Floods and Tornadoes and Earthquakes, Oh My! Are Your Patients Prepared?

by Misty Kevech, HHQI RN Project Coordinator

Weather extremes keep hitting the U.S. throughout the year. In your area of the country you might be experiencing violent storms, tornadoes, or hurricanes. Others may be dealing with excessive heat, black outs, or forest fires. Flooding and landslides are also occurring in many parts of the country. In fact, California recently experienced the most intense earthquakes in 20 years. Natural disasters are happening constantly across the country, including locations that are not usually affected. Beyond the weather related disasters, other emergencies we could encounter include terrorism, shootings, or cyber and other security threats.

So how do we prepare for our patients for emergencies and disasters?

The Centers for Medicare & Medicaid Services (CMS) released the Emergency Preparedness regulation in fall of 2016 and healthcare providers were to be compliant by November 15, 2017. The Interpretive Guidance was published by CMS in June 2017. CMS released an Emergency Preparedness rule update this past February that includes added “emerging infectious diseases” to the definition of all-hazards approach for both natural and man-made disasters. Examples provided were influenza, Ebola, and Zika virus, but could be any new or trending infection threats.

All providers, including home health and hospices, are required to include the Four Core Elements of Emergency Preparedness:

• Risk Assessment and Emergency Planning
• Communication Plan
• Policies and Procedures
• Training and Testing

This site also includes general resources for Emergency Preparedness and OCR Emergency Preparedness HIPPA Disclosure documents.

Individual Patient Emergency Plans and Evacuation

Let’s take a look at a few regulations related to creating patient emergency plans and considerations for evacuation. Each patient must have an individual plan for disasters as part of the patient’s assessment. The plan needs to be in writing and discussed with patients, their representatives, and their caregivers. The following information is from several CMS Emergency Preparedness (EP) documents.

In the 2016 EP rule, HHAs are required to minimally have policies and procedures for five different areas. The following are three of the five topics that related directly to addressing evacuation for patients:

1. The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at § 484.55.
2. The procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.
3. The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact.

[Emergency Preparedness regulation (2016) p. 176]

HHAs must include policies and procedures in its emergency plan for ensuring all patients have an individualized plan in the event of an emergency. That plan must be included as part of the patient’s comprehensive assessment.

For example, discussions to develop individualized emergency preparedness plans could include potential disasters that the patient may face within the home such as fire hazards, flooding, and tornadoes; and how and when a patient is to contact local emergency officials. Discussions may also include patient, care providers, patient representative, or any person involved in the clinical care aspects to educate them on steps that can be taken to improve the patient’s safety. The individualized emergency plan should be in writing and could be as simple as a detailed emergency card to be kept with the patient. HHA personnel should document that these discussions occurred and also keep a copy of the individualized emergency plan in the patient’s file as well as provide a copy to the patient and/or their caregiver.

Survey Procedures

• Through record review, verify that each patient has an individualized emergency plan documented as part of the patient’s comprehensive assessment.

[Emergency Preparedness Interpretive Guidance (2017) pp. 24-25]

Mobility is an important part in effective and timely evacuations, and therefore facilities are expected to properly plan to identify patients who would require additional assistance, ensure that means for transport are accessible and available and that those involved in transport, as well as the patients and residents are made aware of the procedures to evacuate. For outpatient facilities, such as Home Health Agencies (HHAs), the emergency plan is required to ensure that patients with limited mobility are addressed within the plan.

[Emergency Preparedness rule update (2019) p. 14]

Are Your Patients Prepared?

Here are a few questions to consider related to EP individual plans:

If you are a HHA leader:

• Does your staff know and understand the regulations related to individual plans?
• Is EP and individual care plans part of your orientation process?
• Do you have a method to track transportation needs/limitations including mobility?
• Have your audited charts for realistic plans and confirmed the patient/caregivers are aware?
• Has your testing including practice with staff on patient evacuations?
• Have you began addressing “emerging infectious diseases” with your EP plans related to patients?

If you are a HHA clinician:

• Are you aware of the EP regulations?
• Do you know the agency’s EP policies and procedures are located? Have you read them?
• Are you creating individual EP care plan for each patient taking in consideration of any mobility issues?
• Do you notify your patient needs/limitations for evacuation to the appropriate person within your agency?
• Do you know where to access patient materials to provide additional information for patients/caregivers to discuss and plan?

Additional Resources:

• CMS Emergency Preparedness Rule web page provides up-to-date information and documents for providers that include home health and hospice. There are also links to valuable resources for various threats as well as templates and checklists.
• The Ready.gov (FEMA) website provides resources on specific types of disasters including information sheets, preparation and survival documents, videos, additional links, and much more.
• MyHHQI Blog, 09/13/18, September is National Disaster Preparedness Month: Social Determinants, Health Care Coalitions and Disaster Preparedness. Guest blogger: Barbara B. Citarella, RN, MS, CHCE, NHCP-BC, President & CEO, RBC Limited Healthcare & Management Consultants
• MyHHQI Blog, 07/31/18, Summer Heat and the Risks for Seniors
  • CDC’s Warning Signs & Symptoms of Heat-Related Illness
• MyHHQI Blog, 01/19/18. Preparing for Winger Weather: What to Have in Case of Emergency Guest Blogger: Patricia Sarmiento, writer for Public Health Corps
• Also go to HHQI’s Resource Library and use the Topic Filter for “Emergency Preparedness” to see additional resources

Summer is Finally Here! Let’s Talk Sun Safety

Misty Kevech, HHQI RN Project Coordinator

Summer is officially here according to the calendar, schools are out, and the weather is heating up! Time to spend time catching some sun and enjoying the outdoors for many people and their families, including you. Are you and your family using caution in the sun to prevent skin cancer? What about your patients? Maybe they are sitting on their porch this summer for periods of time. Here are some facts and tips on preventing skin cancer. Share with your friends and family, too.

Skin Cancer (Centers for Disease Control and Prevention – CDC, 2017)

Nearly 5 million people are treated for skin cancer each year in the United States. Skin cancer can be serious, expensive, and sometimes even deadly. Fortunately, most skin cancers can be prevented. The sun’s ultraviolet (UV) rays can damage your skin in as little as 15 minutes.

• Ultraviolet (UV) rays from the sun or from artificial sources, like tanning beds, are known to cause skin cancer.
• Damage from exposure to UV rays builds up over time, so sun protection should start at an early age.

Signs of Skin Cancer (National Institution for Occupational Safety and Health – NIOSH, 2014)

The most common types of skin cancer include basal cell carcinoma, squamous cell carcinoma, and melanoma. Signs of skin cancer may include:

• Irregular borders on moles (ragged, notched, or blurred edges)
• Moles that are not symmetrical (one half doesn’t match the other)
• Colors that are not uniform throughout
• Moles that are bigger than a pencil eraser
• Itchy or painful moles
• New moles
• Sores that bleed and do not heal
• Red patches or lumps

Stay Sun-Safe Outdoors (CDC, 2017)

• Seek shade, especially during midday hours. Umbrellas, trees, or other shelters can provide relief from the sun.
• Be extra careful around surfaces that reflect the sun’s rays, like snow, sand, water, and concrete.
• Wear sun protection gear, like a wide brim hat and sunglasses, to protect your face and eyes. Wrap-around sunglasses that block both UVA and UVB rays offer the best protection by blocking UV rays from the side.
• Wear a long-sleeved shirt and pants or a long skirt for additional protection, when possible. If that’s not practical, try wearing a T-shirt or a beach cover-up.
• Apply a thick layer of broad spectrum sunscreen with an SPF of 15 or higher at least 15 minutes before going outside, even on cloudy or overcast days. Reapply sunscreen at least every two hours and after swimming, sweating, or toweling off.

Limit UV Exposure: Discourage Indoor and Outdoor Tanning (CDC, 2017)

UV rays are strongest late morning through mid-afternoon. Remember that sunburns and skin damage can occur even on cloudy or overcast days.

Indoor and outdoor tanning often begin in the teen years and continue into adulthood. Don’t wait to teach your children about the dangers of tanning. Children may be more receptive than teens, so start the conversation early, before they start outdoor tanning or indoor tanning. For example, you can—

• Help preteens and teens understand the dangers of tanning so they can make healthy choices.
• Talk about avoiding tanning, especially before special events like homecoming, prom, or spring break. Discourage tanning, even if it’s just before one event like prom. UV exposure adds up over time. Every time you tan, you increase your risk of getting skin cancer.

Indoor tanning exposes users to intense levels of UV rays, a known cause of cancer. It does not offer protection against future sunburns. A “base tan” is actually a sign of skin damage. Indoor tanning can lead to serious injury. In fact, indoor tanning accidents and burns send more than 3,000 people to the emergency room each year!

Sunburn (NIOSH, 2014)

It usually takes four hours after the sun exposure for sunburn symptoms to occur. The burn will get worse within 24-36 hours, and resolve in 3-5 days.  Symptoms include:

• Red, tender and swollen skin and blistering
• Headache
• Fever
• Nausea
• Fatigue
• Sunburned eyes become red, dry, painful, and feel gritty

First Aid (NIOSH, 2014)

• Take aspirin, acetaminophen, or ibuprofen to relieve pain, headache, and fever.
• Drink plenty of water to help replace fluid losses.
• Comfort burns with cool baths or the gentle application of cool wet cloths.
• Avoid further exposure until the burn has resolved.
• Use of a topical moisturizing cream, aloe, or 1% hydrocortisone cream may provide additional relief.

If blistering occurs:

• Lightly bandage or cover the area with gauze to prevent infection.
• Do not break blisters. (This slows healing and increases risk of infection.)
• When the blisters break and the skin peels, dried skin fragments may be removed and an antiseptic ointment or hydrocortisone cream may be applied.

Seek medical attention if any of the following occur:

• Severe sunburns covering more than 15% of the body
• Dehydration
• High fever (>101 °F)
• Extreme pain that persists for longer than 48 hours

 

References

Centers for Disease Control and Prevention. (2018). Skin cancer – Basic information about skin cancer.

Centers for Disease Control and Prevention. (2018). Skin cancer – Basic information – What can I do to reduce my risk of skin cancer? 

Centers for Disease Control and Prevention. (2018). Skin cancer – Sun safety.

Centers for Disease Control and Prevention. (2017) Skin cancer – Sun safety tips for families.

Califf, R.M. & Shinkai, K. (2019). Editorial – Filling in the evidence about sunscreen. JAMA, 321(21):2077-2079.

Metta, M.K.,Zusterzeel, Pilli, N.R., Patel, V., Volpe, D.A., Florian, J.,… Strauss, D.G. (2019). Effect of sunscreen application under maximal use conditions on plasma concentration of sunscreen active ingredients – A randomized clinical trial. JAMA, 321(21): 2082-2091.

National Institution for Occupational Safety and Health. (2014). NIOSH Fast Facts: Protecting Yourself from Sun Exposure.

Resources

A.K. Julian. (2019, May 1). Blog – The truth about sunscreen: 7 facts that will set you straight for skin protection this summer.

Basic Information About Skin Cancer webpage (CDC, 2019)

Protect Your Family From Skin Cancer Fact Sheet (CDC, 2017)

Sexual Abuse of Elderly Women Is an Ongoing Issue

Guest blogger: Nursing Home Abuse Center

Sexual abuse of the elderly is one of the most unfathomable crimes and it’s critical to shed light on it. Women over the age of 70 who suffer from Alzheimer’s or dementia are more likely to become victims of abuse.

This is because most abusers look for a victim that they believe is weaker or less likely to report them for their crime. Unfortunately, victims of sexual assault who also suffer from cognitive decline can also have a more traumatic response after an incident of sexual abuse.

Effects of Sexual Abuse in Elderly Women

A common misconception is that elderly people are depressed or sad because they are more conscious of death. In reality, the opposite is more often true. Most seniors are happy with their accomplishments and feel satisfied with life. If this isn’t the case with your loved one, it could indicate abuse. Depression can be a sign of elder abuse and possibly even sexual or emotional abuse.

Other effects of sexual abuse in the elderly include:

• Post-Traumatic Stress Disorder (PTSD)
• Flashbacks
• Loss of appetite
• Lack of participation in social events
• Emotional withdrawal

Belonging to an older generation often stops victims from reporting abuse. They may feel ashamed, weak, angry, anxious or scared. It becomes the responsibility of doctors and family members to take action and ask questions.

Sexual abuse in the elderly can be detected if you notice any of the following warning signs:

• Change in behavior
• Bruising or bleeding on the breasts or genitals
• Torn or bloody underwear
• Frequent UTIs (urinary tract infections)

Sexual abuse can also impact an entire family and community. Family members can often feel guilt or shame for having placed their loved one in someone else’s care that led to that loved one becoming the victim of a horrific crime.

Who Commits Sexual Abuse?

As with many sexual abuse cases, the perpetrator is often someone the victim knows and felt they could trust. Studies show that abusers are more likely to be male and more likely to be a spouse. If sexual contact is not consensual, even with a spouse, it’s considered abuse and should be reported immediately.

Perpetrators of sexual abuse are more likely to:

• Be socially withdrawn
• Have a history with law enforcement
• Problems with drugs or alcohol
• Display signs of major stress
• Have mental or physical health issues
• Be unemployed
• Have financial problems

It’s crucial to know the people that are caring for your loved one. If you are a nurse or caretaker, it’s just as important to know family members, friends or others who come to visit the patient.

Society often portrays the elderly as fragile and unable to think and care for themselves. This can make home health patients a target and be a cause for sexual abuse. The moments when your family member is recovering from a surgery or procedure can also be a time of vulnerability.

As we age our cognitive abilities change. The way we think and process information may slow down due to age or disease. When trauma or abuse is suspected in someone with cognitive decline, it’s important to directly approach the issue with the victim. Sometimes the best way to care for our loved ones is to have uncomfortable conversations.

Reporting Sexual Abuse in the Elderly

Educate patient’s families to stay involved in the care of their loved one. Get to know the staff who are providing direct care to them and understand the living arrangements. If a person is living in a congregate (group) situation, are male and female residents living together? Do they spend time unsupervised? These are just a few proactive questions that a family member can ask to help protect their loved one. Tell the family to contact the home health agency supervisor or director with any concerns.

If you, as a healthcare worker, feel someone you know or care for has been a victim of sexual abuse, please notify the police immediately. You may also report elder abuse to the local Adult Protective Services. Many states mandate certain healthcare workers to report any suspected abuse.

Sources:

“Elder Abuse and Women’s Health”. American College of Obstetricians and Gynecologists. Retrieved from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Elder-Abuse-and-Womens-Health. Accessed on November 5, 2018.

“Elder Abuse”. Office of Women’s Health. Retrieved from: https://www.womenshealth.gov/relationships-and-safety/other-types/elder-abuse. Accessed on November 5, 2018.

“Understanding Elder Abuse and Neglect”. Mobile Help. Retrieved from: https://www.mobilehelp.com/resources-information/senior-health/elder-abuse.stml. Accessed on November 5, 2018.

“Elder Sexual Assault”. Pennsylvania Department of Aging and the Pennsylvania Commission on Crime and Delinquency. Retrieved from: https://www.nsvrc.org/sites/default/files/Elder_Sexual_Assault_Technical-Assistance-Manual.pdf. Accessed on November 5, 2018.

“Sexual Coercion”. Office of Women’s Health. Retrieved from: https://www.womenshealth.gov/relationships-and-safety/other-types/sexual-coercion. Accessed on November 5, 2018.

Related HHQI Resources & Education:

• UPDate newsletter (June 2017) focuses on elder abuse
• Depression Management BPIP
• Creating Dementia-Capable Systems of Healthcare webinar
• Meeting the Needs of Caregivers & Care-Receivers HHQI University course
  • This includes watching the following webinars:
    • Alzheimer’s Disease: A New Way of Understanding for the Home Care Worker
    • The Universal Language of Caregiving

Occupational Therapy and Data Collection in Home Health

by Karen Vance, BSOT, Senior Managing Consultant | Clinical Operations Specialist, BKD Health Care Group

The Patient-Driven Groupings Model (PDGM) portends significant changes to the way Medicare currently pays home health agencies (HHA) under Prospective Payment System (PPS). PDGM is an effort to transition from volume- to value-based payment. Occupational therapy (OT) can provide assistance to home health agencies (HHAs) in several ways to improve the accuracy of those payments received as well as the effectiveness of the clinical outcomes achieved.

The Centers for Medicare and Medicaid Services (CMS) summarizes the Patient-Driven Groupings Model (PDGM) as 30-day payment periods placed into different subgroups for each of the following categories:

• Admission source (two subgroups): community or institutional admission source
• Timing of the 30-day period (two subgroups): early or late
• Clinical grouping (twelve subgroups): musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds; medication management, teaching, and assessment (MMTA)
• Functional impairment level (three subgroups): low, medium, or high
• Comorbidity adjustment (three subgroups): none, low, or high based on secondary diagnoses.

The overview can be found here.

The biggest change from PDGM affecting therapy is the removal of therapy thresholds triggering additional payment based on combined visit utilization. PDGM accounts for therapy provision on the plan of care based on patient characteristics, namely diagnoses and functional scoring.

OT can and should assist in identifying the diagnoses or conditions that best explain the reason for the home health episode. Providing such input improves the accuracy of the clinical grouping into which the patient is categorized. In many cases, a nurse is performing the comprehensive assessment and selecting the diagnoses meant to drive the plan of care, even when the original referral may be more focused on therapy need. The nurse’s selection may also drive a less accurate clinical or comorbidity subgroup without input from OT regarding the focus and intensity of OT services.

OT involvement is most critical to ensure data accuracy when painting the picture of the patient’s functional status. The patient’s Outcome and Assessment Information Set (OASIS) scoring on grooming, dressing, bathing, transferring and mobility, as well as the risk for hospitalization, make up the PDGM functional impairment level portion of the payment. Once again, OT collaboration with other members of the home health team can greatly improve the accuracy of the data collection, and hence the accuracy of the resources available for therapy utilization on the plan of care.

The opportunities for collaboration on diagnosis and functional scoring depend, of course, on each HHA. Regardless of an agency’s current processes, OTs should make opportunities to communicate and collaborate with other disciplines about the results of their assessments. Optimizing communication technology is the most obvious, and easy, method for immediate dissemination of assessment results, particularly regarding specific areas relating to key OASIS items. Case conferences are also a wonderful venue for sharing specifics of an individual patient while simultaneously revealing assessment ideas for gathering more accurate data on all patients. For example:

• A patient’s ability to put on and take off clothing may be easily observed during a nurse’s head-to-toe assessment to answer M1810 and M1820, but environmental issues identified during the OT Activities of Daily Living (ADL) assessment may impact the patient’s ability to safely obtain clothing out of dressers or closets. A patient who has to let go of the walker to pull on a drawer that sticks, or reach too high in the closet may have compromised balance.
• A patient with chronic obstructive pulmonary disease (COPD) may be able to demonstrate getting in and out of a shower during a ‘dry run’, however standing in a warm, moist environment for twenty minutes may compromise breathing capacity.

Diagnosis coding has always been an important function of the PPS payment, however ‘muscle weakness’ has been overused to explain the need for OT services. Even though OT may be on many plans of care for patients with musculoskeletal or neuromuscular diagnoses, the most common diagnoses in home health are chronic conditions such as COPD, congestive heart failure (CHF), hypertension and diabetes. OT has much to contribute to these types of patients such as energy conservation, pursed lip breathing and environmental modifications to improve their safety and daily function. As important as it is to assist in identifying the most appropriate diagnosis, it is as important to develop a plan of care that is most appropriate to the patient.

OT contribution is indeed critical to the accuracy of data collection and coding in preparation for PDGM as well as now. However, in addition to the accuracy of payment, it is also important to remember that accurate data collection also improves the accuracy of the clinical outcomes of an agency. If OASIS items are not properly captured at the beginning of an episode, then the improvements made by the end will not be truly represented.

As mentioned earlier, agencies may not currently have processes in place for good collaboration on OASIS data collection, however OTs can make opportunities to do so and model best practice for their agencies. The American Occupational Therapy Association is developing resources and education to help with this transition. See more information at www.aota.org/value.

Watch the American Occupational Therapy Association’s (AOTA) video, Payment Shift from Volume to Value: Maximizing the Opportunity for OT 2018.  This is for Post-Acute Providers including home health and the role of OTs.

Home Care… we have a problem!

By Tina Hilmas, RN, BSN, MS, CPPS
Center for Patient Safety, Assistant Director

Did I get your attention? Good! We do have a problem, and it’s not the usual having to deal with Conditions of Participation (CoP) or with the ever-changing reimbursement model, but the problem is with patient care. You see, this week (March 10–16) is Patient Safety Awareness Week. This week highlights the need for everyone to increase their awareness that patients are suffering harm – ranging from mild to severe – and even death due to preventable medical errors. And patient harm doesn’t just occur in hospitals, it is occurring under our watch in home-based care.

The Institute of Medicine (IOM) came out with an initial report 20 years ago which estimated that there were approximately 98,000 deaths per year due to preventable harm. In 2016, a journal article estimated that number to be even higher, more around 250,000 deaths per year, making it the third leading cause of death. And even more importantly, there are documented patient safety events reported that show harm is coming to patients in home-based care, including falls that cause intracranial bleeds and medication errors that send patients to the emergency room. The Center for Patient Safety, as a federally designated patient safety organization (PSO), identifies over 1,800 patient safety events in the home-based care environment that demonstrate adverse events are occurring under our watch.

Have you ever heard of patient safety organizations (PSOs) before? If you answered no, I am not surprised. Even though these organizations have been around since 2008, it can be hard to define exactly what a PSO is and what services they offer. The Agency for Healthcare Research and Quality (AHRQ) website provides in-depth information on PSOs. However, simply put, PSOs collect and aggregate patient safety incidents with the goal of improving patient care. The benefit of working with a PSO is that active participation provides legal protections that are supposed to remove fear of legal liability.

This can be important because as the original IOM report noted, a large factor that is a barrier to improving patient safety is the culture of healthcare. Unfortunately, we are not very good at trying to use mistakes as learning opportunities. Think for a moment about what the response would be to the following scenario:

Your nurse goes out to do a Start of Care (SOC). While completing the SOC, the patient’s adult child bursts into the house, aggravated and angry. The patient whispers that the child has been involved with the law due to a drug problem. The police are called, the situation is resolved, and the nurse finishes the SOC. When you, as a supervisor, are reviewing the paperwork, you notice the fall risk assessment wasn’t completed and there was no assessment of the house for fall hazards. As you notice this, you get a call from the patient’s spouse stating that the patient tripped and fell over a rug and is in the Emergency Room with a broken hip. Do you:

1. Call the nurse, inform her of the situation and tell her she is suspended pending investigation of the incident, and that this incident will go into her personnel file?
2. Call the nurse, explain the situation, then tell her the incident is not her fault and absolve her from all responsibility?
3. Call the nurse, ask her to come in and do a root cause analysis together to not only look at the situation that was present during the SOC, but also to review your agency’s policies, processes and the system that goes into completing SOCs?

My hope is that you would choose option 3. However, too many organizations fall into the category of option 1. It may seem that, of course, this is the logical answer. Nurses should know what goes into a SOC. They should know that a fall risk assessment should be completed with every admission. Let’s take this example a step further. What if the nurse who completed this SOC was your star performer? The patients like her. She always goes by the book and submits her paperwork on time. She also knows how to coordinate care and the rest of the team really likes her. But how would you respond if it was not your star performer? Let’s say this event happened to one of your borderline nurses. This nurse is always a little late with paperwork and you regularly need to monitor her. While the care she provides to her patients isn’t bad, and for the most part her patients seem to like her, she seems to do the bare minimum. Would your response be different or would you treat them the same?

I’m certain you would like to say both nurses would be treated the same, but many times this is not what happens. This type of behavior points to the culture of the organization. Yep, that’s right, culture. I know it sounds soft. Culture is not hard science and it isn’t black and white. It’s… touchy-feely stuff. I get it. However, your culture plays a huge part in the quality of care being provided to your patients.

Think about your turnover rate. How high is it? Do you do exit interviews? Do you know why employees are leaving your organization? Also, think about your Quality Assurance and Performance Improvement (QAPI) projects. How do you know you’re being successful? Do you know how your staff views the organization and it’s quality improvement projects? Do you truly know if your employees trust the organization and feel challenged/engaged to participate in quality improvement projects? Or do they think it’s just the flavor of the month and if they keep their heads down and avoid attention that things will just go back to where they feel comfortable and they won’t really have to change?

These are hard questions to answer. Many organizations send out employee engagement surveys, which are good to an extent, but they don’t really measure how your staff views the organization. The best survey would be one that measures your organization’s culture and asks staff if they believe the organization is committed to supporting it’s staff and protecting it’s patients. Lastly, the survey should be administered by a third party. This last point is very important. If your organization is one that is punitive in response to errors and the survey is administered by leadership, employees may worry that they will be identifiable based on their answers. This won’t provide the organization with a starting point to change it’s culture. You want your staff to be truthful because to be successful in quality improvement, the culture of your organization must support it.

Home-based care is faced with many challenges to maintaining patient safety that other areas of healthcare don’t face, with the main challenge being the actual environment in which healthcare is provided. But that doesn’t mean we should just shrug our shoulders and say that patient safety is a province of hospitals. It means that we need to find ways to take the lessons learned regarding patient safety from hospitals and figure out how they can be applicable to our setting. You see, our future depends on it. Home-based care is being challenged and pushed to meet the same safety and quality standards that other areas of healthcare are expected to achieve without any of the tools that were developed to help these other areas. We need to push for research regarding patient safety in our area. We need to push for ways to improve the culture of our organizations. And lastly, we need to keep patient safety and quality of care top priorities in all the care we provide.

 

HHQI University Offers Free Patient Safety Courses

Learn more from Tina in the following HHQI University courses which include free nursing CEUs:

• Patient Safety Culture: A Foundation for a QAPI Program
• Patient Safety: All in a Day’s Work! (2-hour virtual workshop to begin developing a patient safety Performance Improvement Project)

New Cholesterol Management Guidelines and the Effects on Home Health Patients

by Misty Kevech, HHQI RN Project Coordinator

Heart disease is the leading cause of death in the U.S. for men and women (CDC, 2017). Every year, 735,000 Americans have a heart attack (CDC, 2017). Cardiovascular health is important to the well-being of people for primary and secondary preventation of atherosclerotic cardiovascular disease (ASCVD), which can lead to heart attacks and strokes. The CDC (2015) states, “People with high cholesterol have about twice the risk of heart disease as people with lower levels.” Your home health patients often have a high cholesterol diagnosis, but do they understand and have a plan to address the levels?

Patient Confusion & Non-Adherence

Patients are often confused over how to interpret their blood lipid panel results and to differentiate common myths from evidence-based facts. For example, many people think that heredity affects cholesterol levels, not lifestyle choices. The truth is that lifestyle modifications are recommended for everyone, no matter their cholesterol level. Yes, heredity does factor in for some patients, but there are important lifestyle changes everyone can make. Many Americans continue to not eat heart-healthy diets and are not getting enough exercise. The U.S. Department of Health and Human Services recently released the second edition of the Physical Activity Guidelines for Americans that reinforces the 150 minutes to 300 minutes/week recommendation, if physically able, but now adds that any amount of exercise is beneficial (HHS, 2018). Would exercising 5 to 10 minutes several times a day sound more reasonable to your patients?

Lipid-lowering medications are added to lifestyle modifications for people with higher levels of cholesterol or to reduce the level more quickly. Medication adherence for these medications (e.g., satins) is only at 55% (CDC, 2018). The 39.1 million people who are at high risk for an ASCVD event, but are not taking a statin, could reduce their risk of a heart attack or stroke by up to half if therapy was taken regularly (Million Hearts®, 2018). Consider using open-ended questions to ask your patients about how, when, or how they physically feel related to cholesterol medications. Some examples of questions are, “Tell me how/when you take the ___________ pill?” and “How does the pill make you feel?” Explain that there are other medications that can be ordered if there are side effects.

Home Health & Cholesterol Management

Where does cholesterol management fit into your home health visits? Patient education on cholesterol effects, lipid levels, diet, exercise, and medications are essential for cardiovascular (CV) health. Educating your patients on reducing CV risk factors, especially lifestyle management, often aligns with other chronic disease management interventions you are teaching your patients. You could use pictures or videos as visual education to show the effects of cholesterol on the CV system. Check out the American Heart Association’s Watch, Learn and Live: Cholesterol resources. HHQI’s My Questions about My Heart for My Doctor tool can be utilized to prep your patients to discuss CV concerns with their doctor, including what their lipid results mean.

A heart-healthy diet often aligns with other disease dietary recommendations and fits nicely into your patient’s care plan. Increasing exercise is also appropriate for most chronic diseases. Consider making a therapy referral to set up a safe home exercise program for your patients, if appropriate. Even older patients with chronic diseases can increase activity levels at home, even if chair-bound. Use the Exercise & Keep Your Seat patient education tool (a diabetes tool, but appropriate for all) for those who need to safely exercise from a chair. This tool is also available in other languages.

Medication teaching is part of the Home Health Conditions of Participation. As a clinician, you need to understand and be able to explain to patients the importance of taking cholesterol-lowering medications to decrease their risk of heart attacks and strokes. You must also educate patients on the common side effects with tips and tricks to address them or work with the practitioner to try alternative medications. Teach your patients to speak up and communicate their concerns about side effects. These interventions will assist with disease management of all chronic conditions.

It is important that home health clinicians to stay up to date with all evidence-based guidelines so you can teach patients the rational and guide them toward adherence with better outcomes.

Updated Cholesterol Clinical Practice Guidelines

In November 2018, the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released the 2018 Cholesterol Clinical Practice Guidelines. The report was approved by many other leading organizations (see the report for listing). This is the first update since 2013.

The key changes include creating two classifications in the Secondary Prevention group for those patients with atherosclerotic cardiovascular disease (ASCVD) including a “very high risk” and recommendations for these groups (see below). LDL-C threshold returns to the guidelines to assist practitioners with prescribing statins and alternative therapies (see below). The ACC/AHA recommends the use of either fasting or non-fasting lipid panels for monitoring of cholesterol levels. An unusual recommendation is for insurers to consider a no co-pay for cholesterol-lowering medications that are evidence-based (A or B categories).

The report provides the Top 10 Take-Home Messages to Reduce Risk of Atherosclerotic Cardiovascular Disease Though Cholesterol Management (see pages 5-6 for more specifics for each item).

1. In all individuals, emphasize a heart-healthy lifestyle across the life course.
2. In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.
3. In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy.
4. In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), begin high-intensity statin therapy without calculating 10-year ASCVD risk.
5. In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk.
6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy.
7. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
8. In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy (see No. 7).
9. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC.
10. Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.

Resources

• Are You at Risk for Heart Attack or Stroke? patient video provides risk factors and signs/symptoms (HHQI)
• CVD: Reduction of Risk & Treatment through Diet & Lifestyle Changes course features a webinar by an expert on Therapeutic Lifestyle Changes including the DASH diet (HHQI)
• Cardiovascular Health Part 2: Cholesterol management & Smoking cessation Best Practice Intervention Package (BPIP) provides evidence-based practices and resources (HHQI)
• Cholesterol Management: The Good, the Bad and the Ugly course includes webinar by pharmacist with educational information and patient tips/tricks (HHQI)
• Home Health Cardiovascular Data Registry is an optional, powerful, and convenient quality improvement tool available to CMS-certified home health agencies. Using this tool will help target potential disparities in care and advance cardiovascular health improvement efforts, including the use of statin therapy for targeted populations. Learn more and register. (HHQI)
• Lifestyle Modifications Part 1 clinician video focuses on weight reduction, DASH eating plan, and sodium reduction (HHQI)
• Lifestyle Modifications Part 2 clinician video focuses on physical activity, alcohol moderation, and smoking cessation (HHQI)
• My Healthy Heart Workbook provides key information to patients to improve their cardiovascular health including cholesterol management and is available in many languages (HHQI)
• Statin Therapy for the Prevention & Treatment of CVH course features two pharmacists providing information on treatment guidelines and medication including mitigation of side effects and how to work with local pharmacist.
• Take Control of Your Cholesterol is a patient handout on cholesterol management and is available in Spanish (HHQI)
• Cholesterol and Statins Infographic provides a visual description of how cholesterol works in the body (FDA)
• High Cholesterol Tools and Training for Professionals website includes fact sheets, guidelines, tools and training, and journal articles (CDC)
• Preventing and Managing High Cholesterol website provides information about patient actions including medications (CDC)

Safety First: Winter Driving Tips

by Misty Kevech, HHQI RN Project Coordinator

There have already been several major snow and ice storms across the country this year. Now that the heart of winter is upon us, HHQI would like to provide some driving tips to protect healthcare workers as they travel to care for their patients. Home health is similar to the unofficial motto of the U.S. Postal Service, “Neither snow nor rain nor heat nor gloom of night stays these couriers from the swift completion of their appointed rounds.” While not all parts of the U.S. will see snow or ice this winter, rain can also cause major problems for healthcare providers that need to get to their home-bound patients. In this blog we’ll address each of these problems with expert advice from the American Automobile Association (AAA). Home health agency (HHA) leaders may consider adding these tips as part of their Emergency Preparedness education.

The following are winter driving tips are from the AAA Exchange website.

• AAA recommends the following winter driving tips:
  • Avoid driving while you’re fatigued. Getting the proper amount of rest before taking on winter weather tasks reduces driving risks.
  • Never warm up a vehicle in an enclosed area, such as a garage.
  • Make certain your tires are properly inflated.
  • Never mix radial tires with other tire types.
  • Keep your gas tank at least half full to avoid gas line freeze-up.
  • If possible, avoid using your parking brake in cold, rainy and snowy weather.
  • Do not use cruise control when driving on any slippery surface (wet, ice, sand).
  • Always look and steer where you want to go.
  • Use your seat belt every time you get into your vehicle.
• Tips for long-distance winter trips:
  • Watch weather reports prior to a long-distance drive or before driving in isolated areas. Delay trips when especially bad weather is expected. If you must leave, let others know your route, destination and estimated time of arrival.
  • Always make sure your vehicle is in peak operating condition by having it inspected by a AAA Approved Auto Repair facility.
  • Keep at least half a tank of gasoline in your vehicle at all times.
  • Pack a cellular telephone with your local AAA’s telephone number, plus blankets, gloves, hats, food, water and any needed medication in your vehicle.
  • If you become snow-bound, stay with your vehicle. It provides temporary shelter and makes it easier for rescuers to locate you. Don’t try to walk in a severe storm. It’s easy to lose sight of your vehicle in blowing snow and become lost.
  • Don’t over exert yourself if you try to push or dig your vehicle out of the snow.
  • Tie a brightly colored cloth to the antenna or place a cloth at the top of a rolled up window to signal distress. At night, keep the dome light on if possible. It only uses a small amount of electricity and will make it easier for rescuers to find you.
  • Make sure the exhaust pipe isn’t clogged with snow, ice or mud. A blocked exhaust could cause deadly carbon monoxide gas to leak into the passenger compartment with the engine running.
  • Use whatever is available to insulate your body from the cold. This could include floor mats, newspapers or paper maps.
  • If possible run the engine and heater just long enough to remove the chill and to conserve gasoline.
• Tips for driving in the snow:
  • Accelerate and decelerate slowly. Applying the gas slowly to accelerate is the best method for regaining traction and avoiding skids. Don’t try to get moving in a hurry. And take time to slow down for a stoplight. Remember: It takes longer to slow down on icy roads.
  • Drive slowly. Everything takes longer on snow-covered roads. Accelerating, stopping, turning – nothing happens as quickly as on dry pavement. Give yourself time to maneuver by driving slowly.
  • The normal dry pavement following distance of three to four seconds should be increased to eight to ten seconds. This increased margin of safety will provide the longer distance needed if you have to stop.
  • Know your brakes. Whether you have anti-lock brakes or not, the best way to stop is threshold breaking. Keep the heel of your foot on the floor and use the ball of your foot to apply firm, steady pressure on the brake pedal.
  • Don’t stop if you can avoid it. There’s a big difference in the amount of inertia it takes to start moving from a full stop versus how much it takes to get moving while still rolling. If you can slow down enough to keep rolling until a traffic light changes, do it.
  • Don’t power up hills. Applying extra gas on snow-covered roads just starts your wheels spinning. Try to get a little inertia going before you reach the hill and let that inertia carry you to the top. As you reach the crest of the hill, reduce your speed and proceed downhill as slowly as possible.
  • Don’t stop going up a hill. There’s nothing worse than trying to get moving up a hill on an icy road. Get some inertia going on a flat roadway before you take on the hill.
  • Stay home. If you really don’t have to go out, don’t. Even if you can drive well in the snow, not everyone else can. Don’t tempt fate: If you don’t have somewhere you have to be, watch the snow from indoors.

The following are wet weather driving tips are from the AAA Exchange website.

• General Wet Weather Tips
  • Replace windshield wiper inserts that leave streaks or don’t clear the glass in a single swipe.
  • Make sure all headlights, taillights, brake lights and turn signals are properly functioning so other drivers will see you during downpours. Turn on your headlights whenever you drive.
  • Proper tire tread depth and inflation are imperative to maintaining good traction on wet roadways. Check tread depth with a quarter inserted upside down into the tire groove. If you can see above Washington’s head, start shopping for new tires. Check each tire’s pressure, including the spare, at least once a month… and be sure to check the pressure when the tires are cold.
• Avoid Cruise Control
  • Most modern cars feature cruise control. This feature works great in dry conditions, but when used in wet conditions, the chance of losing control of the vehicle can increase. To prevent loss of traction, the driver may need to reduce the car’s speed by lifting off the accelerator, which cannot be accomplished when cruise control is engaged.
  • When driving in wet-weather conditions, it is important to concentrate fully on every aspect of driving. Avoiding cruise control will allow the driver more options to choose from when responding to a potential loss-of-traction situation, thus maximizing your safety.
• Slow Down and Leave Room
  • Slowing down during wet weather driving can be critical to reducing a car’s chance of hydroplaning, when the tires rise up on a film of water. With as little as 1/12 inch of water on the road, tires have to displace a gallon of water per second to keep the rubber meeting the road. Drivers should reduce their speed to correspond to the amount of water on the roadway. At speeds as low as 35 mph, new tires can still lose some contact with the roadway.
  • To reduce chances of hydroplaning, drivers should slow down, avoid hard braking or turning sharply and drive in the tracks of the vehicle ahead of you. Also, it’s important for motorists to allow ample stopping distance between cars by increasing the following distance of the vehicle in front of them and beginning to slow down to stop for intersections, turns and other traffic early.
• Responding to a Skid
  • Continue to look and steer in the direction in which the driver wants the car to go.
  • Avoid slamming on the brakes as this will further upset the vehicle’s balance and make it harder to control.
  • If you feel the car begin to skid, continue to look and steer in the direction you want the car to go. Don’t panic, and avoid slamming on the brakes to maintain control.

Resources:

• How to GO on ICE and SNOW (AAA)
• GET A GRIP: A Guide to Wet-Weather Driving Techniques (AAA)
• Flood Information Sheet (FEMA)