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Best Practices

Created on October 03, 2017

“Insanity is doing things the way we’ve always done them and expecting different results.”
Albert Einstein

Unplanned emergency department visits is a priority indicator for the QIP. This indicator provides information on the percentage of home care clients with an unplanned, less-urgent emergency department (ED) visit within the first 30 days of discharge from hospital. In Ontario the percentage of ED visits by home care patients has remained fairly steady at 26% during the last six years.

Below are best practices and change ideas for decreasing unplanned, less urgent ED visits from the home care sector. Many of these change ideas are also used for “Reducing Hospital Readmissions”. They are graded according to Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice refer to Health Quality Ontario’s report The Emergency Department Return Visit Quality Program: Results from the First Year. Or browse the interactive table below for a quick summary of how to improve and decreased unplanned ED visits.

  1. Berkman ND, Sheridan SL, Donahue KE, et al. (2011).
    Health Literacy Interventions and Outcomes: An Updated Systematic Review.
    Evidence Report/Technology Assessment No. 199. AHRQ Publication No. 11-E006.
    Rockville (MD): Agency for Healthcare Research and Quality; 2011 Mar.

  2. Blum K., Gottlieb SS. (2014).
    The effect of a randomized trial of home telemonitoring on medical costs, 30-day readmissions, mortality, and health-related quality of life in a cohort of community-dwelling heart failure patients.
    Journal of Cardiac Failure. 20(7): 513 – 521.

  3. Brink P., Partanen L. (2011).
    Emergency Department Use Among End-of-Life home Care Clients.
    Journal of Palliative Care. 27(3): 224 – 228.

  4. Burt S., Berry D., Quackenbush P. (2015).
    Implementation of Transitions in Care and Relationship Based Care to Reduce Preventable Rehospitalizations.
    Home Healthcare Now; 7: 390 – 393.

  5. Chen HF., Calrson E., Popoola T., Suzuki S. (2016).
    The impact of rurality on 30-day preventable readmission, illness severity, and risk of mortality for heart failure medicare home health beneficiaries.
    The Journal of Rural Health; 32: 176 – 187.

  6. Chen HF., Popoola T., Radhakrishnan K., Suzuki S., Homan S. (2015).
    Improving Diabetic Patient Transition to home healthcare: leading risk factors for 30-day readmission.
    American Journal of Managed Care; 21 (6): 440 – 450.

  7. Dhalla I, O’Brien T, Ko F, Laupacis A.
    Toward safer transitions: how can we reduce post-discharge adverse events?
    Healthc Q. 2012 Apr;15(Spec No.): 63-67.

  8. Hayes C, Yousefi V, Wallington T et al.
    Case study of physician leaders in quality and patient safety, and the development of a physician leadership network.
    Healthcare Quarterly. 2010; 13(Sp): 68-73.

  9. Health Quality Ontario.
    Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/analysis-home-care-2016-17-en.pdf

  10. Living a Healthy Life with Chronic Conditions South West Self-management Program.
    South West Self-Management Program Helping People Help Themselves [Internet].
    South West CCAC and South West LHIN; [cited 2012 Dec 19].

  11. Marrelli T. (2010).
    “Take aways” for moving toward prevention: home care can play an important role.
    Home Healthcare Nursing. 28(8): 453 – 455.

  12. Means A., Werneke C., Paquin T., Greenberg EL. (2016).
    Partnering with the ED Improving Home healthcare referrals to reduce hospitalizations and Repeat Emergency Visits.
    Home Healthcare Now; 34 (3): 165 – 167.

  13. Mierdel S., Owen K. (2015).
    Telehomecare Reduces ER Use and Hospitalizations at William Osler Health System.
    Studies in Health Technology & Informatics. 209 : 102 – 108.

  14. Morris JN., Howard EP., Steel K., Schreiber R., Fries BE., Lipsitz LA., Goldman B. (2014).
    Predicting risk of hospital and emergency department use for home care elderly persons through a secondary analysis of cross national data.
    BMC Health Services Research. 14:519.

  15. Neufeld E., Viau KA., Hirdes JP., Warry W. (2016).
    Predictors of frequent emergency department visits among older adults in Ontario using the Resident Assessment Instrument-Home Care.
    Australian Journal of Rural Health. 24(2): 115 – 122.

  16. National Center for Ethics in Health Care.
    “Teach Back” a tool for improving provider-patient communication.
    In focus Topics in Health Care Ethics. 2006 Apr: 1-2.

  17. Newton A, Sarker SJ, Parfitt A, Henderson K, Jaye P, Drake N.
    Individual care plans can reduce hospital admission rate for patients who frequently attend the emergency department.
    Emerg Med J. 2011;28(8): 654-57. A

  18. Ontario Health Technology Advisory Committee.
    OHTAC Recommendation: Impact of Advanced (Open) Access Scheduling of Patients with Chronic Diseases (Draft).
    Toronto: Health Quality Ontario; 2012 Aug.

  19. Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E.
    How-to-Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations.
    Cambridge (MA): Institute for Healthcare Improvement; 2012 June.

  20. Rosenberg T. (2012).
    Acute hospital use, nursing home placement, and mortality in a frail community dwelling cohort managed with Primary Integrated Interdisciplinary Elder Care at Home.
    Journal of the American Geriatrics Society. 60(7): 1340 – 1346.

  21. Schoonover H., Corbett CF., Weeks DL., Wilson MN., Setter SM. (2014).
    Predicting potential postdischarge adverse drug events in 30 day unplanned hospital readmission from medication regimen complexity.
    Journal of patient safety. 10(4): 186 – 191.

  22. Seow H., Barbera L., Pataky R., et al. (2016).
    Does Increasing Home Care Nursing Reduce Emergency Department Visits at End of Life?
    A Population Based Cohort Study of Cancer Decedents. Journal of Pain & Symptom Management. 51(2): 204 – 212.

  23. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL.
    Discharge planning from hospital to home.
    Cochrane Database Syst Rev. 2013 Jan 31;1:CD000313.

  24. Sinn CL., Tran J., Pauley T., Hirdes J. (2016).
    Predicting adverse outcomes after discharge from complex continuing care hospital settings to the community.
    Professional Case Management; 21 (3): 127 – 136.

  25. Tenetti ME., Charpentier P., Gottschalk M., Baker DI. (2012).
    Effect of a restorative model of posthospital home care on hospital readmissions.
    Journal of the American Geriatrics Society. 60(8): 1521 – 1526.

  26. Tung TK., Kaufmann JA., Tanner E. (2012).
    The effect of nurse practitioner practice in home care on emergency department visits for homebound older adult patients: an exploratory pilot study.
    Home Healthcare Nursing. 30(6): 366 -371.

  27. van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, Austin PC, Forster AJ.
    Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community.
    CMAJ. 2010 Apr 6;182(6):551-57.

  28. Wood SL. (2015).
    A Home Visit Checklist to Reduce Rehospitalisation.
    Home Healthcare Now; 33 (8): 431 – 436.

  29. Woods LW., Snow SW. (2013).
    The impact of telehealth monitoring on acute care hospitalization rates and emergency department visit rates for patients using home health skilled nursing care.
    Home Healthcare Nursing. 31(1): 39 – 45.

Measurement

Created on October 03, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Unplanned emergency department visits
Topic Readmission
Quality Dimension Effective
Type of Indicator Process
Measure Percentage (%)
Data Source Discharge Abstract Database (DAD), Home Care Database (HCD), National Ambulatory Care Reporting System (NACRS)
Data Collection Instrument Collected by Health Shared Services Ontario (formerly the Ontario Association of Community Care Access Centres (OACCAC))
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of adult home care clients who had an ED visit assessed at Canadian Triage and Acuity Scale levels 4 or 5 (but who were not admitted to hospital) in the first 30 days after hospital discharge.

Denominator: # of total adult CCAC home care clients discharged from a hospital.

Target Lower is better
Range 0 – 100%
HQO Reporting Tool Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Background

Created on October 03, 2017

Issue

In 2014/15, people in Ontario made approximately 5.9 million visits as patients to emergency departments (HQO 2016; HQO 2015). The majority of people in Ontario appear satisfied with the emergency care they receive, Ontarians are spending less time in Ontario’s emergency departments and seeing emergency doctors more quickly than in previous years (HQO, 2016; HQO 2015). A mix of sociodemographic and clinical characteristics, rather than disease diagnoses are the main drivers for the visits we are seeing (Neufeld et al., 2016). In 2014/2015 26.3% of ED visits were unplanned less urgent visits by home care patients (Figure 1).

FIGURE 1: Percentage of emergency visits by home care patients in Ontario, 2006/07 to 2014/15 - Overall

Data source: Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS), Registered Persons Database (RPDB), Home Care Database (HCD), provided by the Institute for Clinical Evaluative Sciences (ICES).

Considering unplanned ED visits based on Local Health Integration Networks (LHINs) we see that most LHINs are within the provincial range or lower. However, there are a few LHINs in the north and central areas that are above the provincial average (Figure 2).

FIGURE 1: Percentage of emergency visits by home care patients in Ontario, by LHIN region, (2014/15) - Overall

Data source: Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS), Registered Persons Database (RPDB), Home Care Database (HCD), provided by the Institute for Clinical Evaluative Sciences (ICES).


Call to Action

Despite the success of keeping unplanned, less urgent ED visits fairly stable, emergency departments are still under a great deal of pressure. Factors such as the ageing population, difficulty in securing same / next day primary care appointments and patients coming in sicker than before puts extra pressure on emergency departments. Thus, reducing or even attempting to eliminate unplanned, less-urgent emergency department (ED) visit within the first 30 days of discharge from hospital would greatly reduce the stress on the ED and help keep patients at home (HQO 2016; Neufeld et al. 2016; Seow et al., 2016).

  1. Health Quality Ontario (HQO).
    Under Pressure Emergency Department Performance in Ontario.
    Queens Printer for Ontario. 2016, Toronto ON.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/system-performance/under-pressure-report-en.pdf

  2. Health Quality Ontario.
    The Common Quality Agenda 2015 Measuring Up A yearly report on how Ontario’s health system is performing.
    Toronto: Health Quality Ontario 2015.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2015-en.pdf

  3. Neufeld E., Viau KA., Hirdes JP., Warry W. (2016).
    Predictors of frequent emergency department visits among older adults in Ontario using the Resident Assessment Instrument-Home Care.
    Australian Journal of Rural Health. 24(2): 115 – 122.

  4. Seow H., Barbera L., Pataky R., et al. (2016).
    Does Increasing Home Care Nursing Reduce Emergency Department Visits at End of Life?
    A Population Based Cohort Study of Cancer Decedents. Journal of Pain & Symptom Management. 51(2): 204 – 212.