OSF Home Care Services is critical to the OSF HealthCare Pioneer Accountable Care Organization (ACO) model. We are an accountable health care organization, which means caregivers and patients work more closely together for better health, better care and better cost containment. The goal is to coordinate care to ensure patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
OSF Home Care Services’ Home Health team struggled to provide a continuity of one. What this means is we often had multiple nurses seeing the same patient. This added time to the visit because the nurse who was unfamiliar with the patient had to review their history before they could provide care. This was frustrating for the patient as well, as they had to discuss their case repeatedly since no one person “owned” their home care.
OSF Home Health identified a opportunity to implement a well-defined case management model, improve our ACO capture rate of 61 percent, and our continuity from 3rd Quarter Fiscal Year 2013 of 2.5. clinicians per patient. Our continuity metric definition excluded admit visit, weekends, WOCN, and BID visits. The opportunity existed to also increase patient and physician satisfaction with our services.
In the new case management model, the goal was to have a continuity of one caregiver per patient. To achieve this goal, we redefined continuity to include all Home Health visits. We changed from an admission nurse model to a model of case manager accountability for the patient from Home Health admission to discharge. We wanted to improve the patient experience so our patients received the highest quality care. This change has built trusting relationships between patients and their case manager, helped the case manager easily identify changes in the patient status, and improved collaboration with physicians to prevent re-hospitalizations.
This focused care also allowed our Case Managers to work directly with the patient’s physician to provide the best care possible. Our physicians no longer had to consult with multiple members on our team instead of just one Case Manager. In the new model, Case Managers are responsible for all orders, communications and requests for clarification that come through a providers office. This allowed our clinicians and referring providers to build a relationship through regular collaboration on patient care and progress.
We piloted the case management model in our Western region office and are implementing in all our regions. In the new model, our Care Managers provided and were responsible for the care of 25 patients (maximum). Case Managers set their own schedules and had a “buddy” caregiver as their back-up. They were the only two nurses that a patient would see for their care.
- Average Skilled Nurse Continuity of 2.25 or less for excluding four or less visits, therapy only and continuity of zero cases.
- Patient Satisfaction Telephone Surveys at 90 percent or higher.
- Physicians will recognize OSF Home Care as trusted partner providing exceptional care.
Average continuity over four visits provides a metric that better reflects continuity over the entire Home Health episode. Our pilot began in the Western region, with a baseline performance of 2.92 skilled nurses per patient episode. At 60 days, the Western region team had decreased this metric to 2.13 skilled nurses per patient episode, resulting in 27 percent improvement. Currently, the Western region has achieved and maintained the target of less than two for the past four weeks. The Peoria region has improved from 3.59 at their go-live to 2.46 at 60 days, or a 31 percent improvement.
Based on patient satisfaction telephone surveys, we received real-time patient satisfaction feedback and data to improve our performance. Patients have told us overwhelmingly they would recommend us to others 99 percent of the time, rate our care at 97 percent, and are very pleased with our staff. Typical comments from patients include:
- “Roger provided excellent care and made arranges for medical supplies and social worker assistance.”
- “Excellent services. No improvement needed, just keep up the good work.”
- “Great – I feel like they’ve helped me and given ideas I didn’t have.”
- “I can’t think of anything to improve when you have a good Case Manager and they are so thorough. Its just so nice when as a patient you don’t have a medical background.”
- “You guys are great. Everyone is friendly. They keep me motivated when I don’t feel like being motivated. Kristin is absolutely the BEST EVER. I love her.”
- “Absolutely wonderful; I even put on Facebook how wonderful it is!”
- “Everything is fine, very attentive, polite, caring. Anthony and Rachael were really good. Give them a raise!”
Providers in our pilot (Western region) are pleased with the new program. Our team created Case Manager biography sheets to introduce our Case Managers and their “buddy” to providers.
Supervisors meet with Case Managers every two weeks to review their work in patient care to assure best practice. We are improving the safety of our patients. In one example, a patient was at risk of bleeding due to a medication erro. It was corrected and the patient avoided an adverse event. This has huge potential to improve the safety of care for patients. We have the ability to review cases and identify patients at risk of hospitalization and assure those risks are mitigated. Review sessions allow supervisors to mentor newer staff to improve their skills in patient case management.