Table 2 Needs Assessment Objectives and Questions

Objective 1. Understand current acute care processes for identifying sepsis patients

How are sepsis survivors identified in your hospital?

 1. Who is involved in clinical documentation and coding that the patient has/had sepsis?

  o What do you do with the information? How is it shared/alerted and with whom?

 2. What IT systems/tools are used?

  o How are the IT systems used? (what function do they complete?)

  o Criteria used to code sepsis categories?

 3. How is success in identifying sepsis patients monitored?

 4. What is your accuracy rate for identifying sepsis patients?

  o How do you measure accuracy?

 5. What are the steps in identifying sepsis patients that you think need improvement? Why?

  o What is needed to achieve improvement?

 6. What strategies were tried and failed?

 7. What are the successful strategies?

 8. What are the barriers to identification, IT documentation and communication, accuracy, monitoring accuracy?

 9. To make improvements in this process, who should we work with?

  10. How is sepsis defined in your hospital?

Objective 2. Determine the workflow for referral of sepsis survivors to home health care

What is the process for identifying sepsis survivors for referral to home health care?

  1. What criteria are used to determine the need for home health referral?

  2. Who is involved in making this decision?

  3. When is the decision to refer the patient for home care made?

  4. What IT tools are used?

  5. What are the barriers to getting sepsis survivors to home health care?

  6. What are some ways we could improve the process?

  7. What resources are needed for improvement?

  8. What are the similarities in this process across units/floors? What are the differences?

  9. To make improvements in this process, who should we work with?

Objective 3. Map the process for how and when home health is notified about the referral

How are home health personnel notified that there is a referral to home health?

  1. Who gets the notification?

  2. When are they notified?

  3. How are they notified?

     a. Do they know the expected discharge date?

  4. What IT tools are used to make the referral?

  5. What are the barriers to making the referral to home health care?

  6. How are the patient and family involved?

     a. Who involves them?

  7. We are interested in learning about areas for improvement in the process. What are some areas for improvement for the process of notifying home health of the referral?

     a. What resources are needed to make improvements?

  8. To make improvements in this process who should we work with?

Objective 4. Determine what patient information is transferred during the transition to home health care

What data elements are transferred to home health care about the referral?

  1. How is the information transferred (paper, electronic, verbal)?

     a. If electronic: What IT tools are used for information transfer?

     b. If paper: Is this faxed or a hard copy hand off?

  2. Thinking about information transfer, what challenges do you experience with transferring information from hospital to home health?

  3. What makes the transfer of information easy?

  4. Who sends the information and who is it intended to be received by?

  5. What information is placed in the HHC record, and who uses it and for what?

  6. How do nurses decide what to document as diagnoses on the OASIS?

  7. Name some areas for improvement in the transfer of information and the documentation of sepsis

  8. To make improvements in this process, who should we work with?

Objective 5. Analyze the barriers and enablers of making the outpatient follow-up appointment

How are outpatient follow-up appointments made?

  1. What people are involved (hospitalist, patient, caregiver, case manager, outpatient staff, social work) in making outpatient follow up appointments?

  2. How is the appointment made (what time frame, by phone, direct access)?

  3. What IT tools are used to make the appointment?

  4. What is the criteria for who gets an early spot on the outpatient schedule?

  5. What do you do if there is no outpatient provider?

      o What proportion of patients do not have an outpatient provider?

  6. Would telehealth be possible if the patient does not want to make an office visit?

  7. Is there a home physician/NP visiting program available?

  8. How is success in making the appointment monitored?

    o What proportion of the time are you successful in making the appointments?

  9. What are the barriers to making the appointment within 7 days?

  10. What are examples of enablers, (staff, IT, patient education, availability) to making the appointment?

  11. How are patients and their caregivers involved in making follow up appointments?

  12. How is the appointment communicated to the patient and/or family?

  13. What are some areas for improvement in making follow up appointments?

  14. What strategies were tried and failed in making follow up appointments?

  15. What works?

  16. Do the insurance companies play a role in facilitating early follow-up? If so, how?

  17. To make improvements in this process, who should we work with?

Objective 6. Determine the process for how home health activates timely visits

How do you implement timely home visits (defined as: visits within 48 h of hospital discharge)?

  1. What people are involved in scheduling the home health care admission visit?

  2. Do the home health agency personnel know the expected hospital discharge date?

  3. What conflicts arise when trying to schedule timely home health admission visits?

  4. What IT tools are used?

  5. What criteria is used to prioritize patient visit timing?

  6. How is start of care visit timing monitored?

  7. What is your current success rate for making the admission visit within 48 h of discharge?

  8. What makes this difficult to do?

  9. How do you think we could improve the success rate for achieving timely visits?

  10. What strategies were tried and failed?

  11. What works?

  12. What role does geographic area play?

  13. What role does the day of the week play?

  14. What role does staffing play?

  15. Is patient acceptance of timely visits a barrier? (just got home from hospital, don’t want you to visit)

  16. To make improvements in this process, who should we work with?

Objective 7. Determine the typical visit pattern for week one of post-acute home health care

How are visit timing and frequency scheduled in week one for post-acute patients at home?

  1. What people are involved in scheduling week one visits?

  2. What IT tools are used?

  3. How are the visit patterns communicated to the nurse or schedulers?

  4. How is success of timing and frequency of visits during week one of care monitored?

  5. What is your current visit pattern in week one for typical patients?

  6. What are the barriers to achieving at least two visits in week one?

  7. What are the areas for improvement?

  8. What strategies were tried and failed?

  9. What works?

  10. To make improvements in this process, who should we work with?

Objective 8. Explore how home health personnel can facilitate completion of the outpatient provider follow-up by one week after discharge

Please describe the role of home health care and the processes used to encourage and help the patient keep their outpatient provider appointment?

  1. Who are the people involved in encouraging the patient to attend their outpatient provider visit?

  2. Who is involved in helping the patient attend the visit?

  3. How is the visit attendance documented?

  4. Are any IT tools used, and if yes what is used?

  5. How does home health know whether or not the patient has an appointment?

  6. What role does the home health provider play in obtaining an appointment for patients in the first week of home health?

  7. What role does the home health provider play in facilitating attendance at outpatient appointments for patients in the first week of home health?

  8. What is the current success rate for completion of timely outpatient follow-up visits?

  9. How is that measured and within what time frame (7 days, 14 days)?

  10. What are the barriers to the patient being seen by an outpatient provider by day 7?

  11. What are the areas for improvement?

  12. What strategies were tried and failed?

  13. What works?

  14. To make improvements in this process, who should we work with?