How to make home care a seamless transition for patients

Patients are discharged as quickly as possible, whether from acute care or rehab, and nurses are ultimately responsible for the seamless transition of patients to home. As a specialty, home care has established best practices to help in this process.

Karen Marshall Thompson, MS, RN, CNS, talked with about these best practices as well as strategies that have worked in her organization. She also shared advice for nurses who are new to the specialty as well as for those who want to become more involved in professional organizations and political advocacy.

Karen Thompson, RN

Thompson is the director for the Southern Ohio Medical Center Home Services in Portsmouth, Ohio. She has been a nurse for 41 years and has practiced home care nursing for 38 years. Thompson also serves as ANCC Magnet co-leader for SOMC and provides administrative direction to the SOMC Wound Healing Center. She is active in her state and national associations for home care and hospice. At the National Association for Home Care and Hospice 2018 annual conference, Thompson and 27 other board members were inducted into the 2018 Caring Hall of Fame.

Q: What are best practices that help achieve safe patient transitions, and how can nurses use them effectively in home care?

There are two best practices that promote safe transitions for the patient from the hospital or skilled nursing facility to the home. The first is the ability of the nurse to rapidly reconcile a patient’s medication regimen. The second is the ability of the patient to make and keep a follow-up visit with his or her healthcare provider within two weeks of discharge from the hospital or skilled nursing facility. These two strategies are supported by evidence as best practices by the Home Health Quality Improvement.

Patients’ failure to follow the prescribed medication regimen is a primary reason for re-hospitalization. Using Quality Assessment Performance Improvement processes, we implemented the following best practice strategies to improve patients’ management of their medications.

  • Nurses provide patients with pillboxes and assist with prefilling the boxes with their medications.
  • Nurses were given printers to use in their own homes to print patients’ current medication profiles. They hand deliver the profiles to patients during home visits. Medication profiles are updated and printed on every patient’s start of care, recertification or any time a medication changes.
  • Patients are instructed to take their medication profile with them for review with their providers during office visits.
  • Upon discharge from home care, all patients receive their current medication profile via mail.
  • Patient teaching processes were improved. Plastic accordion-style file folders were purchased for nurses to store and transport medication teaching sheets.
  • Easy reference sheets were created for nurses to carry with them. The reference sheets list the purpose and side effects of the most common medications. Nurses document purpose and side effects on the patient’s home medication profile as they review them with the patient. This information will be present on the next printed copy.
  • By discharge from home care, all patient medications have purpose and side effects noted on the medication profile. Nurses teach and document this teaching on two to three medications during every visit.

Patient satisfaction with medication management processes improved and clinical outcomes related to medication management also were improved.

Another example is our implementation of the HHQI Zone Tools for those with congestive heart failure and chronic obstructive pulmonary disease. The tools help patients better manage these chronic conditions at home and reduce hospital readmissions.

Zone Tools are color-coded green (all clear), yellow (caution) and red (emergency-act now). The tools list specific symptoms in each category and specific actions for the patient to take. The Zone Tools also serve as a guide to nurses on how best to intervene for the patient, based on the zone of symptoms.

Q: What best practice tools does your staff use to improve your patients’ care at home?

Using best practices supported by evidence is required of nurses and other healthcare providers to help standardize care, reduce variability in the care patients receive, improve patient outcomes, and improve cost control. The HHQI is a terrific source of evidence-based best practices in home health. We have implemented many of the best practice tools provided by the HHQI.

One example is the LACE index tool, which identifies the patient’s risk of rehospitalization. Based on the patient’s risk level, specific strategies can be implemented by the home care nurse. Patients who score 10 or greater on the LACE index tool are deemed to be at high risk for hospital readmission. They receive front-loaded skilled nursing visits twice per week for two weeks, a follow-up phone call at the end of each of the first two weeks on service to assess the patient’s status and the possible need for an additional nursing visit, and a social work referral to identify social barriers to care. They also may receive physical and occupational therapy evaluation visits.

Our 30-day readmission rate decreased by 5% in four months because of the LACE tool.

Q: How would you advise nurses who are new to home care?

I have practiced nursing for 41 years and have been in home care for most of my career. I think that home care is an area that nurses are not lukewarm about; you either love it or hate it.

Home care provides unique challenges of an uncontrolled environment and requires the nurse to be able to serve the patients on their turf.

The great thing about home care is nurses can see patients improve and help them better manage their illnesses on a day-to-day basis. On the other hand, the home care nurse can assist the patient in moving along the wellness-illness continuum through referrals to palliative care and hospice.

Q: What are ways home care nurses can get more involved in their professional organizations and in political advocacy?

I have had great opportunities to affect the practice of home care, both at the state and national level, by serving on the Ohio Council for Home Care and Hospice and the National Association for Home Care and Hospice. I have …read more

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