Yakima, WA agency covers all the bases in its efforts to reduce rehospitalizations

Concerned over their rehospitalization rate—which had been climbing for several years—a team at Yakima’s Memorial Home Care Services decided enough was enough. They needed to figure out a way to reverse this trend.

Over the course of 2006, not only did they see a substantial drop in their ACH measure (from 31.8% in January to 25.4% in November), but they implemented a myriad of new processes to identify high-risk patients and prevent them from being re-admitted to the hospital.

“We started with a core set of changes that grew as we spent more time thinking creatively about this issue,” Memorial’s director, Carolyn Neiswender, RN, said. “Now we’re trying to cover all the bases.”

Some of these changes include using an assessment form to screen new patients for their rehospitalization risk, front-loading visits to higher-risk patients (which necessitated changing their staff scheduling, especially on weekends), modifying education tools to help families better decide when a situation needs emergent care, flagging patients’ vaccination status, and meeting with the hospital’s discharge planners to share ideas and new procedures.

It can be difficult for any organization to make a single process change. How did Memorial manage to implement so many within such a short time period?

“We stressed rehospitalization at every opportunity. We kept up with the reminders and the cheerleading,” Neiswender said. At every staff meeting, computer users’ meeting, and weekly case conference, they discuss an element of the rehospitalization effort—for example, how to document a particular issue or how a specific nurse was successful in keeping a patient from being re-admitted.

In addition to diligently working to keep the issue front-of-mind with staff, Neiswender thinks three additional keys to their success would transfer to other home health agencies’ quality improvement efforts: involving field staff, understanding the OASIS data, and keeping things fun.

Memorial included field staff in their improvement team. “We really listen to the field and if something isn’t working, we keep tweaking until it does,” she explained. “It’s hard to change the way you’ve always done something. We have to acknowledge that, figure out how to make it easier, and cheer them through it.”

Another key is really diving into your agency’s OASIS data. For instance, Memorial found that among their patients, those who had a son or daughter as the primary caregiver were more likely to be re-hospitalized. Field staff are alerted to those situations and can provide specially tailored education to those caregivers.

With a strong understanding of their own unique population, the team at Memorial was also better prepared to evaluate and customize tools provided by Qualis Health.

Finally, Neiswender believes that for a long-term, challenging project such as this, it’s important to have some fun. Role-playing, eye-catching printed materials, even developing a positive affirmation and listing all the fun things patients might do if they weren’t being zipped to the hospital all the time has helped keep the team engaged. “Everyone can use a little laughter,” Neiswender said.

Memorial’s comprehensive approach has certainly created positive results. In recognition of all their creative and impactful work, they were recently honored with a 2006 Award of Excellence in Healthcare Quality from Qualis Health.