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Impact of a Home Care Staff: HHCAHPS Scores Intervention
There is a continuing need and awareness for quality health care services in the modern world. Health professionals and health care organizations are under constant pressure to improve patient outcomes whether in a fee-for-service or value-based care environment. Health care policies are responsible for pushing towards quality services, reduced cost of care, and better patient satisfaction. The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) is a credible example of the continued efforts towards better patient care. Under the Medicare/Medicaid Services (CMS), the HHCAHPS acts as a standard measure for home health services. The survey has 34 questions under global measures (overall quality of care and willingness to recommend the HHA to other people) and domain measures (communication, patient care, and specific care issues.
The home care staff have a paramount role to play in influencing high HHCAHPS scores from patients through quality service delivery. Nonetheless, organizations often face challenges in patient management. A major problem for a home care staff is effective pain relief for their patients. For instance, the Accredited Home Hospice of America, Houston Texas has had a lower score on pain relief for their patients necessitating quality improvement measures. A systematic approach to the problem using the FOCUS framework will help identify effective measures towards changing the status quo. Additionally, a Fish Bone diagram will depict the interrelationship between inconsistent pain management in the facility and its root causes for home care workers. By understanding the position of Texas Home Hospice in pain control for patients will provide an accurate basis for understanding the impact of a home care staff on initiating quality improvement measures towards better HHCAHPS Scores.
Effective physical, emotional, and spiritual pain management is a critical component of home care. Pain robs a patient's life and predisposes them to other detrimental health consequences. While pain may not be the reason for a patient’s death, untreated or under-treatment may beget worse pain (Goldstein & Glasser, 2011). Increases pain may result in anxiety and depression in addition to harmful effects on their entire body system like weight loss, tachycardia, fever, and shock (Wells, Pasero & McCaffery, 2008). Of importance to home care is the impact on reduced mobility leading to DVT, pneumonia, and pulmonary embolus. Poor pain management may also impact an organization's reputation through patient and family dissatisfaction. It is a distinct elaboration of the role of effective pain management to influence HHCAHPS Scores.
Effective pain promotes quality of life for patients and their families/caregivers. Today, there are effective pharmacological and non-pharmacological approaches to pain management. Nonetheless, pain control remains a challenge for home care workers and collaborative health professionals. It is a troubling phenomenon in an era where scientists are in a race to discover effective pain management for quality care. For example, a study by Won et al. (2004) reveals that 24.5% of 49% of patients in a nursing home and after discharge for home care with persistent pain received no analgesics. Other scientists, Goldstein and Glasser (2011) add that 26% of cancer patients with daily pain fail to get any help for symptom relief. Shockingly, patients older than 85 years may not get the required pain relief for their symptoms (Wells et al., 2008). Recent evidence reveals that patients with moderate to severe pain are also not likely to get help on pain relief (Egnatios, 2015). Such reports are inconsistent with pain management guidelines and a threat to the nobility of best practice. Making amends is paramount to promote quality management in hospice home care.
The setting for the project is the Accredited Home Hospice of America, Houston Texas. The facility is a Medicare accredited facility- trusted to provide comprehensive hospice and home care to Houston and surrounding areas. 78% of the patient population in the facility uses Medicare, are of mixed races/sex, and have an average of 68 years. Patients get services from a team of nurses, physicians, social workers, volunteers, chaplains, and nurse aides for all their care needs in the facility and home care. Every decision in the facility is based on a philosophy of mutual respect, trust, and belief that every individual is entitled to a life of dignity and comfort surrounded by family and loved ones. The facility is re-certified after every three years by the Centre for Medicare and Medicaid Services. Recertification requires adherence to the stipulated health records, guidelines on quality care, and involvement of patient and family consent in all plans of care. Also, to continue providing quality services, Texas Home Hospice requires that staff go through continuing education workshops to improve their knowledge on hospice care and patient experience.
Adult home care is one of the major programs for Texas Hospice care. The program provides a variety of services for adults of all ages and health care needs. It offers services in therapy, rehabilitation, and personalized nursing care services. Most patients requiring home health in the facility are chronic with a significant level of pain that inhibits their daily activities of living (DOL's). Irrespective of the purpose of home health care for a patient, the Texas Home health program aims to assist individuals to recover faster, live healthily, and stay independent at the comfort of their homes.
Local Problem /Needs Assessment
Texas Home Care center is not immune from the general inability to recognize and effectively treat pain for their patients. Although the facility is one of the best in hospice and home health, it is faced with difficulties in sufficient pain management for its patients. The challenge is evident in the latest CAHPS survey revealing a score of 80 for getting help for symptoms. 89% of the surveyed patients reported that they got the needed training about side effects for pain management (national average- 75%). 89% received the necessary training about when and if they needed more medication for their pain (national average 72%). Although the national average stands lower than the facility's score, quality improvement is necessary for higher scores. The approach is consistent with Robert Wood Johnson's Foundation definition of product and service quality improvement- “there is always a room for quality improvement in healthcare (McLees et al., 2015).” By engaging in quality improvement measures to change the statistics, Texas Homecare can display its ability to adhere to the required modern health care quality consistent with value-based purchasing terms.
Quality scores from the HHCAHPS are released to the public to influence stakeholder decisions in choosing a home health facility over another. Texas Home Health is CMS accredited and adherent to these terms and conditions of service delivery. It means that the facility must engage in continuous quality improvement measures as a prerequisite for health care delivery. Consequently, providing quality healthcare increases its chances of moving towards achieving the global triple aim for improved population health, reduced patient costs, and better patient experience (McLees et al., 2015). It also helps to achieve better HHCAHPS scores and improve the facility’s reputation in the region. A good reputation increases the chances that stakeholders will choose the facility for their health care needs compared to other facilities in the region. It makes it paramount that Texas Home health initiates effective measures for pain relief for their home health services.
Home care professionals collaborate with other professionals to promote patient care far away from the health facility. Texas home health professionals have shown success in adhering to the documented process of obtaining pain medications for their patients (Appendix 2). A significant concern for health professionals is the lack of an effective approach to pain relief for the elderly in home care. However, it is necessary to understand that the problem is not a Texas Home health organization issue but a global concern for the elderly amidst multiple chronic health concerns. Developing a solution would provide insight into the problem towards quality improvement. It would also highlight the role of a home care aid towards better patient outcomes.
Current Practice and Proposed Change
There is a general inability for home health workers to treat pain for their patients in home care (Appendix 1). The challenge rises in drastic proportions for the old due to age-related disorders. However, this assertion is not meant to shift attention to the complexity of pain management for these patients. Rather, it is to signify the health disparity and need for better approaches to elderly pain management for home health workers. It is also a fact that elderly pain management is grossly under-recognized, undertreated, and underreported (Egnatios, 2015). It amplifies the deficit for effective pharmacological approaches amidst modern technological breakthroughs. There is also a general inability for home care aids to consider non-pharmacological approaches in pain relief. Moreover, there is no single effective approach for every type of pain (Egnatios, 2015). It is an opportunity to develop multiple approaches as a care bundle for solving existing pain-related difficulties in home health for Texas Home health practice. Developing an effective evidence-based approach towards pain management provides new hope for the clinical issue in home health nursing and the Texas Home Health Facility.
Evidence-based practice (EBP) is the gold standard of quality improvement in healthcare. The practice stems back from Florence Nightingale when she noted that proper ventilation is necessary for better health (Black et al., 2015). Times have changed and EBP made easier by the ever-evolving electronic milestones. Nonetheless, the superiority of EBP in solving clinical problems is still unmatched. Today, it is possible to electronically search for quality evidence to a clinical problem, gather solutions from highly-rated evidence, analyze the evidence and apply the solution to the existing clinical problem. It is also common for scientists to continuously search for effective measures to eliminate organizational and individual barriers to EBP (Black et al., 2015). It is proof of the efficacy of EBP in achieving quality in health care delivery.
EBP has had enormous success in the health care field by standardizing health care delivery to science and scientific solutions. It has also helped eliminate illogical variations for health professionals to reduce unpredictable patient outcomes. Therefore, applying the same EBP in solving pain management for the elderly in Texas Home Health Centre is a credible approach consistent with best practice.
An evidence-based care bundle is an effective approach to solving the pain management problem in Texas Home Hospice Health Center. A bundle is a set of evidence-based interventions for a specific population and region (Lavalle et al., 2017). To ensure its efficiency, health professionals must utilize all its specifications unless there is a contraindication. According to previous success stories, a care bundle provides an economical solution to clinical issues (Lavalle et al., 2017). Developing a care bundle in Texas Home hospice care is from the fact that there is no single approach for pain control for the facility's patients. It can provide an economical solution to the Texas Home health organization issue and help increase the organization's rating in the region for quality service delivery.
The improvement strategy is based on a thorough electronic search for high-quality sources that provide scientific recommendations for effective pain management. The final bundle is a combination of three approaches from Hartford Institute for Geriatric Nursing (2020), The American College of Physicians (Horsley, 2008), and the British Geriatric Society (Schofield, 2018). All the guidelines meet the AGREE II guideline for quality, a proof of high evidence level for incorporation into a care bundle. The recommendations for practice change include:
Combining pharmacology and non-pharmacology measures for pain relief.
Utilizing psycho-educational measures as part of pain management for patients.
Recognition of cognitive behavior therapy and rehabilitation as effective approaches for chronic non-malignant pain.
There is no single approach for pain management in home care. Moreover, home care professionals heavily rely on pharmacological measures for pain relief and some of the available options may not be suitable or effective for all types of pain. Untreated or under-treated pain is a risk to quality home care and a threat to an organization's reputation. A care bundle- an approach from the Institute for Health Improvement (IHI) would be an appropriate intervention to solving the clinical issue. It would, in turn, improve pain scores for patients, attain patient satisfaction and increase Texas Home Hospice Centre's reputation for quality health care.
The project aims to determine whether utilization of a pain management bundle for a year by home health staff is effective in reducing pain scores for home care patients whose pain interferes with DOL’s for six months. The aim is consistent with CMS guidelines for quality health care measures for “received as much help for pain relief as needed.”
The last process of the FOCUS approach of quality improvement is to identify the process improvement strategy. The improvement strategy for Texas Home Hospice Centre is based on the potential causes for ineffective pain management for their patients. Approval for the project will be sought from the hospital’s Institutional Review Board. Subject privacy will be maintained by using data without patient information to determine the bundle use in patient care. Any identifiable personal data will be eliminated before using the data in the data collection tool.
The first approach is mandatory education for all home health professionals about pain, its impact on QOL, and the care bundle as an effective approach to the problem. Since it’s a requirement for all health providers in Texas Home Hospice Centre to go through continuous health education, the sessions will be considered necessary for all the staff. Session speakers will include a Texas nursing research scientist on pain management, an anesthesiologist, a physical therapist, a counselor, a pharmacist, and home care nurses in the center. The pain expert will present the various myths and caregiver attitudes that hinder effective pain management for home care patients. He/she will also provide suggestions necessary for empowering the patient and the home staff about effective pain management.
A two-hour class will be used to train five nurses who will be used as ‘super trainers’ for the unit. They will help clarify any concerns about the bundle and help distribute educational materials throughout the facility. To ensure that the staff gets the appropriate knowledge about the intervention, classes will be held at three different times. Doing so will also ensure that there is adequate time with the staff to clarify any concerns about the intervention through an interactive question-answer session.
The staff will also get patient educational materials on non-pharmacological pain approaches like exercise. It will ensure that they have the right teaching tool for patient education even when they have limited knowledge about a certain modality for pain relief. It will also increase their confidence during patient education. They will be instructed that it is necessary to use all three interventions to determine the bundles' utilization in patient care. They will also be expected to provide feedback about the bundle through the super trainers to make any amendments to the approach.
A process evaluation will focus on data collected from the educational sessions, staff sign-in for participation in the sessions, and documentation about the efficacy of the bundle in pain management in the home care settings. It will entail any challenges that the staff may encounter in utilizing the bundle. Outcome evaluation will focus on how many patients qualified for the care bundle, how often the staff felt confident utilizing the bundle, and the utilization of any other measure not specified in the care bundle. The outcome measure will focus on pain score improvement enough to help the patient resume their normal activities of living.
An approach is relevant if it influences a substantial improvement in the quality of care. The expected goal for the care bundle is its utilization for more than 60% of patients that meet the inclusion criteria for pain that interferes with ADL’s. To show success, pain scores improvement will be expected to meet a statistical significance of p>0.05. It will be proof of the efficacy of the bundle on pain improvement. It will also demonstrate the efficacy of home health care staff in improving HCAHPS scores for patients.
Black, A. T., Balneaves, L. G., Garossino, C., Puyat, J. H., & Qian, H. (2015). Promoting evidence-based practice through a research training program for point-of-care clinicians. The Journal of nursing administration, 45(1), 14. Doi: 10.1097/NNA.0000000000000151
Egnatios, D. (2015). Improving pain outcomes in home health patients through implementation of an evidence-based guideline bundle. Home healthcare now, 33(2), 70-76. https://nursing.ceconnection.com/ovidfiles/01845097-201502000-00003.pdf
Goldstein, L., & Glaser, D. I. (2011). Pain Management in Nursing Homes and Hospice Care. Practical Pain Management, 9(7), 1-2. https://www.practicalpainmanagement.com/resources/hospice/pain-management-nursing-homes-hospice-care
Hartford Institute for Geriatric Nursing. (2020). Pain management. https://hign.org/consultgeri/resources/protocols/pain-management#tab-1
Horsley, E. (2008). ACP guidelines for the diagnosis and treatment of low back pain. American Family Physician, 77(11), 1607. https://www.aafp.org/afp/2008/0601/p1607.html
Lavallée, J. F., Gray, T. A., Dumville, J., Russell, W., & Cullum, N. (2017). The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implementation Science, 12(1), 1-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5707820/
McLees, A. W., Nawaz, S., Thomas, C., & Young, A. (2015). Defining and assessing quality improvement outcomes: a framework for public health. American journal of public health, 105(S2), S167-S173. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355721/
Schofield, P. (2018). The assessment of pain in older people: UK national guidelines. Age and aging, 47(suppl_1), i1-i22. https://academic.oup.com/ageing/article/47/suppl_1/i1/4944054
Sholjakova, M., Durnev, V., Kartalov, A., & Kuzmanovska, B. (2018). Pain relief is an integral part of palliative care. Open access Macedonian journal of medical sciences, 6(4), 739. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5927513/
Wells, N., Pasero, C., & McCaffery, M. (2008). Improving the quality of care through pain assessment and management. Patient safety and quality: An evidence-based handbook for nurses. https://www.ncbi.nlm.nih.gov/books/NBK2658/
Won, A. B., Lapane, K. L., Vallow, S., Schein, J., Morris, J. N., & Lipsitz, L. A. (2004). Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing Home Residents: (See editorial comments by Dr. Debra Weiner on pp 1020–1022). Journal of the American Geriatrics Society, 52(6), 867-874.
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