2007 Annual Report: We're Here. - Visiting Nurse Service of New York

pg 24pg 25Penny Hollander Feldman, Ph.D.In 1993, when VNSNY first asked Penny Feldman, whowas on the faculty of Harvard School of Public Healthand the Kennedy School of Government, what she thoughtof a VNSNY research center, she had doubts. “VNSNY isso focused on delivering services—and rightly so. I wasn’tsure the organization would have the patience it takes todo good research.”Penny eventually came to believe that a research centerfocused on the improvement of home care was sorely needed,and that VNSNY was the right organization to do it. Whenthe first director of the newly created VNSNY Center forHome Care Policy & Research left after a brief tenure,Penny was asked to step in and lead the fledgling researchinstitution. She has never looked back.“I have always been interested in how to make thingswork better. In health care, people talk about the 17/17rule. Only about 17 percent of health care research findingsget adopted, and it takes about 17 years for research toaffect patient care. But we have developed ways to diguseful data out of the enormous amount of informationVNSNY gains from caring for over 100,000 patients ayear. And we have pioneered ways to do really high-qualitylong-term studies. We can give VNSNY managers rapidanswers to immediate questions, and tackle tough questionsover the longer term to advance home care practicenationwide as well.”After commuting between Boston and New York while herthree children were in school, Penny and her husband nowlive in New York City. Penny notes, “VNSNY hasproven its commitment to research to improve the healthof our patients and the cost-effectiveness of our care. We canreally make a difference on the front line of patient care.We’re negating the 17/17 rule, and that’s exciting to me!”The Research Center is also planning for the next phase—translating the framework into practical applications andintegrating this effort with other Center projects. “Ultimatelywith this project, VNSNY is taking the lead in ensuringthat the home care industry offers care that is tailored tothe specific needs of older people, allowing them to age intheir communities,” says Dr. Totten.ReACH CollaborativeResearch shows that the use of certain evidence-based practicesin home care can reduce patients’ re-hospitalization rates. Yetmany home care agencies struggle to bring re-hospitalizationrates down to those stipulated by the Centers for Medicareand Medicaid Services. From 2006 to 2007, the ReACHCollaborative, the Center’s most ambitious research translationand dissemination effort to date, worked with 169 home careagencies nationwide to provide targeted staff with informationand resources that would help lower the risk of re-hospitalizationamong home care patients....the ReACH Collaborative...worked with169 home care agencies nationwide toprovide targeted staff with informationand resources that would help lower therisk of re-hospitalization among homecare patients.Research Center staff collaborated with 16 QualityImprovement Organizations (QIOs) across the United Statesto engage home care agencies in 19 states in an effort toreduce acute-care hospitalizations among their patients.QIOs, which provide technical assistance to home care agenciesand personnel in their areas, served as a bridge betweenthe collaborative agencies and brought a local flavor to theproject. To maximize resources and expand participation,the Collaborative used distance-learning technology (WebExand teleconferencing) and provided support to the QIOs toconvene local workshops of frontline professionals, primarilynurse managers, working to implement new practices withfield staff. Aided by the QIOs, each month, home careagencies entered hospitalization rates, both for the study’starget population and the agency, along with process of caredata, into a dedicated Web site (www.paqh.org/reach).Participating agencies used the site to compare their agencydata with national norms. VNSNY was the coordinatingcenter as well as a participating agency in the collaborative.As the Collaborative was rolled out, sets of agencies focusedon selected quality improvement areas and developed actionplans for high-risk populations, which included implementingpractices such as frontloading home care visits or assessingpatients for their risk of being hospitalized. Each agencyselected a target group of patients and a team to work withthese patients.In Wave I of the collaborative, agencies posted a 4 percentreduction in hospitalization rates among target patients. InWave II, there was a 7 percent reduction among targetedpatients. In addition, there was a significant increase—morethan 40 percent—in the number of patients who receivedcompleted risk assessments.“The big lesson of ReACH is that a national practiceimprovement collaborative is effective,” says MargaretMcDonald, M.S.W., project manager, “even when you’reworking with home care nurses, who are a decentralized,difficult-to-reach group.”Home-Based Blood Pressure Interventionsfor African AmericansApproximately 8 percent of home care patients are admittedwith essential hypertension (HTN) as a first, second, or thirddiagnosis, yet management of high blood pressure has notoften been subject to guidelines or quality-improvementactivities in home health care. Many patients with high bloodpressure have diabetes, heart disease, or other conditions forwhich HTN represents a major risk of complications andpoor health outcomes. African Americans receiving homecare are a particularly high-risk population.Nursing personnel in home care are uniquely positioned to usetheir care management and patient education skills to increasethe proportion of HTN patients achieving adequate bloodpressurecontrol. Therefore, the Research Center in 2004launched Home-Based Blood Pressure Interventions for AfricanAmericans—an NIH-funded, randomized trial managed byJennifer Mongoven, M.P.H.—to examine the effectivenessand cost-effectiveness of two organizational interventionsaimed at improving blood-pressure control among AfricanAmericans in home care. The two interventions include:(1) a “basic” intervention that delivers key “just-in-time”information to nurses, physicians, and patients while thepatient receives traditional post-acute home health care; and(2) an “augmented” intervention that transitions patientsto a home-based HTN support program, extending theinformation, monitoring, and feedback available to patientsand primary care physicians for an 18-month period beyonda home-care admission. These interventions are being assessedrelative to usual care and to each other. The analysis willestimate the impact of each intervention on nursing practicesand processes of care, on patient hypertension management(for example, medication adherence), blood pressure outcomes,and costs. As of April 2008, 328 nurses and 867 patientsthroughout New York City’s boroughs are participating inthe study.“What has been helpful to the patients in this program,is that focusing on one condition helps them feel moreconfident in their ability to manage it,” said Paula Wilson,B.S.N., M.P.H. “From there, it is easier for the patient to seehow their co-morbidities are interrelated and that ultimatelyby managing one condition, it may help improve another.”