Executive Summary
Norwell Visiting Nurse Association (NVNA) and Hospice, a non-profit home health and hospice care provider, faced challenges tracking and improving metrics required for achieving consistent 5-star ratings. Partnering with Strategic Healthcare Programs (SHP), NVNA adopted real-time, actionable analytics to address documentation gaps, improve staff education, and optimize performance. With SHP’s tools and support, NVNA transformed their operations, achieving consistent 5-star ratings and earning the highest bonus for Medicare’s Home Health Value Based Purchasing (HHVBP) program.
Introduction
Founded with a mission to provide high-quality care, NVNA and Hospice is a non-profit organization serving 27 towns in Massachusetts. Providing services such as home health care, palliative care, and hospice, NVNA has established itself as a leader in patient-centered care on the South Shore. However, as patients’ needs grew and government metrics became stricter, NVNA faced challenges in improving its star ratings for Quality Measures and HHCAHPS (Home Health Consumer Assessment of Healthcare Providers and Systems). To overcome this, NVNA teamed up with SHP for data-driven solutions and support.
The Problem
Despite a commitment to delivering excellent care, NVNA struggled to translate its efforts into the publicly-reported 5-star ratings crucial for maintaining trust and demonstrating credibility to potential patients and families. The HHVBP program was expanded nation-wide in CY 2023 creating financial risks and opportunities ranging from a -5% penalty to a 5% bonus based on agency’s quality performance.
Key Challenges
- Difficulty identifying and focusing on low-performing metrics in real-time.
- Documentation inconsistencies that inaccurately reflected the complexity of patient care.
- Gaps in staff training to properly assess and document patient conditions.
- Struggles to address patient satisfaction feedback effectively.
“With static reporting tools, identifying issues often took too long, meaning improvement opportunities were either delayed or missed completely,” explained Kate Mercier, NVNA's Chief Operating Officer.
The Solution
By implementing SHP’s advanced analytics platform, NVNA gained access to real-time data and actionable insights, revolutionizing its approach to quality improvement and patient satisfaction. As Lean trained leaders, the data from SHP supported setting targets, tracking poorer performers and identifying root causes for follow-up.
Key Strategies
1. Real-Time Analytics for Proactive Measures
NVNA relied on SHP’s Clinical Scorecard, Star Ratings Preview Report and HHVBP Preview report to track performance metrics monthly. These tools allowed staff to address gaps in documentation, resolve underperforming measures, and predict future star rating outcomes.
2. Staff Education and Onboarding
NVNA prioritized educating clinicians on documentation best practices and the importance of accurate OASIS (Outcome and Assessment Information Set) reporting. A team of certified OASIS specialists conducted audits, tracked changes, and provided peer-to-peer field coaching.
We invested in creating a culture of continuous improvement. It’s not just about data but ensuring our clinicians feel confident in the care they deliver and how it’s represented.
- Kate Mercier, Chief Operating Officer
3. Improved Patient Engagement
Dedicated teams followed up with patients and families to address concerns between visits and at discharge. NVNA engaged with a local ambulance company, with extra capacity to make follow-up calls once on service. Customized surveys helped identify pain points early, leading to enhanced patient experiences and better sentiment in formal HHCAHPS surveys.
4. Benchmarking and Monitoring
SHP’s benchmarking allowed NVNA to measure their performance against state and national averages while creating accountability metrics internally. Collaborative efforts focused on root-cause analyses and targeted improvements through continuous auditing and dashboard monitoring.
Cultivating a Quality-Driven Culture
To ensure lasting success, CNHC prioritized the establishment of a culture focused on quality and teamwork:
- 5-Star Ratings: NVNA accomplished 5-star ratings in both Quality Measures and HHCAHPS across multiple reporting periods, demonstrating sustained excellence.
- Reduction in Readmissions: NVNA reduced the percentage of patients readmitted within the first 14 days from 9.4% to under 3%, improving on the new Potentially Preventable Hospitalization (PPH) metric for HHVBP.
- Significant Financial Gains: Since CY 2021, weighted points for HHCAHPS increased by 50%, while OASIS weighted points doubled through robust education and auditing programs leading to the maximum 5% bonus on all Traditional Medicare payments.
We’ve built dashboards for consistent monthly reviews, flagging any performance areas below 4 stars in red. This disciplined monitoring ensures we address issues before they escalate.
- Melissa Thompson, Director of Home Care
The collective impact of these efforts solidified NVNA’s reputation for excellence, while the adoption of SHP’s tools streamlined workflows to sustain long-term success.
Conclusion
NVNA and Hospice’s achievements highlight the transformative potential of data-driven decision-making and collaboration. Thanks to SHP’s real-time analytics, practical scoring tools, and dedicated support, NVNA has not only achieved its goal of consistent 5-star ratings and highest HHVBP bonuses, but also created a blueprint for scalable and sustainable growth.
Moving forward, NVNA plans to further integrate SHP’s predictive capabilities to stay ahead of evolving healthcare standards, including preparing for the latest changes to the HHVBP measures.
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