Home health agency shrinks readmission rates with PLACES tool and training

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December 5, 2013
Jan O'Dell

Customizing a widely used tool for risk assessment enabled Signature Home Health to pursue a successful new approach to care coordination for high-risk patients.


Home health agencies provide a variety of in-home services, from nursing care to physical therapy. Many home-health patients have serious or multiple illnesses, increasing the odds that they will be readmitted to the hospital within 30 days of discharge.

Signature Home Health, part of the Avamere Family of Companies with offices in Oregon and Washington, recognized that a well-coordinated system of care could be a game-changer in keeping patients medically stable in their own homes. Two years ago, Signature began exploring what more the company could do to keep patients from requiring a return trip to the hospital or emergency room. The search led Signature to implement a newly adapted risk assessment tool and a new approach to coordinating care for high-risk patients, with a positive impact on readmissions.

Assessing patient risks

Staff began by identifying the factors driving the majority of readmissions. Five rose to the top of their list:

• Length of stay—three or more days in the hospital

• Diagnosis—congestive heart failure, chronic obstructive pulmonary disease, stroke, kidney disease, and diabetes

• Polypharmacy—six or more prescribed medications

• Behavioral—patients’ ability to care for themselves

• Social—patient’s support system and social network

Armed with this analysis, they set out to find a risk assessment tool they could adapt to home health care. They found a potential candidate in the LACE index, a validated tool used by many hospitals to focus interventions on patients who are at highest risk for poor post-discharge outcomes. LACE is an acronym for Length of Stay, Acuity of admission, Comorbidities, and number of previous ED visits in the six months preceding the current admission.

Signature staff adapted the LACE tool to include two other drivers they had identified as risk factors for their seriously ill patients—Polypharmacy and Social factors—and the LACE index became Signature’s PLACES tool.

Administrator leads company charge

Autumn Mercer, RN, is the administrator at Signature’s office in Medford. She frequently takes part in networking meetings convened by Acumentra Health, focused on developing community solutions to avoidable readmissions in southern Oregon. Mercer said these meetings provided her with valuable opportunities to vet the PLACES assessment with peers and to inform and build trust with primary care physicians.

As response to the PLACES tool was favorable, Signature decided to train staff and conduct a pilot project in the company’s Portland office, beginning in March 2013. Before implementation, 30-day rehospitalizations for the Portland team’s patients were running at a rate of 14%. After using PLACES for two months, the rate fell to 9%. As of November, the rate had dipped further to 8%.

The results can be traced to changes in the way staff coordinate care for high-risk patients. At intake, each patient is evaluated for risk factors based on the PLACES index. With the patient’s risk score in hand, home health nurses then prepare a color-coded “zone” chart that specifies care interventions based on the patient’s symptoms and characteristics. Everyone who is part of the clinical care team—RNs, LPNs, physical and occupational therapists, home health aides, speech-language pathologists—is trained to use the same tools in managing a patient’s care. These team members are also trained to help patients fill out and keep current a health diary that they bring to every doctor’s visit—another important component in a system of coordinated care.

“Our new approach is helping staff talk about each patient a lot more,” says Mercer. “Complications can come on so slowly that it’s hard sometimes to recognize the warning signs. Now, every member of the staff knows their role, and these tools help them connect the dots.”

An additional benefit from the PLACES program is more efficient interactions with physicians. Mercer says, “When you have an issue that requires physician advice, it’s often after hours. We train staff clinicians to be ready to provide both a summary of the problem and a suggested solution.”

Focus on skilled nursing facilities

Based on the success of the pilot project, Avamere’s corporate leadership decided to evaluate the impact the PLACES program could have on the company’s skilled nursing facilities (SNFs). Company analysts studied a sample of SNF residents and concluded that the program would work well in this setting. As a result, the company is training all SNF staff to use PLACES. Mercer said the company is on track to implement the program in all its agencies and facilities by next summer.

Mercer believes her company’s investment in staff training and new tools offers great promise for improving care for patients with complex diagnoses. “What we’re really doing now is like managed care. RNs direct the team. We’ve changed the face of what home health looks like.”


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