St. Peter?s Hospital - Helena, MT

Compass Award Winner: Home Health Care

Over the last two years, HomeLink of St. Peter’s Hospital has initiated the mandated OASIS data sets, as have all Medicare certified agencies. Although this was a daunting and time-consuming task that required many hours of staff education, it does provide a very in-depth assessment of patients that are being served in the agency. HomeLink also implemented a point-of-care documentation system at the same time the OASIS data collection began. Although this doubled the learning requirements of the staff, we found it gave us a better picture of our clients from start of care through discharge, and gave staff focal points for their documentation. We now are implementing clinical pathways and hope to be able to integrate several questions to lessen the time of the assessment for our staff and clients.

We have seen our scores in infusion therapy increase. We have worked closely with our hospital pharmacy to develop a home infusion program that focuses on educating the client and family to assist in the administration in a safe and effective manner. We also encourage the use of Social Services in the cases that would benefit from other community resources and financial assistance. Client response to social worker involvement has been very positive.

Our program also provides many Physical Therapy services. We have seen the referrals for therapy-only cases increase dramatically over the last two years. Our clients’ responses concerning the quality of our therapists, and how they feel about the therapists encouraging their independence, have improved. We feel that having therapists that are employees of the agency, and not contracted to do visits, greatly benefits our staff and our clients. Our therapists are trained home care therapists with many years of experience. Our physicians have learned to depend on them to get their clients independent in their homes after major joint replacements or injuries.

We have also seen improvement in the area of “help of person making the home health arrangements.” We have a designated referral phone line that is always answered by a Registered Nurse who can take referrals, answer questions from physicians and clients, and is knowledgeable about reimbursement for all services we offer.

We work closely with the Discharge Planners in our hospital to provide seamless discharges across our continuum of care. Our staff can respond to any concerns regarding the patient’s hospital stay or discharge process - this is a benefit of being a hospital-based agency. We encourage interaction and communication with all inpatient and outpatient staff, and we see that any concerns about a patient’s hospital stay are addressed immediately by the appropriate personnel.