers of care in this sector.
Like many home care organizations, Kaiser was spurred into action by the onset of public disclosure of patient satisfaction scores and rankings. By the spring of 2012, the Centers for Medicare and Medicaid Services will begin public reporting of data from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey. Agencies have already begun collecting survey data. Kaiser believes that higher patient satisfaction leads to better clinical quality. Decreasing patients' anxiety increases their compliance with treatment and makes them open and honest, which means better clinical care as a result.
Kaiser uses Press Ganey's HHCAHPS InsightsSM survey tool to guide decision-making. It created a position of national service quality consultant for home care, and hired Shruti Kothari to fill it. She has driven along with dozens of front-line home health workers as they make patient visits in California, Hawaii and the Pacific Northwest. She has interviewed dozens more workers at nine Kaiser Permanente home care agencies. She has compiled reports on her findings and conducted two major presentations to all staff at regional events. And she leads monthly phone calls with representatives from each of the organization's four home care regions to ensure the promotion of best practices.
Performance and Outcomes
Kothari's widespread efforts have yielded clear areas of potential improvement: communication, patient engagement, and courtesy and respect.
Under communication, she found that explaining key concepts clearly to patients and what the caregiver is in the home that day to do is critical to patients feeling they are part of the process.
One best practice she learned while on one of the many ride-alongs she did with home care staff was related to the use of a computer in the home. "Sometimes the nurse would be typing in complete silence for 10 minutes. That may not seem like a long time, but it's long enough that the patient can get really antsy and frustrated. I watched one clinician, however, who set up the computer, turned to the patient, and said, 'Now I am going to take a few minutes recording the things we did today, so the entire team is kept up-to-date about your care.' Later, he took a few seconds to read out loud what he was entering, such as 'Ms. Smith was able to walk up and down stairs today.'"
Disseminating those best practices is now a key to her job, Kothari says. A lot of service improvement results from similarly small details, she says.
At kickoff events in Northern and Southern California earlier this year, she presented her findings to hundreds of front-line staff and agency leaders. The five-hour sessions started with general presentations to all staff on surveys, what the questions mean and what the scores reflect. Then, she and her colleagues, along with a Press Ganey client improvement manager, met with agency leaders, teaching them how to use Press Ganey Online, how to create ad-hoc survey data reports, and how to read data and comment reports.
Kothari also leads monthly conference calls with designated point people from each region, a leader of Kaiser Permanente's data team, the service director in the national office and Press Ganey. "We try for group consensus around what we are going to be doing to improve," she says. "This is really trying to replicate what we found in our hospitals – when improvement efforts were driven regionally and nationally with consistency, that's when we saw broad-based improvement in patient experiences and increases in patient satisfaction scores." So far, Kaiser Permanente hasn't established numerical goals for scores. "Right now we have a lot of energy and engagement on improving. If we focus too much on the numbers right away, we think we will lose that focus and enthusiasm," Kothari says.
One of the big quality-of-care efforts in Kaiser Permanente home care, reflecting Medicare's new focus, is on reducing avoidable hospitalizations. "It's kind of a large, 10,000-foot-view quality measure, but we think it is a good one," Kothari says. "Because you can say, 'Oh, well, I did that or I did this to improve care,' and that's great, but if the patient is winding up back in the hospital, you didn't do enough. If you can keep patients happy and healthy in their homes, that's good for everyone."
That effort has found particular expression in Hawaii, where the home care team on Oahu is partnering with the Hawaii Permanente Medical Group director to improve care transitions from hospital to home health and to the primary care physician.
"Over a year ago, we started testing the idea of having our medical director – who is a continuing care physician and therefore covers the hospital as well – be a bridge for all referrals from the hospital," says Gary A. Wong, MSPT, CHCA, Kaiser Permanente's administrator for home health and rehab services in Hawaii. The medical director signs off on all home health patient plans of care, if referred from the hospital; discusses high-risk/complex patients with the home health staff during an intra-disciplinary one-hour weekly meeting; adjusts, terminates and creates new orders for the patients to ensure timely and optimal care; and does just-in-time training/instructions for home health providers to improve competencies and knowledge.
"These key elements have helped improve our ability to care for our high-risk patients and reduce our hospitalization rate," Wong says.
In 2010, Kaiser Permanente-Oahu achieved a non-case mix adjusted hospitalization rate of 15%, which was in the top 15th percentile in the nation.