IDENTIFYING INFORMATION MANAGEMENT CHALLENGES FACED BY HOME HEALTHCARE PROFESSIONALS MANAGING OLDER ADULTS TRANSITIONS FROM HOSPITAL TO HOME CARE

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1 IDENTIFYING INFORMATION MANAGEMENT CHALLENGES FACED BY HOME HEALTHCARE PROFESSIONALS MANAGING OLDER ADULTS TRANSITIONS FROM HOSPITAL TO HOME CARE Alicia Arbaje, M.D., M.P.H. Assistant Professor of Medicine, Director of Transitional Care Research Division of Geriatric Medicine and Gerontology Sept., 2014 Singapore Second International Home Care Nurses Organization Conference

2 Care Transitions out of the Hospital 2 Common, complicated, and costly Older adults are particularly vulnerable Going home with home care is especially risky Coleman, 2003; Arbaje, 2014; Murtaugh, 2002

3 Skilled Home Healthcare (SHHC) 3 Care Delivery Challenges Homebound patients Residential environment Dependence on informal caregivers Short-term duration Intermittent care High adverse event and rehospitalization rates Ongoing Research Needs Risk factors Information management Establishment of roles Measures Track transitions Assess quality Provide real-time feedback Wolff, 2008; Arbaje, 2014

4 4 Role of Human Factors Engineering to Improve Transitions Goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems Supports the cognitive and physical work of healthcare professionals Promotes high quality, safe care for patients Evaluates individual work system components and their interactions with each other Proactively understand risks in complex systems Qualitative and quantitative research methods Helpful for errors that occur across multiple people or settings Carayon, 2012; Gurses, 2011; Russ, 2013

5 Study Objectives 5 For older adults requiring SHHC services after hospital discharge: Identify critical tasks in SHHC workflow Identify challenges faced by SHHC professionals in information management

6 6 Study Population Older Adults Aged 65 years Can speak English or Spanish Hospitalized on a medical service Referred for nursing SHHC after hospital discharge Family Caregivers Unpaid Assist the older adult with at least one healthcare task (e.g., taking medication) SHHC Providers Employed by participating sites Directly provide care to, or arrange services for, an eligible older adult 9 med/surg units, 2 hospitals, 1SNF, 1SHHC agency

7 Transitions of Care From Hospital to Home Health Care Settings 7 Period of study: t days after discharge Close to hospital discharge (t 0 ) 1-3 days after DC 1-3 days after home visit Process flow Referral Admission Initial evaluation Follow-up evaluation Location Care providers Hospital Discharge planner Home care services coordinator SHHC agency Intake staff Field staff Home Field staff Older adult Caregiver Home Field staff Older adult Caregiver

8 8 Human Factors Conceptual Framework Hospital/SHHC Work System Tools, Technology The objects used to perform tasks. Ex: electronic medical record Tasks Actions performed within the work system External Environment Outside factor affecting tasks performed in the system. Ex: insurance policies Older Adult Home Care Coordinator Caregiver Home Care Nurse Person Any person or team of people that interacts within the work system. Organization Policies, procedures, and culture of the system Ex: safety culture. Internal Internal Environment Environment Physical environment a person operates within. Ex: patient home Care Transitions Processes Information Management Establishment of Roles Outcomes Outcomes Overall care transition quality Serious safety events 30-day hospital readmission Patient/ Caregiver satisfaction

9 HCC Assistant Helps gather info and complete referrals Home Care Coordinator Identify referrals, gather info, complete referrals Inform patient of agency details Fax additional documents Fax referral to intake Insurance Expert Physician Case Manager Nurse Create EHR Verify insurance Ensure acceptance Discuss home care options Send patient referral to intake Refer to skilled provider Train patient and caregiver on discharge Intake Nurse Enter patient info and send to scheduler Scheduler Start of care visit scheduled/ completed Place additional orders/requests clarification Patient Caregiver Patient Caregiver Primary Care Physician PRE-HOSPITAL DISCHARGE ADMISSION TO HOME CARE POST HOSPITAL DISCHARGE

10 Information Management-Related Challenges Cross-Team Challenges Physician Accessibility Challenges Patient- Related Tools and Technology Difficulty obtaining information from multiple sources Incomplete information to prepare referral Changes in patient status Multiple electronic systems Difficulty managing multiple players in one transition Lack of physician ownership Uncertainty in care plans Electronic Paper Electronic Communication breakdown after patient discharge Limited access to PCP Unclear expectations about home care No coordination or cognitive aids Difficulty identifying PCP Challenges communicating with patient Incomplete or missing information 10

11 Risk Prioritization INFORMATION 11 MANAGEMENT Risk Factor for Suboptimal Care Transition Home care provider gathers information from multiple sources Home care provider receives incomplete and/or missing information Home care provider experiences communication breakdown with physicians during care transition Home care provider encounters physician who does not have the information needed to assume responsibility for patient Home care provider experiences has challenges regarding changing care plans How often does the risk factor occur during care transitions? Rarely (-) Sometimes (+/-) Very often (+) How likely is the risk factor to contribute to: Serious pt safety events* 30d hospital readmission Negative pt experience Overall quality of care tx Unlikely Somewhat likely Very likely * E.g., falls, adverse drug reactions, clinical deterioration

12 In Their Own Words The ideal transition would be being given adequate notice [about] what the needs of the patient are [and] not at the last minute when they are ready to go out the door. Home care coordinator 12

13 In Their Own Words I d say about 50% of the time there seems to be something that requires a call to the doctor to get straightened out. Home care nurse 13

14 Implications 14 Home care agencies and patients Improve SHHC workflow and documentation Facilitate information exchange among healthcare providers Organize the scheduling of home care visits Design of patient/caregiver educational tools Researchers Integration of HFE and HSR Predictive validity

15 15 Current Approaches to Improving Care Transitions and Contribution of the Study Current Approaches Study Risk factors Patient level Healthcare organization Home environment Target processes Settings Data sources Methods Intervention Discharge planning One-way communication Hospital Skilled/long-term care Medical records Administrative data Patient report Health Services Research (HSR) Coaches Navigators Information management Establishment of roles Systems redesign Communication networks Hospital Home healthcare agency Home Organizational data Healthcare providers Family caregivers HSR + Human Factors Engineering + CBPR Index to identify and reduce potential safety risks

16 Future directions 16

17 Research Team and Funding Division of Geriatrics and Armstrong Institute Bruce Leff, MD Ayse Gurses, PhD Elizabeth Tanner, PhD, RN Albert Wu, MD, MPH Mahiyar Nasarwanji, PhD Nicole Werner, MA JH Home Care Group Funding Agency for Healthcare Research and Quality National Patient Safety Foundation Johns Hopkins Clinical Research Scholars Division of Geriatric Medicine and Gerontology JHU School of Nursing Center for Innovative Care in Aging Mary Myers, RN, VP and COO Kim Carl, RN, BSN, Director of HH Services Dawn Hohl, RN, PhD, Director of HH Coordinators

18 18 Discussion Contact Information Alicia I. Arbaje, M.D., M.P.H.

19 19 Supplementary information

20 Domains with Example Items 20 Technology and Tools Difficulty reading hand-written care plans Difficulty using equipment or supplies Lack of access to electronic medical record Establishment of Roles Unclear expectations about role of home care Ambiguity in responsibility for patient after DC Provider takes on tasks beyond normal duties SHHC Provider Challenges communicating with team members Challenges reconciling medications Patient located in distant geographic area Patient/ Caregiver Does not understand care plan Dissatisfied with discharge process Challenges obtaining medications

21 Patient Perspectives Pre-hospital discharge Time when patient finds out about discharge vs. actual time of discharge Instruction and discharge instructions although provided tend to be forgotten Admission to home care Not sent home with all medications Transportation challenges Delay in setting up home care admission visit Post-hospital discharge Adhering to care plan Difficulty with equipment delivery and utilization Family/caregiver issues 21

22 In Their Own Words We had no inclination that we were leaving [the hospital]. I come up from [therapy], lunch is sitting there, and in the same breath they go, Pack up your bags, you re going home. Older adults and caregivers 22

23 Home Care Coordinator Perspectives Pre-hospital discharge Patient discharged before home care recommendation Incomplete information to prepare referral Challenges associated with multiple systems and sources of information Challenges identifying eligible patients Difficulty communicating with PCP Admission to home care Updating medication list as care plan changes 23

24 Home Care Nurse Perspectives Post-hospital discharge Challenges with medication reconciliation at patient s home Equipment not sent home with patient Challenges reading hand written referrals Lack of PCP ownership Communication breakdown after discharge 24

25 In Their Own Words If I don t have the correct information simple things like the address is completely wrong, the phone number is wrong, the phone number is not in service then I can spend the day spinning wheels calling here and there, calling emergency numbers and trying to find the patient. Home care nurse 25