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Learning Scope #409
1 contact hour
Expires Nov. 26, 2014
You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.
Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The goal of this continuing education article is to review the latest information on health risk tools. After reading this article, you will be able to:
- Utilize a health risk assessment tool to identify patients at risk for disease or patients at risk for further progression of their disease processes.
- Implement strategies for developing a collaborative plan of care utilizing the health risk assessment results and best practices.
- Identify available resources and tools for health risk assessments
The author has completed a disclosure form and reports no relationships relevant to the content of this article.
You are the home care nurse assigned to a new patient: a 74-year-old female with a history of hypertension, hypothyroidism and hyperlipidemia. You complete the admission database and start a review-of-systems assessment with the patient. The patient said she feels great and decided to cut back on her blood pressure medication. However, on exam, you note her blood pressure is 160/80, there are lung sounds with crackles in the bases, and she has +2 edema in the lower extremities. What do you suspect is going on? What important interventions will be included in your care plan? What teaching can you employ to help the patient avoid these symptoms in the future?
The health risk assessment is a vital skill necessary for nurses in all settings. The nurse's primary role is to assess patients' knowledge deficits, develop teaching plans and communicate those plans so patients can understand and implement them. Providers benefit from having an empowered healthcare consumer who can participate in the process and a partner to address lifestyle changes that directly affect healthcare status.
In addition, health risk assessment is becoming increasingly important with the recent passage of the Affordable Care Act and its focus on disease prevention and health promotion.
In this article, we will discuss the purpose of health risk assessment and identify interventions for preventing hospitalizations or readmissions for patients in the home care setting. This offering also will provide strategies for designing and implementing a collaborative team with the patient at the center of the care plan.
Where Do We Start?
A health risk assessment is "a systematic approach to collecting information from individuals that identifies risk factors, provides individualized feedback and links the person with at least one intervention to promote health, sustain function and/or prevent disease," according to the CDC.1 Sound familiar? Nursing has used this process for decades to develop a care plan. Therefore, we can start with the nursing process but we also need to add our own critical thinking skills to optimize outcomes.
Next, we need to look at what diseases are associated with modifiable risk factors so we can teach our patients what lifestyle changes can improve their odds of preventing a chronic illness. Lack of physical activity, poor nutrition, tobacco use and excessive alcohol consumption are responsible for much of the illness, suffering and early death related to chronic diseases.1 The top seven diseases associated with 70 percent of deaths in the U.S. are heart disease, cancers, stroke, chronic respiratory diseases, diabetes, Alzheimer's disease and kidney diseases.2 Coupling the information from these statistics can assist the nurse in developing a toolkit that can be used for teaching patients about the most common prevention strategies.
If you are working in the hospital setting, you begin to assess a patient's risk on the admission database, which usually includes past medical history, a family medical history, smoking history, occupation, medication reconciliation, skin assessment, falls risk assessment, depression screening and functional ability screening. All of these are excellent tools to determine if the patient is at risk for injury or skin breakdown.
Tools of the Trade
In the home care setting, patients have an admission database similar to that used in the hospital setting; however, the home care nurse also is assessing the patient's home environment for risks. The assessment includes identifying fall risk issues such as steps, tripping hazards (throw rugs, furniture, clutter, etc.) and any barriers that may inhibit the patient from functioning fully at home.
The most widely used tool used in home care nursing (and also a requirement for Medicare payment) is the Outcome and Assessment Information Set (OASIS) (www.medicare.gov/HomeHealthCompare/Data/Quality-Measures/Risk-Adjustment.aspx).
The OASIS datasets are used for multiple purposes, including calculating risks factors and patient acuity as well as enabling the home health agency to retrieve statistical data geared toward quality and performance improvement.
Other tools useful to identify risk of hospitalization include the Risk-Standardized Readmission Rate (RSRR).3 With this tool, the patient is assessed and receives a risk stratification score. In general, the higher the score, the higher the risk for readmission before 30 days. This focus on 30-day readmission is fueled by decreasing Medicare reimbursements of 1 percent (increasing to 3 percent in FY 2015) for patients readmitted to the hospital following acute myocardial infarction, heart failure or pneumonia. Nationally, 25 percent of heart failure patients, 20 percent of heart attack patients and 18 percent of pneumonia patients are readmitted within 30 days of discharge.4
For registered nurses and advanced practice nurses, the transitional care model can be used to identify patients at risk prior to being discharged from the hospital.5 In this model, the advanced practice nurse works with the patient, family and hospital team to help the patient transition from hospital to home. Once in the home setting, patients are followed by visits, phone calls, support and collaboration with other medical providers on a scheduled timeframe starting within 24 hours of being discharged. This model is highly successful at reducing hospitalization and can be used by RNs in the home care setting as a best practice tool and model for assessing risk.
Nurses on the Home Front
Home care nurses and agencies are on the front lines for preventing hospitalizations and readmissions. To reaffirm the statistics and common risks, ask nurses working on the home front what they see in practice with their patients and you might find parallel statistics and a few common themes. One such nurse is Betsy McLaughlin, BSN, RN, branch manager for the Pennsylvania division of Southeastern Home Health Services.
She and her team of home care nurses are challenged with patients living much longer with complex disease processes and multiple comorbidities. Some of the most common disease processes seen at Southeastern Home Health Services are congestive heart failure, cancer, stroke, diabetes and orthopedic injury related to falls. Home care nurses also experience a great deal of follow-up wound care.
Nurses caring for patients in their homes face new challenges today. For many older adults, home is often in an assisted living facility (ALF), where they may have multiple caregivers. Home care nurses must ensure all caregivers understand the required follow-up care. This may mean teaching or in-servicing several direct care workers for the ALF community.
The Southeastern team uses the Acute Care Hospitalization Tool and the Morse Falls Risk Scale for identifying risk factors.6,7 The Acute Care Hospitalization Tool consists of assessing the patient for age, number of recent hospitalizations, number of co-morbidities and many other factors that may place the patient at high risk. A patient who scores high may require a frontload of skilled nurse visits and a physical and occupational therapy evaluation.
The Morse Falls Risk Scale works similarly where patients are assessed based on how many falls they had in the past 3 months, how many medications they are taking, sensory deficits, and a number of questions that may lead the evaluator to the conclusion the patient is at high risk. Each question has a number value, and higher scores indicate the need for fall precaution implementation.
A Collaborative Approach
Additional resources are helpful to incorporate into the care plan. For example, oncology patients are high risk for malnutrition. Dietician intervention helps the oncology patient deal with the weight loss associated with the side effects of chemotherapy. In addition, it helps the patient feel better while undergoing treatments because patients have more energy if properly nourished.
Social workers also are valuable at identifying additional resources for our patients outside their usual care. The patient described in the introduction decided to cut back on her blood pressure medication, which put her at risk for cerebral vascular accident, kidney failure, retinopathies and congestive heart failure.
Perhaps financial reasons came into play for this decision. The social worker would help identify resources available for those who may not be able to afford their medications; non-compliance with medication is a frequent cause of hospitalizations and readmissions. In addition, social workers also can identify additional resources to help homebound patients with transportation needed for early follow-up care to their physician. In the case of a referral, the primary care provider will be notified of all findings and recommendations for a care plan. The provider would then manage the patient based on recommendations set forth.
Another example of a collaborative approach at Southeastern Home Health Services is a program for patients who have a history of or are at high risk for congestive heart failure. The team works with patients in the home setting utilizing telemonitoring devices that can measure and report blood pressure readings and weight to determine early onset congestive heart failure.
Nurses notify providers and adjustments of diuretics usually can prevent exacerbation of symptoms. They also use a "teach-back" method to help patients self-manage their congestive heart failure. Patients are given specific instructions then demonstrate for the nurse what they have just learned. As a result, the heart failure team has reduced heart failure readmission rates to below the national standard.
The nurse in the home setting plays an instrumental role in reducing the occurrence of hospitalizations and readmissions. The nurse empowers patients by teaching them about their disease process and assisting them to take control of their own health. Many tools and applications can assist the nurse in assessing and identifying risk factors that can potentially cause further progression of disease or a hospitalization.
Therefore, preventive home care services become a win-win situation. Patients benefit from not being hospitalized and the healthcare community benefits by having fewer costs associated with hospitalizations and readmissions. The ultimate result is an empowered and informed patient population.
1. CDC. (2010). Health risk appraisals. Retrieved Nov. 20, 2012 from the World Wide Web: http://www.cdc.gov/nccdphp/dnpao/hwi/programdesign/health_risk_appraisals.htm
2. National Center for Health Statistics. (2012). Tools for performing a health risk assessment. Retrieved Nov. 20, 2012 from the World Wide Web: http://www.cdc.gov/nchs
3. National Quality Measures Clearinghouse. (2012). Heart failure (HF): Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following HF hospitalization. Retrieved Nov. 20, 2012 from the World Wide Web: http://www.qualitymeasures.ahrq.gov/content.aspx?id=35576
4. Krumholz, H.M., et al. (2008). Hospital 30-day heart failure readmission measure methodology. Report prepared for the Centers for Medicare & Medicaid Services. Retrieved Nov. 20, 2012 from the World Wide Web: http://www.qualitynet.org
5. Naylor M.D., et al. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675-684.
6. Rosati, R.J., et al. (2003) Risk factors for repeated hospitalizations among home healthcare recipients. Journal for Healthcare Quality, 25(2), 4-10.
7. Morse, T. (1997). Morse Fall Scale. Retrieved Nov. 20, 2012 from the World Wide Web: http://www.patientsafety.gov/CogAids/FallPrevention/index.html#page=page-4
The Calculate. Helps interpret echocardiography results and hemodynamic monitoring results, and has built-in risk assessment tools such as the Framingham and Reynolds Risk Scores, BMI calculations, and classification of angina and congestive heart failure risk analysis: http://itunes.apple.com/us/app/cardio-calc/id299841203?mt=8#
Electronic Preventive Services Selector is based on the most current, evidence-based recommendations of the U.S. Preventive Services Task Force and can be searched by specific patient characteristics, such as age, sex and selected behavioral risk factors: http://epss.ahrq.gov/PDA/index.jsp
Hartford Institute for Geriatric Nursing: www.consultgerirn.org
Healthy People 2020: http://healthypeople.gov/2020/about/prevStrategies.aspx
National Library of Medicine. Teaching video for congestive heart failure: www.nlm.nih.gov/medlineplus/tutorials/congestiveheartfailure/htm/lesson.htm
STAT Depression Screener: http://itunes.apple.com/us/app/stat-depression-screener/id348793894?mt=8#
Transitional Care Model: www.transitionalcare.info
Maria Lauer-Pfrommer is assistant professor of nursing at Holy Family University, Philadelphia, and the chief clinical officer/owner of iHealth Services LLC, Moorestown, NJ.