NR 447 Collaborative Health Care

NR 447 Collaborative Health Care

Following Safety and Medicare Requirements in Home Care
Introduction
The first SMART goal is regarding the elevated re-hospitalization rates, and how as a team we can reduce these numbers by 10% within the next six months. I chose this goal because the Medicare requirements are changing for reimbursement rates and we are a non-for profit organization where cutting down on any costs are important for not only our organization but also for our patients. Secondly, the next SMART goal I chose was how we can increase the compliance of incident reports being filled out for patient injuries, falls and infections by 10% within the next 3 months. I chose this SMART goal because this is an area in which we have been falling behind and this is an lack in compliance. Case Managers and Triage Nurses are responsible for making sure these are completed and returned to our managers in a timely manner. Goal 1: Leadership Development

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The complete Hospice Team; Social worker, CNA, Pastoral Care, Bereavement Services, RN/ Case Manager and Volunteers will all work together to achieve this goal by beginning teaching at time of admission. The Hospice team will all work together in order to make sure that the patient will die comfortably in their home with their family by their side and will do this without returning to the hospital. .We will provide the family with all of the information and support they will need in order to feel comfortable in keeping their loved one at home without returning them to the hospital. They will have access to a nurse 24 hours a day/7 days a week through our Triage line and will be reminded at each visit to use this form of communication in order to prevent re-hospitalization. Peer-Reviewed Articles

In the article, Hospital Readmission Rates in Medicare Advantage Plans, this article speaks about the changes that CMS (Centers for Medicare & Medicaid Services) put into effect this year (2013). The changes are to establish a hospital readmissions reduction program in Medicare, when implemented, the program reduces payments to hospitals based on their readmission rates by 20% and hospital-acquired conditions or adverse events among patients with Medicare by 40%. This was a good article to explain why as a non-for profit organization, we must drop the rehospitalization rates. Credible Websites

The website, Agency for Healthcare Research and Quality, has several tools and articles speaking of how to avoid rehospitalizations. They have materials, documents and tools called, State Action on Avoidable Rehospitalizations or STAAR. This aims to reduce avoidable rehospitalizations and is focused on how to improve transitions of care and how to address systemic barriers to reducing avoidable rehospitalizations. This is helpful and useful information to use for our SMART goal, as it provides a lot of tools we could use in reducing our rehospitalization rates. Informational Expert

Amy Suydam RN CPS (Clinical Practice Supervisor) is over the Hospice RN/ Case Managers at our office. Amy and I discussed the SMART goal about rehospitalization rates and how we are going to decrease these rates. Amy agrees with all of the teaching with the family from admission on and making them aware of all the assistance they have available from our services. One thing she also did mention is that we could do more in-services with our staff regarding this and make sure everyone does understand the decline in reimbursement rates that we are receiving at this time compared to the costs to the organization. Summary

In searching information regarding the rehospitalization rates and the drop of Medicare reimbursements for those stays, I was surprised to have found there was so much information regarding this and the tools that are out there also to use. My direct…