Strategies for Clinical Excellence in Home Health Care Delivery

A recent webinar - "Strategies for Clinical Excellence" - hosted by Home Health Care News highlighted the challenges faced by HHAs. Homecare Homebase Senior VP for Professional Services, Martha Stuart Williams, and Catherine Frasco, Senior Director for Clinical Operations at VNA Care, headlined the event and discussed how HHAs can adapt and thrive in today's competitive environment. Most agencies are not operating at peak clinical excellence yet, but this roadmap will get you moving in the right direction.


The US health care system is in a state of disruption, with new initiatives like alternative payment models and outcomes measurement challenging providers to deliver a new level of value for consumers while controlling costs. As US health care costs in the US are grow faster than the country's Gross Domestic Product (GDP) the Center for Medicare and Medicaid (CMS) is focused on measuring outcomes and increasing value. Iit expects providers to deliver higher quality of care with better outcomes at lower cost.

That's a tall order, but home health agencies (HHA) must be ready. Home health care is generally much less expensive care model than other options, so HHAs are well-positioned to benefit from the disruption. However, if agencies hope to sit at the value-based table, they must concentrate on improving outcomes, efficiency, and productivity.

Outcomes & Efficiency Drive Patient Satisfaction

To achieve clinical excellence, HHAs have to focus on three major areas: outcomes measurement, process measures, and patient satisfaction. As Frasco noted, these are "so tied together that patient outcomes can truly drive patient satisfaction."

1.  Better Communication = Better Patient Outcomes

Successful outcomes depend on successful care delivery. Patients must feel comfortable with clinicians, and that's easier if clinicians are efficient and supported by HHA schedulers and staff. All stakeholders should communicate well and often.

  • Document in the home: Home documentation paints the most accurate picture of the patient's condition because it's done in the moment, not hours later. However, some patients may be put off by a clinician who seems more interested in entering data into a tablet than keeping a personal focus, so there's a delicate balance.  Make sure clinicians make an effort to engage patients personally - and with eye contact! - during the documentation process.

  • Establish a standard and measure progress: Ideally, HHAs should have a measurement system that provides aggregate measurements for the agency as a whole and for individual clinicians, said Williams.  The productivity tool should help you measure the efficiency of clinicians and give "hard and fast data needed to be able to objectively address an issue." HCHB's "Field Productivity Dashboard" is one effective tool for this process.

  • Be prepared: In home health care, today's work should have started yesterday. Schedulers should provide clinicians with schedules in advance so they can map out the next day's schedule and confirm patient visits. Train clinicians to break down patient resistance to visits; outcomes suffer if you don't provide care. Review charts and patient requests like "knock at the side door" before the visit. Those small personal touches make patients feel respected.

  • Focus on the patient: Treat each patient engagement as unique. Ask detailed and probing questions to collect specific information about the patient's condition. At each visit, review the emergency response plan and make sure the patient can describe steps to take in case of emergency. These "teachback" sessions ensures that patients know what to do in specific situations.

  • Build relationships: People can tell if you're just going through the motions, so engage them on a personal basis. Use their preferred name, know the pet's name, and look for a common connection. Successful clinicians start the visit with some personal discussion before engaging with their device and always ask, "can I do anything else for you?" before leaving.

2.  Track & Improve Operational Efficiency Indicators

Everything runs smoothly, most of the time, in an efficient operation.  When there is a problem, good organizations have processes in place to correct problems and learn from mistakes. Several key indicators of operational efficiency include:

  • Timely admissions: The goal is always same-day admissions because it's better for patients. It's also a great way to differentiate your agency from competitors. A regular "daily huddle" between stakeholders helps communication flow easily through the agency and overcome obstacles that delay care. Track the length of the approval process and time until first visit. Shorter is always better!

  • Clinician productivity: Empower schedulers to manage daily schedules in a manner that keeps clinicians at or near full productivity. Frasco stressed the importance of "clarifying expectations of productivity from the start. Your clinicians can't be successful, and it's hard for your agency to be successful if your clinicians aren't."
  • Top of license staffing: Study how well you're leveraging RNs, LPNs, and other clinicians, during visits. Optimizing those staffers can really drive operational efficiency, but always check state regulations before making any changes. Move slowly: these types of changes require strong leadership and clear expectations.
  • Resolve service breakdowns - and learn from them:  Treat each complaint as an opportunity to improve service. Set up a process that details who addresses complaints and defines a successful resolution.

Frasco emphasized the importance of good communication within the HHA, with other care providers, and with patients. "Poor communication trickles down to patients and referral sources alike."

3. Field Staff Satisfaction & Retention

Patients aren't the only people who need to feel satisfied with your agency.  Clinician burnout is a big impediment to efficiency and job satisfaction. The US Agency for Health Care Research and Quality describes it as a serious problem that affects many health care workers and negatively impacts the quality of care:

"The burned out clinician may develop a sense of cynical detachment from work and view people—especially patients—as objects. Fatigue, exhaustion, and detachment coalesce such that clinicians no longer feel effective at work because they have lost a sense of their ability to contribute meaningfully. In the past few years, the growing prevalence of burnout syndrome among health care personnel has gained attention as a potential threat to health care quality and patient safety."

Work with clinicians to avoid burnout:

  • Be realistic:  Set achievable goals for visits and weight visits to balance caseloads. A "start of care" visit and revisit require different tasks, skills, and time commitment. Ensure that clinicians have reasonable expectations about job requirements (such as on-call weekends and service area size).

  • Optimize caseloads and schedules: Define acceptable caseload size for your agency, keeping in mind that heavier caseloads can lead to burnout. Increase clinicians chances at success by providing schedules in advance so clinicians can plan better and have more control.

  • Be flexible: Many agencies adapt to care volumes with a 75/25 split between full time and part time (or per diem) staff. Be willing to work with individual staffers who are solid employees but may need reduced schedules or more flexibility.  Wouldn't you rather schedule a solid nurse for 32 hours a week than lose her to a competing agency?

Your goal is to make it easier for clinicians to provide good care by maximizing their time in the field. Williams noted:

"Keep your best staff out in the field treating patients. That's what they want to be doing. Not attending meetings, but out doing patient visits. Don't waste their time on paperwork that could be automated."

Frasco concurred. "Everything is derived from patient outcomes. Clinicians need to be out treating patients."

Roadblocks to Achieving Clinical Excellence

In 2005, Wharton business professor Lawrence Hrebiniak identified the top three reasons corporate strategies fail:  "execution, execution, execution." That's because most managers "know a lot about how to decide on a strategy, and very little about how to carry it out."

Williams and Frasco highlighted common roadblocks to clinical excellence and suggested ways to overcome them.

  • Clinicians not on board: Successful change requires a team effort, not a directive from on high, so give clinicians a seat at the table. Meaningful involvement of field staff can be as simple as a survey or involvement in a clinical excellence steering committee. Listen to what clinicians say and let their comments drive solutions.

  • Underestimating the task:  Feedback during the planning process is crucial. Otherwise, you may find that your goals are both complex and conflicting. Be sure to prioritize the value of tasks and concentrate on those that bring the most value.

  • Failure to use a rigorous approach: Thoroughly study your operation to determine what makes sense before beginning a clinical excellence initiative. Identify priorities and plans in advance.

  • Be a leader, not dictator: Model the behaviors you expect from clinicians so they recognize your commitment to and investment in excellence.

Recognize that any solution must be customized to your agency. It can't be a cut and paste approach you heard about at a conference. A project that worked for an electronics manufacturer or restaurant chain can't be transferred directly to home health care, Williams warned:

"The best approach is taking what you learn from other places and then building your own set of goals that align around your culture and your processes".

Five Steps to Clinical Excellence

Think of this process as building a roadmap that defines where you're going, how to get there, and how to know when you've arrived.

  1. Decide to own it. Define what "clinical excellence" means to your organization and describe your vision. Use that vision to establish goals and ensure that everyone in the organization understands them.

  2. Do your homework. Compare today's performance to your goals. Use that as the benchmark to track progress.

  3. Establish performance goals. Remember that change doesn't happen overnight; measure progress within a realistic timeframe. Be specific and align agency goals with clinician goals in the same way that patient goals are aligned with care plans.

  4. Remove the noise. Make sure that departments are pursuing competing initiatives and stay focused on specific goals. Be specific and concise.

  5. Make clinical excellence your top priority. Don't try to do too much at once. Instead, execute 2-3 goals at a time to avoid competing priorities.  Track progress and re-evaluate goals on a regular schedule.  Be transparent about the progress and celebrate even the smallest victories with your team.

Frasco defined clinical excellence as:

"Best in class patient care delivery driven by operational efficiency with the ultimate objective of improving outcomes and driving down the cost of care."

It's crucial that you keep the staff involved and engaged in the process. Success is a team effort; make everyone a partner in improvement. They'll be invested and engaged in the process. Listen to your staff. Take their advice. Support them, and provide feedback.

Let Homecare Homebase help your agency reap the benefits of success that come from improved efficiency, better patient outcomes, and high patient satisfaction. Contact us to learn our cloud-based software can help you increase efficiency, streamline operations, train staff, and monitor the changing regulatory environment.  With our tools, you'll spend less time on administration and more time providing high-quality patient care.