Practice Gap Identification
During the deadly pandemic called Coronavirus or COVID 19, my organization implemented Telehealth. Telehealth implementation was one of the big projects for my organizations to avoid exposure to the virus. Services were suddenly challenged to find a new way of seeing and treating patients to prevent the further spread of the virus. The telehealth implementation has strengthened the capacity of the providers to care for an increased volume of patients without in-person visits. However, despite the telehealth platform’s ability to alleviate many obstacles, it can present new ones for older adults patients. The gap identifies in my practice is the challenges among the older adults with telehealth implementation.
The older population has grown significantly since the onset of the 20th century and will continue to do so for many decades to come. Seniors currently face a subset of barriers to healthcare such as disabilities, chronic disease, rising costs of care while on a fixed income, and limited transportation. The most prevalent disability for all older population age groups is serious difficulty walking. Additionally, more than 40% of seniors have difficulty doing errands alone, such as visiting a doctor’s office. In 2014, patients 65 and older spent over 5 More and almost three times more on personal health care than a child and working-age person, respectively. Though seniors only made up 15% of the population, they accounted for 34% of healthcare spending in 2014.
Potential Quality Improvement Practice Gap For my DNP project
Emails to activate the Telehealth Procle account usually sent out to patients a week before the visit. However, patients over the age of 50 do not activate their accounts most of the time. The purpose of the project is to improve access to telehealth among seniors in the neurology clinic. The project will focus on improving the outcomes in Telehealth among the seniors in my practice. My DNP project will explore the needs of the senior population in a diverse community while advancements towards telehealth are being made for patient care. The project will help identify the subsets of the aging population that need supplemental outreach to activate their telehealth accounts. Acknowledging the technological barriers that seniors may face can help improve health outcomes, especially for patients without caregivers.
Rationale:
Telehealth is becoming more widespread to improve accessibility and address healthcare disparities (Okoye et al., 2021). The importance of online Telehealth platforms has become more evident during the COVID-19 pandemic. While Telehealth can alleviate health obstacles and reduce healthcare-related financial burden, activation, and platform utilization present new challenges for some vulnerable users (CDC, 2020). The project will focus on reaching out to patients over the age of 50 and need assistance activating their Telehealth Procle account. Telehealth Procle is HIPAA compliant social networking platform that helps clinicians connect with their patients. It is important to note that in addition to an age disparity and health inequity among minorities, persons with certain neurological disorders are vulnerable and less conversant to digital technologies (Okoye et al., 2021). Continuous healthcare access and monitoring at home for the senior minority populations While limiting their risk exposure during the pandemic, it has served to improve and implement a patient-tailored Telehealth platform.
Project Methodology
At the onset of the COVID-19 pandemic, all patients in the neurology clinic received an activation email for Telehealth Procle, a HIPAA compliant social networking platform. The project will involve approximately 90-100 participants. All patients Fifty years and older will be contacted to see if they need assistance with activating their accounts. Education sessions on how to activate the Procle telehealth account will be provided. A set of written and verbal instructions will specifically design to disseminate to the patients. The written instructions will be typed in large boldface font with accompanying screenshots to illustrate the steps needed to activate their telehealth account. The written guide will be sent as an attachment via e-mail to those who requested it. Verbal coaching will also provide over the phone as needed.
The level of assistance needed by each patient will be designated into one of the three following categories: (1) written help, (2) written and verbal help, (3) no help. The number of patients who activate their accounts after receiving instructions will be recorded. Additional notations will be made if a family member or caregiver aided the patient.
Rationale:
Older patients may be left behind as telehealth moves forward due to technology barriers. Individuals ages 65 and older have lower instances of internet access compared to the total population. It was found that 55% of the older population living alone had access to the internet compared to 85% of the older population living with family (Okoye et al., 2021). Moreover, telehealth platforms can be over complicated for senior patients due to limited experience with the necessary technology for a successful telehealth visit (Kalicki et al., 2020).
References
Center for Disease Control (2020). Using telehealth to expand access to essential health services during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html
Kalicki, A. V., Moody, K. A., Franzosa, E., Gliatto, P. M., & Ornstein, K. A. (2021). Barriers to telehealth access among homebound older adults. Journal of the American Geriatrics Society, 69(9), 2404. https://doi-org.ezp.waldenulibrary.org/10.1111/jgs.17163
Okoye, S. M., Mulcahy, J. F., Fabius, C. D., Burgdorf, J. G., & Wolff, J. L. (2021). Neighborhood Broadband and Use of Telehealth Among Older Adults: Cross-sectional Study of National Survey Data Linked with Census Data. Journal of Medical Internet Research, 23(6), e26242. https://doi-org.ezp.waldenulibrary.org/10.2196/26242
Irrespective of their health conditions, all patients require timely, effective, and quality health care services. Overall, achieving the desired state of health care quality remains a leading goal of health care organizations. Processes, procedures, and routine interactions should ensure that patients are excellently served. Satisfaction should be a guiding principle. In health practice, quality of care represents the degree to which health services meet the desired outcomes. To examine whether they are providing quality care, organizations should regularly evaluate their performance using rate-based quality measures. Evaluating performance guided by rate-based quality measures is a practical way of improving care delivery and patient outcomes. This paper describes rate-based measures of quality in health care organizations. It further deconstructs each measure, describes the importance, and explains how each measure relates to patient safety and the cost of healthcare delivery.
Rate-Based Measures: Description
Quality measures are reliable indicators of a healthcare organization’s capacity to deliver optimal care. Rates show the difference between performance and expectations. Appropriate rate-based quality measures for in-depth exploration include readmission rates, complication rates, and post-procedure death rates. These measures have been selected since they directly relate to the type of care that patients receive in health care settings. Their rates are inversely proportional to the quality of care. For instance, high readmission rates indicate that the quality of care does not meet the desired performance levels. The same case applies to complication rates and post-procedure death rates.
The other reason for selecting these measures is their significance in the overall health care provision in the United States. The Centers for Medicare & Medicaid Services (CMS) reports that quality health care is a priority for the President of the United States, Department of Health and Human Services, and CMS (Centers for Medicare & Medicaid, 2020). Due to the significance and interest of quality health care, CMS uses quality initiatives for health improvement in many instances and spends considerable resources in quality enhancement programs. As a result, the rate-based quality measures indicate the extent to which health care organizations align with the President’s and CMS’ expectations as far as quality is concerned.
Health care organizations require tools for quantifying healthcare processes. The selected rate-based measures are used for quantifying outcomes. Quantifying the processes and outcomes shows an organization’s ability to provide high-quality care. Quantifying outcomes by rating them also indicates the areas requiring more attention as the organization adopts new quality improvement mechanisms.
Deconstructing Each Measure
When a patient visits a healthcare organization for medical assistance, the general desire is to get an accurate diagnosis and proper treatment. Such assistance promotes healing and helps the patient to recover within the healthcare facility or at home. Unfortunately, health complications may necessitate readmission. Upadhyay et al. (2019) described readmission rate as hospital admission occurring within a specified time frame after discharge from the first admission. As a result, the readmission rate denotes the percentage of patients readmitted after discharge. Readmission rates may be calculated in terms of weeks, months, or annual readmission.
With hospital-acquired infections (HAIs) a sincere concern in health care delivery, the complication rate should guide health care providers in preventing HAIs. Lim (2019) described the complication rate as the percentage of patients developing complications resulting from care. In most instances, complication rates are high in complex procedures such as surgeries. For instance, the complication rate associated with heart surgeries is often higher than treatment for malaria. Routinely, many health care organizations track the complication rate by a specific timeframe or division. In this case, all complications can be calculated together or segmented according to the type of disease. The extent of complication rate indicates the quality of care that patients receive in a particular health care setting.
After the treatment, patients always look forward to a full and speedy recovery. Healthcare organizations also implement the necessary measures to prevent deaths to ensure that the mortality rates for all illnesses are as low as possible. Despite these efforts, deaths still occur after procedures. According to Lim (2019), the post-procedure death rate is the number of deaths occurring after treatment. The death rate usually varies depending on the procedure. Like readmissions and complication rates, a high post-procedure death rate may be an indicator of low-quality health services.
To construct the readmission rate, the number of readmitted patients (numerator) is divided by the number of patients served during a given period (denominator). The figure is given in percentage. For instance, if five patients were readmitted after 200 discharges, the readmission rate would be (5/200) x 100, giving 2.5%. The complication rate is constructed by dividing the number of patients who develop complications by the number who received care in a given timeframe. The post-procedure death rate is calculated by dividing the number of deaths by the number of patients who received treatment. The post-procedure death rate is provided for each procedure. Like complication rates, post-procedure death rates differ depending on the type of procedure.
In each case, comparative data analysis occurs to develop the measure and get the necessary meaning to guide decision-making. For readmission rates, health care organizations may opt to record readmission cases for all illnesses after discharge. Alternatively, they may collect data for specific illnesses, which helps to determine illnesses associated with the highest readmission rates. The same approach can be used for collecting data for complication rates. Data may be case-specific or combine all complications over a given timeframe. Post-procedure death rates’ data can be tracked hospital-wide or for specific divisions and health care teams.
To determine whether a healthcare organization’s performance is within the expected performance levels, data comparison is necessary. According to the Centers for Medicare & Medicaid Services (2020), quality measures should be publicly reported. As a result, health care organizations make their data public when required, implying that their performance is visible to other settings in the same state or different regions. Shah et al. (2019) noted that the availability of such performance data, including readmission rates, allows the Readmissions Reduction Program (HRRP) to incentivize decreased readmissions. A healthcare organization can do comparative performance analysis to reflect on its performance versus other organizations through the publicly reported data.
The rates can be provided as actual figures or percentile ranking. Like illustrated in readmission, complication, and post-procedure death rate calculations, actual rates represent the figures of each measure calculated using historical operating functions and adjustment factors. For instance, the actual readmission rate is the number of readmissions divided by the number of discharges in a given time. Mostly, actual rates are given in percentage. On the other hand, percentile ranking is the percentage of scores in the frequency distribution equal or lower than the score. For instance, if the readmission rate is 65% of a hospital, 65 is the percentile rank. Since readmissions illustrate poor performance, the facility would have performed worse than 65% of other facilities included in the frequency distribution.
Some measures of quality are usually risk-adjusted. For accurate calculations of post-procedure death rate, the measurement must factor the risk level into calculations (Ng-Kamstra et al., 2018). The risk level varies for each procedure. Risk adjustment also applies to complication and readmission rates. Risk adjustment includes risk factors associated with a measure score, allowing fair and accurate healthcare outcomes comparison. A typical risk factor is the health status of a patient.
Healthcare organizations set different goals based on their missions, visions, and performance objectives. For an aggressive organization seeking to excel in the marketplace, a reasonable goal for readmission rate as a measure of quality is to reduce the rates to below the state and nationally minimum allowable levels. As a result, the organization would adopt the necessary measures to reduce the rates, such as bedside patient education and technology adoption in healthcare processes for better communication and patient monitoring. For complication rate, an aggressive organization would set quality improvement goals focusing on reducing the complication rate. As a result, the organization would initiate measures to prevent complications after a medical procedure. Similar goals apply to the post-procedure death rate. The organization should be motivated to have no death case after a medical procedure. The reference point should always be the state and national performance benchmarks.
Importance of Each Rate-Based Measure to a Chosen Clinical Organization and Setting
All healthcare organizations have a moral and legal obligation to promote healthy living in the populace. Besides the usual diagnosis and treatment of illnesses, it is crucial to build lasting patient-provider relationships and adopt mechanisms for enhancing the quality, safety, and timeliness of care. Saint Joseph Hospital, Denver, is among clinical organizations providing primary and specialized care. In primary care, Saint Joseph Hospital’s fundamental principle is that the organization’s primary care providers are the first people that patients visit for their health questions and concerns (SLC Health Saint Joseph, 2021). Advanced care in Saint Joseph Hospital includes heart and vascular care, orthopedics, and emergency.
As a rate-based measure, the readmission rate is crucial at Saint Joseph Hospital as an indicator of the quality of care that patients receive. Gupta et al. (2019) described hospital readmission within 30 days as a significant quality measure since it represents a potentially preventable adverse outcome. With Saint Joseph Hospital engaging in complex procedures such as heart surgery, cardiac rehabilitation, and heart arrhythmia treatment, the chances of readmissions might be high in such settings. Brunner-La Rocca et al. (2020) observed that the readmission rate is high in advanced care such as cardiovascular health procedures. As a result, Saint Joseph’s management should use the readmission rate as a motivation to improve quality outcomes. The rates indicate the magnitude of effort required to achieve the desired level of patient satisfaction.
Like other clinical settings, Saint Joseph Hospital should apply evidence-based practice strategies to improve clinical outcomes. Its primary, emergency and acute care outcomes should match the required performance benchmarks at local, state, and national levels. Achieving this critical goal requires Saint Joseph Hospital to collect data and measure performance on significant outcome areas. Accordingly, complication rates indicate areas that need more intervention as far as the quality of care is concerned. For instance, shock, hemorrhage, urinary retention, and pulmonary embolism are common complications after surgeries. Since they are costly to manage and extend hospital stays, measuring their rates is crucial always. The rate indicates the extent and type of responses required to ensure that Saint Joseph Hospital provides care that meets all the quality standards.
As a measure of care quality, the post-procedure death rate is also crucial to Saint Joseph’s Hospital in decision making and resource allocation. From a general operation viewpoint, healthcare organizations must reduce mortality rates as low as possible. The goal should be conducting procedures associated with zero deaths. Like in readmission and complication rates, post-procedure death rates indicate the areas of attention requiring improvement to reduce mortality rates. For instance, deaths associated with health complications can be prevented by increasing or improving interventions that reduce complications. Deaths associated with home-based care after surgeries can be prevented by improving home-based care.
Relationship with Patient Safety, Cost of Poor Quality, and the Overall Cost of Healthcare Delivery
It is an unfortunate scenario for patients to receive unsatisfactory care. According to Upadhyay et al. (2019), readmissions indicate unsafe transitions between points of care (hospital to home). As a result, readmission rates indicate the extent to which the patient received care that guarantees safety. As an indicator of low-quality services, readmission rates show that the patient receives care in unsafe settings. Health complications, emotional and financial burdens associated with increased readmissions are costly to manage. Patients are forced to travel more to get care, involve family members, and utilize more resources. The entire process is costly and increases the illness burden. Regarding the overall cost of care, the annual cost of readmissions to the US healthcare system is as high as $17.4 billion annually (Warcho et al., 2019). Such resources could be used for illness prevention and promotion programs if there were no readmissions.
Complications have similarly profound effects on safety concerns and cost implications. Health complications risk patient safety due to extended hospital stays and frequent visits. Health complications also increase the mortality rate. Postoperative complications, including atelectasis, wound infection, and deep vein thrombosis, are costly to treat and manage. In a review of postoperative complications cost of 6,387 patients, prolonged ventilation management was found to consume approximately $48,168 and renal failure $18,528 (Merkow et al., 2020). Such costs can be minimized by a proportional reduction in complication rates.
The post-procedure death rate not only indicates patient safety concerns but is a threat to their lives. Unlike readmissions and complications, death rates show a health care facility’s incapacity to guarantee patient safety. Deaths are costly since the patient and the family does not get the value for their money. Hospitals also incur huge costs associated with litigation if the family is not satisfied with how the patient was handled.
In conclusion, rate-based quality measures indicate the extent to which a healthcare organization provides quality healthcare services. In this paper, readmission, complication, and post-procedure death rates have been discussed as rate-based quality measures. The three measures were selected since they directly relate to the type of care that patients receive in healthcare settings. The case of Saint Joseph Hospital has been provided to illustrate the importance of each rate-based measure. In terms of safety, the magnitude of each rate is inversely proportional to patient safety. Poor quality care is costly to manage from a patient’s and healthcare delivery’s dimensions. As a result, healthcare organizations should heavily invest in strategies that reduce readmissions, complications, and post-procedure rates to acceptable levels.
References
Brunner-La Rocca, H. P., Peden, C. J., Soong, J., Holman, P. A., Bogdanovskaya, M., & Barclay, L. (2020). Reasons for readmission after hospital discharge in patients with chronic diseases—Information from an international dataset. PloS One, 15(6), e0233457. https://doi.org/10.1371/journal.pone.0233457
Centers for Medicare & Medicaid Services. (2020, Feb 11). Quality measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures
Gupta, S., Zengul, F. D., Davlyatov, G. K., & Weech-Maldonado, R. (2019). Reduction in hospitals’ readmission rates: Role of hospital-based skilled nursing facilities. Inquiry : A Journal of Medical Care Organization, Provision and Financing, 56, 46958018817994. https://doi.org/10.1177/0046958018817994
Lim, R. (2019). Multidisciplinary approaches to common surgical problems. Springer Nature.
Merkow, R. P., Shan, Y., Gupta, A. R., Yang, A. D., Sama, P., Schumacher, M., … & Bilimoria, K. Y. (2020). A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals. The Joint Commission Journal on Quality and Patient Safety, 46(10), 558-564. https://doi.org/10.1016/j.jcjq.2020.06.011
Ng-Kamstra, J. S., Arya, S., Greenberg, S. L., Kotagal, M., Arsenault, C., Ljungman, D., … & Shrime, M. G. (2018). Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Global Health, 3(3), e000810. http://dx.doi.org/10.1136/bmjgh-2018-000810
Shah, R. M., Zhang, Q., Chatterjee, S., Cheema, F., Loor, G., Lemaire, S. A., … & Ghanta, R. K. (2019). Incidence, cost, and risk factors for readmission after coronary artery bypass grafting. The Annals of Thoracic Surgery, 107(6), 1782-1789. https://doi.org/10.1016/j.athoracsur.2018.10.077
SLC Health Saint Joseph. (2021). Our services. https://www.sclhealth.org/locations/saint-joseph-hospital/
Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission Rates and Their Impact on Hospital Financial Performance: A Study of Washington Hospitals. Inquiry : A Journal Of Medical Care Organization, Provision and Financing, 56, 46958019860386. https://doi.org/10.1177/0046958019860386
Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W. W. (2019). Strategies to Reduce Hospital Readmission Rates in a Non-Medicaid-Expansion State. Perspectives in Health Information Management, 16(Summer), 1a. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669363/
