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  1. Greenberg, E. Liza MPH, RN

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VNAA has used this column to examine quality strategies from a variety of angles-developing programs for high-risk patients, improving management of patient experience, and tailoring quality improvement to specific measures of care. We haven't yet talked about an aspect of quality that is even more fundamental-the nursing model. For this article, VNAA spoke with Mary Linn Hamilton, who arrived as President and CEO of the Visiting Nurse Association of the Treasure Coast (VNATC) in 2014. Like every CEO of a home-based care agency, she brings a relentless focus on quality to her job, along with the goal of demonstrating that quality through high Star Ratings on Home Health Compare.


Ms. Hamilton has leadership experience in both community-based and hospital-based home care organizations. She brought to VNATC a strongly held belief that primary care nursing is the foundation of a high-quality home care program. She says, "The model of care drives quality. The care model either makes it easier or puts barriers in the way of getting the job done. Nurses and therapists have to be accountable for care, and they generally want to be accountable. They may need some guidance in implementing primary home care, but in the long run, primary care is easier. Clinicians are doing things themselves, not delegating and then trying to piece it back together."


Here, we highlight some of the attributes of primary care nursing, showing how they contribute to quality in this new value-based purchasing environment. According to VNATC:


Primary home care is patient-centered: Patients appreciate knowing that one person is "their nurse" (or therapist) and developing a relationship with that person. They also appreciate when their clinician knows who they are and their health history-so the patient or caregiver doesn't have to tell their whole story over at every visit.


Primary home care is efficient: Clinicians can build on the clinical information and patient/family teaching at each visit. Visits are shorter, clinicians know where to find information that they themselves collected, and home care clinicians have relationships with the physician and other caregivers that build over time.


Primary home care improves consistency: When the same clinician conducts the start of care and discharge assessments, they know if the patient has improved clinically or gained understanding of their condition. The clinician's assessment and documentation style is the same at the beginning and end of the visit so interrater reliability is not an issue. The agency can support consistency by providing electronic records and quality alerts to ensure and remind clinicians of essential clinical interventions (and prevent gaps in care).


Primary home care improves accountability: Nurses and therapists understand that they are accountable for their panel of patients. They deliver the right interventions and follow up because no one else on the home care team has that primary accountability. Home care agencies support staff's continuous improvements in accountability providing individualized data and feedback on performance.


Primary home care improves staff satisfaction and "aligns incentives": According to Mary Linn Hamilton, some models of staffing incentivize clinicians to make as many visits as possible, while primary care focuses on meeting patient needs. Primary care has improved continuity of care. Clinicians are more satisfied knowing they are accountable for patient outcomes and the quality of care provided; staff compensation and evaluation are all aligned toward the same quality objectives.


At VNATC, transitioning to a primary care model of home care took planning, lots of discussions with staff, and some time to transition. Now, each nurse has a geographical area of practice, with some overlap to accommodate cross-coverage and higher density in some areas. Cases are assigned by a patient care manager, each of whom who coordinates 5 to 7 nurses. Nurses typically carry a caseload of 22 to 25 patients, making adjustments for patients who are clinically severe (based on OASIS) or who have challenging social factors. Patient care managers assist the primary care nurses with managing the acuity of their caseload and scheduling the visits.


Primary care nurses (and sometimes therapists) visit their own panel of patients as much as possible and are responsible for routine communications with the patient's physician. Registered nurses may have LPN or other coverage for patients with high visit frequency, and are supplemented by dedicated weekend staff. Clinicians may bring in therapists, social workers, and other staff members to the patient care team as needed. These providers are also assigned according to the primary care model.


Primary home care is an integrated piece of VNATC's overall quality strategy. Each clinician has a scorecard generated from patient level data, showing how the clinician performed on Home Health Compare measures. The scorecard is a teaching tool to improve clinical assessments and documentation, and ultimately to improve patient outcomes. The agency also hosts a quarterly town hall, during which the leadership reports on agency-wide performance. Agency metrics line up with clinician level objectives, and also include financial measures and staff satisfaction.


According to Mary Linn Hamilton, patients and caregivers love the primary home care approach. Before the primary care program they might have had a different nurse every visit. Having a personal relationship with "their" nurse adds to patient satisfaction. Star ratings results are moving up too. In one branch VNATC has gone from 3.5 to 4 stars on quality measures, and from 4 stars to 5 stars in patient satisfaction. The agency is 5 stars for quality and 5 for patient experience in the other branch.


Says Mary Linn Hamilton, "We have to remember we're out there to provide care in the most effective and efficient way possible. That means meeting the needs of patients and families. Sometimes we get caught up in meeting home care regulations. But relationships are the foundation of quality in home care. At VNATC our strategy is built like a pyramid: primary nursing, data tools so we can understand what we are doing, and training, to ensure consistency."