Are you sitting on a gold mine or a land fill?

Automated point of care (POC) documentation closes the loop between the office management systems and the clinical documentation requirements for homecare. Point of care helps bring an agency’s standards into the field and enhances best practice. However, the real power of POC, in my opinion, is yet to be tapped.

Data mining- the automated searching of patterns of information using specific criteria- is now coming into its own for homecare. While it’s mainly an advantage to home health, with the coming standardization of hospice quality data collection, it will not take very long for benchmarking firms to get tools up and running for hospice as well. Home health data mining is based upon the OASIS instrument. Substantial reliability has been demonstrated for the OASIS data set items (Madigan, 2002). It’s about time for the time consuming exercise of performing the OASIS to result in something positive!

Most research on clinical data in homecare has been manual and tedious. Now, data mining tools are available and the effort can be outsourced. OASIS has been around long enough that patterns of information can be compared real time to assessment data, so that predictions of outcomes result. When an agency can identify high risk patients in the start, then beat the odds, preventing re-hospitalization or emergency visits, the statistical evidence is a very powerful marketing tool. Take advantage of proactive data tools and find the gold in them thar hills!

That said, data miners will be digging for fool’s gold if they don’t use additional POC tools to standardize the other aspects of documentation- specifically variance reporting necessary to judge the impact of care (Versel, 2003). Documentation of patient responses to care should be simple and reliable. Otherwise the clinical data warehouse will be full of data, but won’t be worth much. Recall the old saw “healthcare is drowning in data and dying of thirst”. Or, what you thought was a gold mine, turns out to be a data landfill.

For variance charting against care plans, I go for the ultra simple model: met, not met, or not applicable. A numerical value can be assigned to each of these outcomes so that a number of meaningful conclusions can be drawn by patient or by group improvements. Check out Melina Huffman’s (2005) book on how to design a homecare outcomes program. Most modern point of care systems can meet the functional requirements of her recommendations.

References

Huffman, M. (2005). Implementing Outcome-Based Home Care. Sudbury, MA: Jones and Bartlett.

Madigan, E. A. (2002). The scientific dimensions of OASIS for home care outcome measurement. . Home Healthcare Nurse, 20(9), 579-583.

Versel, N. (2003). A beautiful mine. Modern Physician, 7(7), 26.

Air Traffic Control for Homecare?

In 2003, Hartford Hospital, a 864 bed tertiary care hospital in Hartford, CT created a “virtual instrumentation “ software application, better known as a web based dashboard. They did so in order to solve inefficiencies related to use of beds, other resources, provider time, and crowding at choke points along the continuum from the front door to discharge (Rosow, 2003). The bed management dashboard is real-time, enterprise wide, and interacts will all departments throughout the hospital.

Imagine the potential of such a dashboard for homecare. What if we could see a patient’s status ? what if each patient was tracked like a UPS package? And, what if you could know where providers were at any given time?

1. A real time screen display of the admission process, linear in nature, showing how far along the admission work has progressed..has the first visit been completed?, has the OASIS been submitted? Has the POC been approved by the clinical manager? Have the admission documents found their way (signed) and back into the patient’s record?

2. I imagine two lines, one above the other, one for business services, billing status, orders status, authorizations status.

3. What if a GPS system could identify the nearest provider to a new admit’s residence? And, you could make new assignments accordingly?

Seems to me it would be awesome to have a per patient dashboard, with a summary level display for team and branch, etc. There could be a counterpart provider dashboard, showing a virtual view of scheduling and routes. Imagine the possibilities…

Reference:

Rosow, E., Adam, J., Coulombe,K., Race, K., Anderson, R. (2003). Virtual Instrumentation and Real-Time Executive Dashboards. Nursing Administration, 27(1), 58-76.

New Homecare Policies and Procedures Wiki

Let's collaborate!

I have initiated a policy and procedure wiki. A wiki is a collection of editable files posted on a website. Many homecare agencies have to revise policies and procedures to accommodate operating process changes due to technology. For example, once an agency implements point of care laptops for field clinicians, new ways of returning completed documentation are necessary, as are new rules of turn-around time and more.

If you want to participate in an effort to store and share generic policies and procedures for a technology enabled agency, here's my offer...

I will give you access to all the policies and procedures- individual Word file templates- contributed by readers- on the honor system that if you use one of the templates, in exchange you will contribute a different and useful one back to the main folder. In this way, all of us will have benefit of our collective wisdom.

Submit a comment to this post and let me know if you are interested in getting started on a collaborative wiki~ why re-invent the wheel?

Physical Therapy- New rules for Documentation, or Not

Seen the OIG 2007 Work Plan?

If you are a homecare agency that provides rehab..and who doesn't?..better check out the OIG's plans for next year. Here's the gist:

• OIG wants to check on the expansion of focus on therapy services in homecare
• Get more specific on "reasonable and necessary"

Generally, the therapists will need to do more to justify the need for therapy. Documentation for high therapy threshold cases will have to support a clear need- not the need for rehab, the need for the number of visits planned.

How do you do that?

Therapy goals MUST be tied to function.
The treatment plan must explain why a therapist is needed, not just a trained family member
The diagnosis must support the plan
And daily notes must justify all the above

If you have ever thought about having a rehab supervisor, now's the time. Nurses reviewing therapy justification of this caliber might not catch problems. How about sharing examples of lingo that would do the trick?

Got denials?

• Patient feels more comfortable
• Patient has no complaints
• Patient is progressing well
• Patient walked 50 feet
• Patient is tolerating the HEP well
• "Independent" with goals

An automated clinical documentation system can provide the cues to make sure the statements necessary to justify rehab therapy are complete under the new regs. This means the system must reach to the point of care. Therapists are often contractors. This presents a special challenge to home health agencies who have to figure out how to equip contractors with laptops or other technology. Some agencies provide contractors with web access to the documentation system while others issue laptops to all on the professional staff, regardless of employment status. Otherwise, the therapy group must provide its own automated documentation system in order to control the quality of documentation in support of new rules for 2008.

One Reason Why I Think Technology (IT) is Important to Homecare Clinicians

Homecare clinicians need technology to help them remain current on best practice (this is only ONE reason). In order to keep up, homecare clinicians need to understand how to access current information, when and where they need it. This requires a skill called "information literacy". OK, so I am a geek and a scholar. UGH! Lets start with information literacy...

The topic of information literacy relates to successful nursing scholarship, practice, and leadership. Knowing how to access relevant information and use it effectively is a necessary skill in today’s nursing profession, especially in the mobile environment of homecare. The importance of teaching-learning approaches that include information literacy skills training within nursing education is not under debate. However, a means of how to include skills training on the job presents a struggle that has not been resolved.

Progress has been slow toward integration of information literacy programming into nursing college course requirements (Ya-Lie, Sheu, & Shih-Ming, 2007, p. 67).

The evolution of nursing as a profession requires the development of evidence-based clinical interventions (Skiba, 2005). As in other professions, nurses are challenged to access and continually evaluate professional and consumer literature in print and on the Internet.

Verhey wrote that information relevant to nursing doubles every five years (Verhey, 1999, p. 1). According to a national survey of registered nurses in the United States, the average age of practicing nurses was 42.5 years in 2002 and over 57% of the nurses from the study graduated prior to 1984 (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2002). According to Verhey’s theory nurses who graduated prior to 1984 have 16 times more information now available for study as of 2007. Using Verhey’s math, during the interval of an undergraduate nurse’s academic career, the amount of nursing information necessary to “keep up” will almost double during the 4 to 5 years it typically takes to graduate.

The amount and complexity of information nurses are expected to manage continues to increase exponentially (Barnard, Nash, & O'Brien, 2005, p. 505). Like academics from all disciplines, nurse educators are engaged in efforts to provide leadership, scholarly expertise, and to eliminate the structural impediments to change so that the proper practice of gathering and synthesizing information is taught at all educational levels. The answer cannot lay in attempting to teach what is currently known. Teaching the process to find answers for oneself will show nurses “how to fish” so they can engage in a lifelong process of professional improvement.

What are your suggestions for how to assure homecare clinicians are up to date on best practice?

Why do you think IT is important to homecare clinicians?

References

(Barnard A Nash R O'Brien M 2005 Information Literacy: Developing Lifelong Skills Through Nursing Education)Barnard, A., Nash, R., & O'Brien, M. (2005). Information literacy: developing lifelong skills through nursing education. Journal of Nursing Education, 44(11), 505-510.

(Bruce C 200207 Information Literacy as a Catalyst for Educational Change: A Background Paper)Bruce, C. (2002, July). Information Literacy as a Catalyst for Educational Change: A Background Paper. Paper presented at the meeting of the Information Literacy Meeting of Experts. Prague, The Czech Republic.

(Owusu-Ansah E 2003 Information Literacy and the Academic Library: A Critical Look at a Concept and the Controversies Surrounding It)Owusu-Ansah, E. (2003). Information Literacy and the Academic Library: A Critical Look at a Concept and the Controversies Surrounding It. Journal of Academic Librarianship, 29(4), 219-230.

(Owusu-Ansah E 2004 Information Literacy and Higher Education: Placing the Academic Library in the Center of a Comprehensive Solution)Owusu-Ansah, E. (2004). Information Literacy and Higher Education: Placing the Academic Library in the Center of a Comprehensive Solution. Journal of Academic Librarianship, 30(1), 3-16.

(American Library Association 10 Presidential Committee on Information Literacy)Presidential Committee on Information Literacy (1989). Retrieved July 1, 2007, from Association of Colleges & Research Libraries Web Site: http://www.ala.org/acri/legalis.html

(Skiba Diane 2005 Preparing for Evidence Based Practice: Revisiting Information Literacy)Skiba, Diane (2005). Preparing for evidence based practice: revisiting information literacy. Nursing Education Perspectives, 26(5), 310-311.

(Spratley Ernell Johnson Ayah Sochaiski Julie Fritz Marshall Spencer William 30 THE REGISTERED NURSE POPULATION, MARCH 2000: FINDINGS FROM THE NATIONAL SAMPLE SURVEY of REGISTERED NURSES.)Spratley, Ernell, Johnson, Ayah, Sochaiski, Julie, Fritz, Marshall, & Spencer, William. (2000). The registered nurse population, March 2000: Findings from the national sample survey of registered nurses. Medical Benefits. Retrieved July 21, 2007, from Business Source Complete database.

(Verhey M 1999 Information Literacy in an undergraduate nursing curriculum: Development, implementation, and evauluation)Verhey, M. (1999). Information Literacy in an undergraduate nursing curriculum: development, implementation, and evaluation. Journal of Nursing Education, 38(6), 252-259.

(Wizcomtechnologiescom 2007)Wizcomtechnologies.com. (2007). Retrieved July 4, 2007, from Answers.com Web Site: http://www.answers.com/topic/scholarship

(Ya-Lie Ku Sheu Sheila Shih-Ming Kuo 2007 Efficacy of integrating information literacy education into a women's health course on information literacy for RN-BSN students)Ya-Lie, Ku, Sheu, Sheila, & Shih-Ming, Kuo (2007). Efficacy of integrating information literacy education into a women's health course on information literacy for RN-BSN students. Journal of Nursing Research, 15(1), 67.

(Zabel D 2004 Reaction to "Information Literacy and Higher Education")Zabel, D. (2004, January). A Reaction to "information literacy and higher education". The Journal of Academic Librarianship, 30(1), 17-21.