Home healthcare providers' infection prevention efforts hampered by dearth of data, tools

Bayada Home Health Care had to go it alone when it developed infection control and prevention protocols for its clinicians.

Unlike the numerous infection prevention resources available to hospitals and nursing homes, there isn't much published guidance for home health providers on how to best protect patients from infections.

The Centers for Disease Control and Prevention hasn't published infection control guidelines specific to the home health industry even though such resources are available for acute-care and long-term care providers.

"There is not a lot out there," said Jennifer Sheets, chief clinical officer of Bayada. "There is a knowledge deficit to the challenges that exist in the home."

The Association for Professionals in Infection Control and Epidemiology is one of the few places home health providers can get resources specific to them. "APIC is somewhat unique in providing resources to this segment," said Karen Hoffmann, president-elect of the association.

At the same time, the stakes for home health agencies to control infections are getting higher—albeit slowly. The CMS this year started requiring home health agencies to have in place an infection control program to receive Medicare payment. But the agency didn't specify what provisions need to be included in the program.

"There is a wide variety of information on this subject available for home health agencies to choose from in creating their own programs, and we don't believe that it is appropriate to specify which standards home health agencies must use," they agency noted.

The CMS' requirements for home health agencies are quite loose compared with hospitals and nursing homes, both of which face tight regulations to prevent infections. As a result, companies have largely taken it upon themselves to develop and enforce infection control and prevention policies.

Bayada applies as best it can CDC's hospital guidelines to its own infection control policy. But over the past decade, the Moorestown, N.J.-based provider has also created an arsenal of resources specific to home care. For example, Bayada offers tips on what nurses should do when a cat jumps on the bed while they are changing a wound dressing or how to respond when a curious child touches the equipment.

"The key in the home is really that critical thinking, learning to adapt," Sheets said. "Home care clinicians are experts at adapting."

Andrea Devoti, executive vice president of the National Association for Home Care and Hospice, said the CMS likely didn't include more specific guidelines for home health providers because "it's tough to dictate parameters when you're in someone's home."

She added that most home health agencies already had an infection control program in place before the CMS rule was released.

The CMS also doesn't require agencies to do much infection reporting. Under the Home Health Quality Reporting Program, the only infection that home health agencies are required to report are urinary tract infections. The program evaluates other aspects of patient safety like an increase in pressure ulcers, fall risk and influenza vaccination rates.

As a result, home care agencies can't benchmark their performance on infections to each other but instead must rely on internal reporting, Sheets at Bayada said. "We track and trend our incidence of infections within the practice—compare ourselves to our other offices."

This is in stark contrast to hospitals, which report infections to the CMS and receive penalties for performance under the Hospital-Acquired Condition Reduction Program.

Although home health agencies may lack infection control resources, the patients they are treating now are sicker than in the past as hospitals use more home care services to shorten lengths of stay and drive down costs.

Roughly 12,180 Medicare-certified home health agencies treated more than 3.5 million patients in 2016, according to the CMS. That's a huge rise from 2000, when there were 7,500 home health agencies that treated 2.5 million Medicare beneficiaries.

"Patients who used to go to a skilled-nursing facility are coming home now—this has resulted in patients entering home health with higher degrees of both acuity and complexity," said Bud Langham, chief clinical officer of Encompass Health, a home health company based in Dallas.

Home health providers are also challenged by limited research on the prevalence of infections in their sector. The most recent and comprehensive study on the incidence of infections for home health agency patients was published in 2015 and relies on 2010 data.

The study found that on average about 3.5% of patients developed infections during their home health experience that led to a hospitalization.

But there are limits to the findings, said Jingjing Shang, assistant professor of nursing at Columbia University and co-author of the study.

For starters, the data only included patients who had an infection that needed to be treated in the hospital. Many infections can be treated—and presumably are treated—in the patients' home.

"A lot of infections in home care may just need antibiotics to treat, so this is definitely underestimating the infection rate," Shang said.

And although the average infection rate in the study was low—3.5%—there was a wide range when individual providers were examined. Some home health agencies had no patients go to the hospital because of an infection, while others had rates as high as 34%.

Shang said she thinks there is such variability because "there are no standardized guidelines for agencies, and so many agencies have their own infection control guidelines."

But even if the CMS required home health agencies to report infection rates there would still be limits to the data. If a patient develops an infection in the home, it's hard to know if the patient received it before being discharged from the hospital or at an outpatient clinic appointment.

"In home healthcare, it's difficult to pinpoint where the infection happens," Shang said.

Despite the limited regulations from the CMS, most home health agencies track and trend their infection rates internally as part of quality improvement efforts, Devoti of the National Association for Home Care and Hospice said.

Encompass Health clinicians are required to report all infections in an electronic health record. Quality managers then track the number of infections every quarter. The most common infections Encompass treats are urinary tract, respiratory and surgical site.

If a spike in a particular infection occurs in one area, leaders work together to tackle the issue. Sometimes the agency will even partner with the local hospital.

"We have done that a couple of times," Langham said. "It's better for us, better for them, and much better for the patients."

New Encompass clinicians receive substantial training in infection control and prevention, and they learn to look for any unique aspects of a patient's home that might pose an infection risk.

For example, proper hand hygiene by patients, their family members and the clinicians is key to preventing infections. But some homes won't have soap. To work around that, Encompass provides clinicians with all the sanitary tools they need like wipes, shoe covers and soap.

Education of patients, family members and caregivers is another substantial part of how home health agencies try to protect patients from infections.

At Trinity Health at Home, part of the larger Livonia, Mich.-based Trinity Health, patients and their caregivers are provided materials when they are initially enrolled in home care on the best ways to prevent infections.

Diligent hand washing is a key tactic highlighted, said Michael Soccio, vice president of clinical operations for Trinity Health at Home.

The system is now working with its agencies to meet the Joint Commission standards for home healthcare accreditation. Soccio said the Joint Commission has stricter regulations involving infection control than the CMS, particularly for hand hygiene.

The accreditor requires agencies to have a hand-washing compliance program, so Trinity is working to deploy employees to observe clinicians in the home for compliance.

"This goes above CMS requirements. We have one agency accredited; our plan over the next 12 months is to have all our agencies accredited," Soccio said.

But even when home health agencies educate and train staff and patients in infection control as best they can, it sometimes still isn't enough. The home setting isn't under the control of the clinicians, so they can't ensure 24/7 that protocols are followed, Sheets said.

"You can do everything right, and someone comes in and there is a breach. That is unique in our setting," she said.