Abstract

New care delivery models and approaches to integrated care have emerged across the country to reduce health disparity, improve outcomes, and address care delivery fragmentation. Home health agencies (HHAs) and the millions of homebound adults in the U.S. are often in the middle of this fragmentation. This article describes a multipronged quality improvement (QI) approach taken by an Illinois HHA to reduce variation and improve the care management of its diabetic population. The agency was experiencing variations in care that misaligned with the parent health system, inconsistent documentation, and higher than desired emergency department (ED) utilization, rehospitalizations, and percentage of patients discharged with fasting blood glucose (FBG) levels outside of their target ranges. A team was formed to identify system gaps of care and develop multipronged mitigating interventions. Based on available data, post-intervention the agency had a 29% increase of patients discharged with FBG levels within target range, and a 15.0% reduction in ED utilization. The agency did not improve its rehospitalization rate. The identified limitations that may have impacted project results include the short implementation period, limited timeframe patients are enrolled in home health, agency operational dynamics, and electronic health record (EHR) barriers.

Author Details

Julianna S. Sellett, DNP

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Other

Research Approach

Translational Research/Evidence-based Practice

Keywords:

Diabetes Self-Management, Diabetes Care Management, Home Health

Advisor

Jill Schramm

Second Advisor

Jocelyn D'Antonio

Third Advisor

Pamela Bigler

Degree

DNP

Degree Grantor

Capella University

Degree Year

2017

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.

All permission requests should be directed accordingly and not to the Sigma Repository.

All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Self-submission

Date of Issue

2017-09-22

Full Text of Presentation

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