Pulse Report

Pulse Report

2009 Home Care Patient Perspectives on American Health Care

®

Executive Summary Home health care and hospice play critical roles in the continuum of American health care. Some 17,000 providers care for nearly eight million people who have acute illness, long-term health conditions, permanent disability, or terminal illness—at an annual cost of nearly $60 billion. Numerous studies have pointed to home health as a lower-cost alternative to nursing home care and to its advantage in allowing patients to live more independent lives, closer to family and friends. These services today are undergoing some profound changes. Starting in January, home care agencies will begin reporting patient satisfaction data to the Centers for Medicare and Medicaid Services through the Home Healthcare Consumer Assessment of Providers and Systems survey; by April 1 that data will be publicly reported. Those agencies that fail to report will lose 2 percent of their Medicare reimbursement. The CMS requires agencies to use an approved vendor to administer the survey and report the data. Already, home care agencies publicly report quality-of-care data, but one of the major health care reform bills being considered in Congress this fall would include home care and hospice in value-based purchasing. That means that a certain percentage of payment would be based on scores received for quality of care and HH-CAHPS. Private payers are also looking at pay-for-performance models for home health and hospice care. Payment is already being reassessed. Two of the major health reform plans call for payment reductions to both home health and hospice in the coming years. The CMS proposed a 2.2 percent market basket increase for 2010, but other payment policy changes would result in a net decrease in Medicare funding to home health agencies next year of $100 million. The president’s budget plan calls for annual cuts to home health providers totaling $37 billion over ten years. Given these changes, it is more important than ever for health care leaders to listen to their patients’ voices. Those organizations that provide high-quality care and service will fare much better in this new climate, providing them with a proven and marketable advantage in the marketplace. Press Ganey data show that patients give consistently high ratings to their home care providers, but significant opportunities for improvement remain. Patients want their administrative concerns addressed professionally and quickly, and also express desire for more of their emotional needs to be met. These research findings are a part of a series of Press Ganey Pulse Reports and Check-Up Reports being released throughout 2009. These reports examine the status of health care quality across different care settings and from different perspectives. Their findings and observations highlight the progress being made in the face of today’s challenging health care landscape, call for some needed change, and explore the path to improving the quality of health care in the United States.

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Contents Section I. Home Health Care Trend in Patient Satisfaction with Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Top Priorities for Home Health Care Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Patient Satisfaction by Survey Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Patient Satisfaction by Provider Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Nursing Care: A Closer Look . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Patient Satisfaction by Time of Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Patient Satisfaction by Length of Time Using Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Patient Satisfaction by Insurance Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Patient Comments Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Section II. Home Medical Equipment Trend in Patient Satisfaction with Home Medical Equipment Companies . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Top Priorities for Home Medical Equipment Companies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Patient Satisfaction by Aspect of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Patient Satisfaction by Length of Time Using Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Section III. Hospice Trend in Hospice Patient Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Top Priorities for Hospice Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Patient Satisfaction by Aspect of Hospice Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 About Press Ganey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Trend in Patient Satisfaction

with Home Health Care

Overall, patients are reporting high levels of satisfaction with the care that they are receiving from their home health agencies. This is encouraging given the fact that the number of people receiving home care in the coming years is expected to increase substantially. Patient satisfaction scores among Press Ganey home health clients increased steadily in the first half of 2008. There was a slight drop in the overall mean score in the fall, which may be attributable to a revision of the Press Ganey Home Health Survey.

Five-Year Trend in Home Health Care Satisfaction

Overall Satisfaction Score

90.5

90.0

89.5

Jul-08

Sep-08

Mar-08

May-08

Jan-08

Nov-07

Jul-07

Sep-07

May-07

Jan-07

Mar-07

Nov-06

Jul-06

Sep-06

Mar-06

May-06

Jan-06

Nov-05

Jul-05

Sep-05

May-05

Jan-05

Mar-05

Nov-04

Jul-04

Sep-04

Mar-04

May-04

Jan-04

89.0

Home Care Patients Are Talking “ If this survey went higher than a ‘5,’ there wouldn’t be a number high enough for me to mark! I miss them now that my allotted time is up, but feel I could contact them if I needed to. I would welcome any one of them into my home again, as friends. AND I THANK YOU!”

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Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Top Priorities for

Home Health Care Agencies

The national priority index is a reflection of both what is most important to patients, as well as where agencies have the most room for improvement. In 2008, the top priority item was “How well office staff handled your request to change nurses or aides.” Patients want to know that their input is valued and that the agency is taking their requests to change aides or nurses seriously. Similarly, there were two other items ranked high by patients related to the responsiveness of the office staff to complaints and emergencies. Another item that made the priority index this year was “How well staff addressed emotional needs.” Patients have a host of emotional needs, in addition to their physical needs, that need to be considered. Ranking fourth on the priority index this year is “Overall improvement in well-being.” One strategy to improve patients’ wellbeing is for the clinical staff members to remind patients of the progress they are making. While improvement may not be dramatic, it may help to point out some of the smaller milestones that patients are meeting in their care so that they realize that they are improving.

National Home Health Care Priority Index Survey Items are correlated to patient ratings of "Likelihood of your Recommending this home health agency to others" Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

Survey Item Request change nurse/aide handled Staff addressed emotional needs Office dealt with problem/complaint Overall improvement in well-being Office handled emergencies

Mean 86.9 89.2 87.1 89.9 88.2

Correlation 0.643 0.657 0.615 0.712 0.621

Priority Rank 1 2 3 4 5

Home Care Patients Are Talking “ When I needed real help it took too long for a response.” “ I feel that my mother and my family received sub-optimal care in this area and lack of support and help. No evidence of caring on her part. I am very disappointed.”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Patient Satisfaction

by Survey Section

Consistent with findings from previous years, the highest standard section score is the Nursing section. Patients are very satisfied with the care they are receiving from their home health nurses. This is likely due to the opportunity that patients have to develop personal relationships with their nurses, which is reflected in the patients’ written comments. The section with the lowest score is “Managing Your Home Health Care.” As discussed with the priority items, one of the common threads in this section is responsiveness. Patients want their voices to be heard, and they want to know that agency staff will act on their complaints and requests. A challenge for home health agencies is to improve policies and procedures for responding to patient needs and ensuring staff have the means to do so.

Home Health Care Patient Satisfaction by Survey Section Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

94.0

Overall Patient Satisfaction

93.0 92.0 91.0 90.0 89.0

93.0

92.2

88.0 87.0

89.9

89.5

86.0

87.5

85.0 84.0

Arranging Your Home Health Care Section

Managing Your Home Health Care Section

Nurses Section

Personal Issues

Overall Ratings

Section

Home Care Patients Are Talking “ My experience with my visiting nurse was a very pleasant one. She was always very thorough and never left me with questions. She is an asset to your home health care agency. Thank you!” “ The nurse changed the day of the visit without informing me or calling my family. Also, she was late for appointments and didn’t call to inform me of delays.”

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© 2009 by Press Ganey Associates, Inc.

Patient Satisfaction

by Provider Type

With the revision of Press Ganey’s home health survey this year, the only section pertaining to a particular provider type that remained standard was the nurses’ section. In addition to this standard section, six optional custom sections were created to ask patients to rate the various types of providers. Agencies were instructed to only include the provider sections that were relevant to their patients. The provider type with the highest scores in 2008 is physical therapists. Nurses had the second highest score, while companions/home-makers received the lowest scores.

Home Health Care Patient Satisfaction by Provider Type Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

Overall Patient Satisfaction

94.0

93.0

92.0

91.0

90.0

93.6 92.9 92.2

89.0

90.8

90.6 89.9

89.6

88.0

87.0 Nurses

Physical Therapists

Home Health Aides

Social Services

Companion/ Homemaker

Occupational Therapists

Speech Therapists

Provider Type

Home Care Patients Are Talking “ This support came at an extremely emotional time and the team provided much needed information and skill. As the spouse, I felt abandoned and alone. Your team made it possible for me to see light at the end of the tunnel.”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Nursing Care:

A Closer Look

Home health nurses are effectively demonstrating concern for their patients’ comfort. Other items in the nurses’ section with high mean scores are “Skill of nurses” and “Concern for privacy.” Patients feel that they are in good hands with the nurses who are providing their care and that the nurses are being respectful of their privacy. Again, with the care being provided in the patient’s home, nurses and other staff are successfully navigating the boundaries that patients are comfortable with. Among the lowest scoring items is “Nurse concern to contact you if he or she would be coming late or cannot make the appointment.” This item has more to do with effective communication than timeliness. Patients want their home care team to arrive on time; but just as important, they want to be notified if there is a change in the schedule. Contacting a patient about an upcoming delay or change demonstrates that nurses respect the patient’s time. Two other low scoring items are, “Nurses taught self-care” and “Paid attention to own ideas.” Patients want to be involved in their care. Learning how to take care of oneself and having input in the care plan gives a patient back some of the control they may have lost as a result of illness or injury. Including the patient as part of the care team is an integral component of providing patient-centered care.

Home Health Care Patient Satisfaction with Nursing Staff Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

94.5

Overall Patient Satisfaction

94.0

93.5

93.0

92.5

92.0

94.2 93.8

93.7

92.7

91.5

92.3

92.2

92.0

91.0

90.5 Nurse concern for privacy

Nurse concern for comfort

Skill of the nurses

Nurse attention to own ideas

Nurses taught self-care

Nurse contact if late/can’t make it

Nurse sensitivity to challenges

Survey Item

Home Care Patients Are Talking “ Sometimes the nurse doesn’t listen to me. It makes me feel bad.” “ Having the visiting nurse helped ensure everything was good (after breast surgery) in between seeing the surgeon. This way, if there is a problem, someone knowledgeable is answering my questions before there is a serious situation. Thank you—your services were greatly appreciated.”

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Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Patient Satisfaction

by Time of Visit

As in past years, there is a general trend of declining patient satisfaction throughout the day, with the highest patient satisfaction scores occurring for morning visits (between 6:00 a.m. and 10:00 a.m.) and the lowest satisfaction occurring for late afternoon appointments (after 4:00 p.m.). There are numerous potential explanations for this finding. For example, delays may be more likely to occur as the day progresses. As we see in the chart below, nearly a quarter of all visits occur within the morning hours, whereas only 3 percent of all visits take place after 4:00 p.m.

Home Health Care Patient Satisfaction by Time of Nurse Visit Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008. 92.0

Overall Patient Satisfaction

91.5 91.0 90.5 90.0 89.5 89.0

91.5

91.5 90.6

88.5

90.1

90.1

88.0 87.5

88.5

87.0 86.5 6:00am - 8:00am

8:01am - 10:00am

10:01am - Noon

12:01pm - 2:00pm

2:01pm - 4:00pm

After 4:00pm

Time of Visit

Home Care Patients Are Talking

Home Health Care Most Frequent Times of Nurse Visit Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

3% 1%

“ Aid was always late or did not arrive at all. Not reliable.”

6:00am - 8:00am

13% 23%

8:01am - 10:00am

“ They call before they come and always think about the patient’s time.”

10:01am - Noon 12:01pm - 2:00pm 23%

2:01pm - 4:00pm After 4:00pm

37%

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Patient Satisfaction by

Length of Time Using Services

Consistent with findings from previous years, patients who have received home health services for the shortest amount of time (0-3 months) are the most satisfied. While the relationship between time using services and satisfaction is not perfectly linear, in general, satisfaction declines the longer the patient receives services. Some patients who only receive care for a short time may be healthier and more independent than those receiving care for longer periods. That we’re observing this trend again in 2008 is a reminder for home health agencies to strategize about how to improve the care experience for their longer-term patients.

Home Health Care Satisfaction by Lenth of Time Using Services Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

91.0

Overall Patient Satisfaction

90.8 90.6 90.4 90.2 90.0 89.8

90.7

89.6

90.3 90.0

89.4

89.7

89.2

89.5

89.0 88.8 0-3

4-6

7-9

10 - 12

13 +

Number of Months Using Services

Home Care Patients Are Talking “ The aid I have had for the last year is extremely competent, helpful, pleasant personality, and very hard working. I’d be lost without her. She is so faithful to her duties.” “ You have excellent physical therapists. The one I had three years ago was very good, and so was this one. I have been able to get back to my old self sooner than family and friends expected. I even surprised myself.”

8

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Patient Satisfaction

by Insurance Type

Consistent with previous years, patients with Medicare, HMO, or private insurance were among the most satisfied with their care. Those with Medicaid and private pay arrangements were less satisfied. Some of the differences in satisfaction may be attributed to differences in patient demographics among each of the groups. Also, private pay patients may be more critical of care since they are paying for it out of pocket.

Home Health Care Satisfaction by Insurance Type Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

Overall Patient Satisfaction

91.5

91.0

90.5

90.0

89.5 90.9

91.1

91.0

89.0

88.5

89.3 88.9

88.0

87.5 Medicare

HMO

Medicaid

Insurance

Private Pay

Insurance Type

Home Care Patients Are Talking “ I was treated with kindness and understanding of my problems. I was encouraged to do more to help myself and shown how to do it. I would highly recommend your services for post-op care. Thank you.” “ My aide and I are like a family. She is so caring and helps me out so much!”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Patient Comments Analysis Given the high patient satisfaction scores observed among Press Ganey’s home health agency clients, it is not surprising that the majority (67.3 percent) of comments made by patients were positive. A common theme of the positive comments is the close, personal relationship with the clinical staff. Neutral comments (19.6 percent) are sometimes about the patient’s health or personal circumstances. Fewer negative comments (9.1 percent) demonstrate that, overall, patients are relatively satisfied with their care. The negative comments tended to reflect frustrations with poor communication and disappointment in specific aspects of care.

Home Health Care Distribution of Comments Represents the experiences of 106,225 patients treated by 553 agencies nationwide between July 1 and December 31, 2008.

Percent of Total Comments

80.0%

70.0%

60.0%

50.0%

40.0% 67.3%

30.0%

20.0%

10.0%

19.6% 9.1%

0.0% Positive

Negative

4.0%

Mixed

Neutral

Comment Type

Home Care Patients Are Talking “ The last appointment they never called or showed up. They were supposed to call to reschedule and never did.” “ Each one of these ladies was caring and wonderful. They really helped me get beyond my pain and move forward. My recovery really was made easier by each of them.”

10

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Trend in Patient Satisfaction

with Home Medical Equipment Companies

There was modest improvement in patient satisfaction among Press Ganey home medical equipment clients for the first half of 2008. This is encouraging given the decline in scores that was observed in 2007. However, the improvement did not continue into the end of the period. Home medical equipment companies will need to continue to focus on quality improvement initiatives in order to produce consistent, lasting changes in satisfaction scores.

Five-Year Trend in Home Medical Equipment Satisfaction 89.5

Overall Satisfaction Score

89.0 88.5 88.0 87.5 87.0 86.5 86.0 85.5

Jul-08

Sep-08

Mar-08

May-08

Jan-08

Sep-07

Nov-07

Jul-07

Mar-07

May-07

Jan-07

Nov-06

Jul-06

Sep-06

May-06

Jan-06

Mar-06

Nov-05

Jul-05

Sep-05

May-05

Jan-05

Mar-05

Nov-04

Jul-04

Sep-04

May-04

Jan-04

Mar-04

85.0

Home Care Patients Are Talking “ The equipment was just what we needed and helped us do things on our own. I would recommend your agency to anyone and would use you again.”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Top Priorities for

Home Medical Equipment Companies

In 2008, results revealed seven priority areas for home medical equipment companies. These items are reflective of what patients consider both most important to their overall satisfaction, as well as the areas in most need of improvement. The 2008 priority items had two major themes. First, companies should be focusing improvement efforts on staff responsiveness and communication. Patients seek information about their rights, want notification of schedule changes, and expect efficient and timely resolution to complaints. The second major theme in this year’s priority index is billing. Patients are clearly indicating that they have questions about how billing works and who they need to contact when they have questions.

National Home Medical Equipment Priority Index Survey Items are correlated to patient ratings of "Likelihood of your Recommending this home medical equipment companies to others" Represents the experiences of 100,591 patients treated by 70 companies nationwide between January 1 and December 31, 2008. Survey Item

Mean

Correlation

Priority Rank

Agency handling of complaints about services or equipment Responsiveness of personnel if you have billing concerns/questions Explanation of how/whom to contact with questions Likelihood of receiving an accurate bill Explanation of your rights and responsibilities

80.5 81.4 80.4 80.3 77.6

0.842 0.700 0.680 0.674 0.629

1 2 3 4 5

Home Care Patients Are Talking “ No one has yet to explain to me what my financial responsibility is for the equipment.”

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Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Patient Satisfaction

by Aspect of Service

Of all of the standard aspects of home medical equipment service that patients are asked to assess, “Use of equipment” was most favorably rated, with a mean score of 90. Consistent with the findings from the priority items, patients are least satisfied with the billing process. In fact, the mean score for this section is 79.8, which has a detrimental effect on the overall mean score for companies nationwide. In addition to billing, patients also seem to be least satisfied with “Arranging for equipment.” If companies were to work on improving their scores in these two areas, their overall mean scores could improve significantly over time.

Home Medical Equipment Satisfaction by Section Represents the experiences of 100,591 patients treated by 70 companies nationwide between January 1 and December 31, 2008. 92.0

Overall Patient Satisfaction

90.0 88.0 86.0 84.0 82.0

90.0 87.6

80.0 78.0

85.6

84.8

81.6 79.8

76.0 74.0 Arranging for Equipment Section

Delivery of Equipment Section

Use of Equipment Section

Billing Section

Clinical Staff Section

Final Ratings Section

Survey Section

Home Care Patients Are Talking “ I was impressed by the fact that fifteen minutes after leaving the doctor’s office your company was confirming the delivery of the equipment. Outstanding customer service!”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Patient Satisfaction by

Length of Time Using Services

There is variation in terms of how long patients will need to use home medical equipment services. The majority of the patients (58 percent) surveyed by their home medical equipment company in 2008 had been receiving services for zero to five weeks. However, the second most common (22 percent) length of time that patients had been receiving services was twenty weeks or more. Patients who received services for less time tended to be more satisfied than long-term patients. There is a full point drop in scores for patients who need services for eleven to fifteen weeks, and another dip in scores for patients who need services for sixteen to twenty weeks. It does appear, however, that the downward trend levels off for patients who had services for more than twenty weeks.

Home Medical Equipment Satisfaction by Weeks Using Represents the experiences of 100,591 patients treated by 70 companies nationwide between January 1 and December 31, 2008.

Overall Patient Satisfaction

87.5

87.0

86.5

86.0 87.1

87.2

85.5 86.2

86.0 85.7

85.0

84.5 0-5

6 - 10

11 - 15

16 - 20

20 or More

Number of Weeks Using Equipment

Home Medical Equipment Number of Weeks Using Equipment Represents the experiences of 100,591 patients treated by 70 companies nationwide between January 1 and December 31, 2008.

22%

0 - 5 weeks 6 - 10 weeks 2%

11 - 15 weeks

4%

16 - 20 weeks 20 or More weeks 14%

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Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

Home Care Patients Are Talking “ (The) person who delivered equipment was knowledgeable, helpful, understanding, and patient. I was scared, and she made me feel much more comfortable.”

Trend in Hospice Patient Satisfaction In 2008, patients and their families remained very satisfied with their hospice care. Satisfaction began to rise and then leveled off towards the end of the year. The consistently high levels of satisfaction among patients and their families is a testament to the excellent quality of care that is being provided by hospice providers around the country.

Five-Year Trend in Hospice Satisfaction 89.5

Overall Satisfaction Score

89.0 88.5 88.0 87.5 87.0 86.5 86.0 85.5

Jul-08

Sep-08

May-08

Jan-08

Mar-08

Nov-07

Jul-07

Sep-07

Mar-07

May-07

Jan-07

Sep-06

Nov-06

Jul-06

May-06

Jan-06

Mar-06

Nov-05

Jul-05

Sep-05

May-05

Jan-05

Mar-05

Nov-04

Jul-04

Sep-04

May-04

Jan-04

Mar-04

85.0

Home Care Patients Are Talking “ We were constantly informed of any changes. Hospice team was like family. My aunt enjoyed the last days of her life. Who could ask for more?”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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Top Priorities for

Hospice Agencies

The top priorities for hospice clients in 2008 are similar to the priorities identified in the other realms of home care in this report. The top priority item for hospice patients is, “How well we handled your request to change nurses or aides.” When patients feel vulnerable, they want to feel comfortable with their caregiver, and they want to know that their request to change nurses is being taken care of. Similarly, as the other top priority items show, hospice patients, like other patients in home care, are asking for improvements in responsiveness to requests, questions, and emergencies. Also, because families are an integral part of the hospice experience, it is imperative that they be involved and kept current about their loved ones’ conditions.

National Hospice Care Priority Index Survey Items are correlated to patient ratings of "Likelihood of your Recommending this hospice service to others" Represents the experiences of 20,810 patients treated by 108 facilities nationwide between January 1 and December 31, 2008. Survey Item

Mean Correlation Priority Rank

How well Home Care handled your request to change nurses or aides How well the office dealt with your problems and complaints How well Home Care handled emergencies Staff's concern to keep your family informed about your treatment, condition or progress How easy it was to get the visiting schedule changed

86.6 86.8 88.0 89.9 87.4

0.639 0.626 0.626 0.704 0.609

1 2 3 4 5

Home Care Patients Are Talking “ Everyone associated with my wife’s care during hospice could not have been more caring and loving towards her. I could not have imagined what I would have done without them. THANK YOU!”

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© 2009 by Press Ganey Associates, Inc.

Patient Satisfaction

by Aspect of Hospice Care

Again, patients and their families are highly satisfied across all aspects of hospice care. In particular, the highest mean scores are observed in the Overall Assessment section and the Hospice Teams Section. Patients often receive care and services from nurses, spiritual leaders, social workers, and others. Each member of the team brings something of value to the patient and family. Clearly, the hospice team is successfully meeting patients’ and families’ diverse needs.

Hospice Satisfaction by Section Represents the experiences of 20,810 patients treated by 108 facilities nationwide between January 1 and December 31, 2008.

95.0

Overall Patient Satisfaction

94.5

94.0

93.5

93.0 94.5 92.5

92.0

94.0

93.1

93.0 92.2

91.5

91.0 Arranging Hospice Care Section

Dealing with the Hospice Office Section

Hospice Teams Section

Personal Issues Section

Overall Assessment Section

Survey Section

Home Care Patients Are Talking “ I appreciate the entire hospice staff so much. They helped our family member have a controlled and dignified, pain-free death, which is so important to the whole family.”

Home Care Pulse Report

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© 2009 by Press Ganey Associates, Inc.

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A Community Health Agency’s

Continuous Quality Improvement Campaign

Home Nursing Agency, a provider of home health, hospice, behavioral health, and other community health programs in central Pennsylvania, has found improvement in the nexus of employee and patient satisfaction and quality of care. At a strategic planning meeting in 2007, agency leaders looked at patient satisfaction scores and realized more needed to be done from a care-coordination perspective. Patients were reporting that too many nurses were handling their cases and not enough communication was taking place. With an average daily home health census of 1,400 patients, that was perhaps unsurprising, but the finding exposed a problem to be solved. The agency’s response is an organization-wide Continuity of Care educational program, the core of which is ensuring that patients are aware of the staff’s sensitivity to meeting or even exceeding their needs. Working with Press Ganey, the agency found that the problem really wasn’t the number of nurses serving a given patient. “It’s about communication and the patient’s perception of how we are handling this episode of care from initial contact onward,” says Celeste Twardon, senior vice president of quality and chief clinical officer for the Pennsylvania-based agency headquartered in Altoona. The educational program was built on data from a decade of patient satisfaction survey data, an employee perspectives survey conducted in 2007, and clinical outcomes. “Our main concept was to have our staff understand the need to manage the entire patient experience by utilizing effective communication skills, being very sensitive to the needs of the patient, and then effectively using resources, which is the number of staff in the home,” Twardon says. Leaders of the agency educated staff on how this holistic approach to the patient experience adheres to each of the agency’s five core principles—leadership, customer satisfaction, employee satisfaction, quality, and profitable growth. Christine Smith, director of customer satisfaction and data integration for Home Nursing Agency, works with staff members on what it means to be sensitive and how to convey that impression through verbal and non-verbal communications. “We wanted to know: What are the words we would be looking at on a patient survey that would speak to sensitivity to patients’ needs,” Smith says. “We also talked about the specific things our clients would expect from us, including understanding, showing empathy, showing care and concern, and listening to them.”

Following the Script Leaders also talked about scripting to standardize the communication techniques that the staff has with the patients and families. “We know that some people converse more easily and convey more warmth than others do,” says Janie Christner, director of home health. This starts with the greeting, in which staff members are expected to introduce themselves by name, and let the patient know they are knowledgeable in that patient’s care needs. “Reassurance is important, and that comes with the greeting,” Christner says. “We’ve had concerns with the patients saying when multiple nurses visited they were unclear who was in charge of their case.” After that, the nurse is to explain what to expect during the visit. Before leaving, the staff member will ask the patient if there is anything more he or she can do on that visit and thank the patient for allowing the agency to take care of them. If it’s a new nurse in the home, staff will let the patient know they have received their report from the case manager, and that they will inform that manager what took place during the visit. This manner of communicating is critical to improving the patient’s perception that their care is coordinated and, at the same time, we are keeping them informed of their progress and treatment. Leaders got an idea from a Press Ganey Partners article (“New Ideas Can Spark Real Change,” September/October 2008, page 8) to hand out M&Ms to employees imprinted with key words of sensitivity to keep the words fresh in their minds and to lighten the education experience.

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Leaders also shared personal mentions from Press Ganey Hot Comments’ reports and direct comments to agency officials where the words they had been talking about—empathy, caring, understanding, and helpfulness—appeared. Negative comments were shared along with the positive. “We wanted the staff to walk in the shoes of the patient,” Twardon says. “It’s not about the skill necessarily; it’s about perception. We could have the same nurse visit the patient every day, but we could still get bad results if that person did not come across as sensitive.” The staff’s commitment to the program was rewarded through the Home Nursing Agency’s existing program, called Staff Working Together to Achieve Results (STAR) program. The program had been based on meeting financial goals, but has now been expanded to include customer satisfaction outcomes. For three years, the goal has been to have at least 85 percent of patient satisfaction survey respondents circle a “5” for “Likelihood to recommend agency services to family and friends” (on a 1-5 scale). The goal was finally met in 2009. That achievement demonstrates a high degree of customer loyalty, as well as the agency’s commitment to its mission of “providing the highest quality of customer service delivered with a sense of warmth, kindness, and individual pride.” Employees clearly took pride in the outcome. Along with high employee satisfaction numbers, the agency—for the sixth consecutive year—was named as a Best Place to Work in Pennsylvania in the large division category. Over the past two years, the agency has also received national recognition from Modern Healthcare as one of the “100 Best Places to Work in Healthcare.” Home Nursing Agency is the only in-home and community-based provider in Pennsylvania nationally ranked in employee satisfaction.

Future challenges With the federal government making administration of the Home Health Consumer Assessment of Healthcare Providers and Systems survey a condition of full reimbursement under Medicare, Home Nursing Agency believes it is ahead of the curve toward improvement. “Still, we need to focus our energies on this,” Twardon says. “We have to continue to improve every aspect of what we do.” Although several health care reform proposals are under consideration, the final version will most likely include methods to revise the home health payment system to more accurately account for the costs related to the role of quality of care incentives and penalties in driving provider and patient behavior. “We’ll have some challenges, but we’ve done our due diligence in quality and performance improvement, and the ROI becomes increasingly evident as we learn more about recommendations to reform the Medicare home care and hospice benefit,” Twardon says. Soon, supervisors will begin onsite evaluations of home health staff and others to ensure they are using the communications skills they have been taught. The effort is being duplicated in hospice and behavioral health. Even clerical staff will be included so they learn about communications skills. “Press Ganey has allowed us to make home health the driving force for the rest of our programs,” Twardon says. “This is how we meet our agency goals.” Case managers will soon have report cards on their performance, including their customer satisfaction data. At this point, leadership wants to ensure the data is accurate and fully understood at the individual manager level. “Once we have this in place, the technology will help aid the review process. Then we’ll feel comfortable giving data to the staff, and we’ll know how to help them improve,” Twardon says. The STAR program will soon have clinical outcomes goals as a basis of the rewards. “Every success we have opens us up to what’s next,” Twardon says. “We’re always looking at how we can make our services better for our customers and employees. Next, we want to know about how we can make this better for our referral sources, including court-appointed customers for behavioral health. The whole process is ongoing; it’s never done.” Home Care Pulse Report

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Methodology

Home Health Care Survey

The Home Health Care survey is used by private duty nursing and traditional home care agencies to improve the quality of their service. Highly valid and reliable, Press Ganey’s survey consists of thirty-eight standard questions in six sections: Background, Arranging Your Care, Managing Your Care, Nurses, Personal Issues, and Overall Ratings. Press Ganey recommends that patients receive their survey after the first month of service.

Home Medical Equipment Survey

The Home Medical Equipment survey is used by providers of home medical equipment, which includes oxygen, wheelchairs, prosthetics, etc. Highly valid and reliable, the survey consists of nineteen standard questions in six sections: Arranging for Equipment, Delivery of Equipment, Use of Equipment, Billing, Clinical Staff, and Final Ratings. Patients using home medical equipment for a short time receive mailed surveys after they have returned the equipment to the agency. Long-term patients receive a survey one month after service begins and every six months thereafter.

Hospice Services Survey

In response to the growing hospice and palliative care movement, Press Ganey developed a tool that can be used to measure satisfaction with end of life care provided in hospice settings. The primary focus of this survey is to measure family satisfaction with hospice services. However, the survey may be used in the following ways: mailed to the primary family member/friend involved in the patient’s care after the patient’s death, mailed to the primary family member/friend involved in the patient’s care while the patient is still receiving hospice services, or mailed to the patient while he or she is still receiving hospice services.

Distribution of Surveys

Surveys are mailed to patients soon after discharge, while their experiences are still fresh in mind. Upon receipt by Press Ganey, completed surveys are processed and added to a national database. Press Ganey complies with the Health Insurance Portability and Accountability Act (HIPAA), which establishes national standards for the security and privacy of health data.

Definition and Calculation of Overall Mean Score

Once surveys are returned to Press Ganey, surveys are processed and added to the client’s electronic data storage area. Processing of surveys takes place immediately so that clients can have up-to-the-minute information about their service quality. Responses to survey questions are converted to a series of 100-point maximum scales so that clients can compare different aspects of their performance on a common yardstick. First, for each person who took the survey, responses to the survey questions are translated from a 5-point scale to the 100-point scale. Items rated “Very Good” are awarded 100 points; those rated “Good,” 75 points; items rated “Fair,” 50 points; “Poor,” 25 points; and any items rated “Very Poor” are awarded zero points. Next, each respondent’s individual item scores within a survey section (see above) are averaged to become scores for each section. Finally, section scores are averaged to become that respondent’s overall satisfaction score. The average of all respondents’ overall satisfaction scores is called the client’s Overall Mean Score, and is stored electronically and made available to the client.

Definition of Correlations

A correlation tells us how much a change in one variable (e.g., an item score) is associated with a concurrent systematic change in another variable (e.g., overall satisfaction). A correlation represents the strength and direction of the relationship between two variables numerically, expressed using a correlation coefficient (called r) which can range from – 1.0 to + 1.0. The greater the distance from 0, the stronger the relationship is between the two correlated items. A positive correlation coefficient indicates that as the value of one variable increases, the value of the other variable also increases. A negative correlation coefficient indicates that as the value of one variable increases, the value of the other variable decreases. It is important to recognize that when two variables are correlated it means that they are related to each other, but it does not necessarily mean that one variable causes the other.

Priority Index Calculation

The Priority Index is an ordered list of survey items that shows the areas needing the most improvement. In the Priority Index, survey items are arranged from the “first item to work on” to the “last item to work on.” The Priority Index reflects service issues that clients are performing relatively poorly on that are important to their patients. The index is calculated by looking at two aspects of each survey item’s data: its average score, and how well it mirrors the respondent’s overall satisfaction score, as determined above. Survey items that have low average scores (indicating that the facility’s quality for that aspect of care is lacking relative to other care aspects) and faithfully mirror the respondent’s overall satisfaction score will have high Priority Index scores.

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About Press Ganey

For more than 20 years, Press Ganey has been committed to providing insightful information that allows our more than 7,000 health care client facilities to continuously improve their performance. Our foundation for success is built upon dedication to scientific integrity, relentless responsiveness to our clients’ changing requirements, and an overall passion for helping our clients succeed. By pursuing and acting upon input from our clients, we are consistently able to develop and deliver the newest innovations. We continue to succeed by exchanging knowledge with our clients, and facilitating the exchange of knowledge between our clients. With more than 11 million surveys processed annually, Press Ganey has the most extensive data and resources for improving patient satisfaction, employee engagement, physician engagement, and patient safety. Press Ganey’s tools and services—measurement tools, consulting services, networking opportunities, and solutions for improvement—use patient, employee, and physician feedback to drive health care improvement initiatives. All data and findings represent surveys returned by patients, physicians, and employees to Press Ganey clients.

Contact information for questions or concerns: Abby Szklarek Public Relations Manager 404 Columbia Place South Bend, IN 46601 (800) 232-8032 [email protected] www.pressganey.com Press Ganey gives acknowledgment and thanks to the following individuals who contributed to this report: Natalie Beasley, Marketing Manager, Home Health Kelly Biscuso, Senior Research Analyst Lisa Cone-Swartz, Vice President, Home Health Business Unit Deanna Garcia, Research Assistant Jennifer Hosey, Research Assistant Cathi Kennedy, Corporate Communications Editor Jessica Langager, Manager, Custom Research Dana Schrader, Research Assistant Todd Sloane, Senior Writer Sarah Stawiski, Independent Research Analyst

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Partners In Improvement® 404 Columbia Place South Bend, IN 46601 800.232.8032 pressganey.com