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Review of Existing Patient Categorization Tools
First, the investigators determined whether any standard requirements or guidance related to patient risk categorization tools exist at a State or national level. A review of the literature revealed some efforts on behalf of State and national associations for home care and hospice agencies to provide guidance on the development of emergency plans and use of an abbreviated patient assessment tool. HHAs participating in Medicare/Medicaid programs are subject to Federal and State regulations and must undertake disaster planning; however, those regulations do not specify the content of plans, and personal care agencies do not appear to have such plans in place (5).
Several examples of patient risk categorization tools were obtained and reviewed. The first documented patient classification system was introduced in 2001 by Barbara Citarella (E-mail correspondence. August 24, 2009.)
In a 2005 letter to home care and hospice agencies, the New York State Department of Health mandated that emergency plans be revised to incorporate a patient risk classification system (6). The sample classification system proposed in the letter is a three-level system, structured as follows:
- Level I: High Priority. Patients in this priority level need uninterrupted services. In the case of a disaster or emergency, every possible effort must be made to see this patient. The patient's condition is highly unstable and deterioration or inpatient admission is highly probable if the patient is not seen. Examples include patients who require life sustaining equipment or medication, those who need highly skilled wound care, and unstable patients who have no caregiver or informal support to provide care.
- Level II: Moderate Priority. Services for patients at this priority level may be postponed with telephone contact. A caregiver can provide basic care until the emergency situation improves. The patient's condition is somewhat unstable and requires care that should be provided that day but could be postponed without harm to the patient.
- Level III: Low Priority. The patient may be stable and has access to informal support to provide care. The patient can safely miss a scheduled visit if basic care is provided by family members, other informal support, or by the patient himself.
Another classification system, developed by a State home care association in 2007 and based on Citarella's earlier version, uses a similar approach to the three-level system described above, and offers examples of patient types for each category (7):
- Examples of patients classified as Level 1 (High Priority): A patient who is bed-bound or paralyzed, ventilator dependent, unable to meet physiologic and safety needs, or who requires daily insulin injections for diabetes but is unable to self-administer the medication.
- Examples of patients classified as Level 2 (Moderate Priority): A patient who uses equipment such as an oxygen tank, suction pump, nebulizer, or patient-controlled analgesia pump.
- Examples of patients classified as Level 3 (Low Priority): A patient who is mobile and independent in functioning or a patient who needs uncomplicated routine wound care.
In 2008, a four-level system was suggested by the National Association for Home Care and Hospice (NAHC) in the report "Emergency Preparedness Packet for Home Health Agencies" (8). The first three levels are similar to those proposed by the New York State Department of Health; a fourth level suggested by NAHC, "Lowest Priority," includes patients for whom visits may be postponed 72 hours or more with little or no adverse effects, patients who have a willing and able caregiver available, or patients who are independent in most activities of daily living (ADLs).
All of these categorization tools are intended for patients who receive care from home health and hospice agencies. The general community-dwelling population also includes many individuals who do not routinely receive services from those agencies but who have the potential to destabilize rapidly during an emergency and require medical care. Other service providers, such as adult day care programs, medical equipment suppliers, or Meals on Wheels programs, may have routine contact with such at-risk individuals. The investigators found no patient classification tools that could apply to community-dwelling patients who receive care or services from these other type of providers, with the exception of one triage tool that was used after Hurricane Katrina to assess vulnerable older adults residing in shelters (9). This tool was used to rate elderly individuals who had no accompanying family members in terms of their ability to access medical and social services at the shelter and from County government. Called SWiFT, for Seniors Without Families Team, the tool consists of 13 questions in three categories (medical/mental health, financial, and social) and places an individual into one of three levels of "assistance required." "Level 1" indicates the need for immediate medical placement/care for older adults who have cognitive deficits and ADL deficits; "Level 2" indicates the need for help with housing and/or income support; and "Level 3" designates a need for assistance in locating family or friends, or other disaster-related problems. Individuals classified as "Level 1" might be at risk of hospitalization if their medical needs are not quickly addressed. The triage tool classifies individuals as "Level 1 (Health/Mental Health Priority)" based on their answers to questions about:
- Medical problems (diabetes, heart disease, high blood pressure, memory loss).
- Medication (does the individual take medication and is the medication with him/her).
- Assistance with ADLs (walking, eating, bathing, dressing, toileting, medication administration) and ambulation/transfer (cane, walker, wheelchair, bath bench).
- Orientation (does the individual know where he/she is and what year it is).
- Short-term memory (ability to recall the names of three items after several minutes).
The developers of the triage tool noted that it could be useful in disaster preparations as a uniform description of level of need and as general guidelines for the type(s) of assistance needed.
The investigators were unable to locate any research studies that evaluated the usefulness or accuracy of patient assessment tools for emergency planning. Given the limited information available on the types and uses of patient classification tools, and their ability to identify those most at risk for hospitalization if community health services are interrupted, the investigators sought additional information from home care agencies and State home care associations about their plans for triaging patients during an MCE.
Discussions With Home Care Agencies
The investigators solicited guidance from members of the Technical Expert Panel (TEP) regarding those States that would most likely demonstrate a range of activities related to emergency planning, and perhaps development and implementation of standardized patient classification tools. TEP members suggested that States with both rural and urban areas that are prone to a variety of natural disasters be represented. TEP members also suggested including some specific States known to have either offered guidance to HHAs or to have been entirely silent on this issue to represent the extremes of the continuum. Based on this criteria, the following six States were selected: Florida, Illinois, Massachusetts, Oregon, New York, and Texas. TEP panelists advised that the use of patient assessment tools is at the discretion of each HHA, and different tools could be used by different HHAs within the same State. To examine the range of patient categorization tools, the investigators obtained examples from several HHAs in each of the six States.
Contact was first attempted with the State home care association, to request referral to HHAs that might be willing to share their patient categorization tools. Some of the State associations were able to suggest knowledgeable individuals at HHAs—usually nursing directors—and these individuals were contacted; other State associations could not provide referrals. For these latter States, the investigators used the Centers for Medicare and Medicaid Services' "Home Health Compare" Web site to identify several HHAs in each State. The investigators also contacted other community service providers (e.g., medical equipment suppliers, Meals on Wheels programs, adult day care programs) in one Massachusetts community to understand whether these other types of providers might use a similar patient risk categorization tool for their clients.
- Does your organization use a patient classification scheme or tool that assigns a numerical value to each patient to represent priority of need?
- If yes, is this tool electronic- or paper-based,, and can you share a copy or screen shot?
- If your organization uses a patient classification system, how is it structured?
- How many levels are there?
- What is the criteria/description of each level?
- When is the information collected, and how often is it updated?
- Did the HHA or service provider create this system or adopt it from somewhere else? If it was adopted from elsewhere, how was it selected?
- Has the HHA or service provider communicated with local emergency planners to share the patient classification system (e.g., participated in a workgroup, informal discussion, local meetings/drills)?
- Has the HHA or service provider experienced an emergency situation (even a minor one) in which patient care was disrupted or challenged (e.g., snow/ice storm, power outage)?
- Can you describe the emergency, and how many people (patients and staff) were affected?
- Did some patients go to emergency departments? For what reasons?
- Did the HHA have a patient classification system in place? If not, how did staff prioritize patient care?
- If a patient classification system was used, how well did it work? Were there any problems? Did the HHA make revisions to the system afterwards? If so, what type of revisions were made?
Calls were placed to a total of 57 home health/hospice agencies in six States and 22 other types of service providers in Massachusetts.
Of the 57 home health/hospice agencies contacted, 21 were interviewed by telephone. Table 1 summarizes the number of HHAs contacted, by State.
Table 1. Number of Home Health and Hospice Providers Contacted, by State
Source: Abt Associates; 6/2009.
Contact with other providers (medical suppliers, oxygen companies, Meals on Wheels programs, adult day care programs, and substance abuse clinics) in Massachusetts was attempted, but yielded limited results, as few were willing to discuss this issue with investigators. One oxygen supplier, two substance abuse clinics, and one Meals on Wheels program were interviewed.
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