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Among the home health agencies (HHAs) reviewed, a significant proportion of their caseloads are classified in the highest risk level, which could potentially make the system cumbersome to use, especially during an MCE with no advance warning. The investigators suggest the following improvements:
- Standardize risk levels as "high," "medium," and "low," rather than using numeric rankings that are not always consistent.
- Standardize the categories for assessing risk (e.g., care needs/clinical diagnoses, caregiver supports, or timeframe for visits) and base risk categorization on common data that are available to every HHA.
- Design systems that can print or transmit lists of high risk patients to emergency responders (assuming that data privacy is protected).
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Standardize Risk Levels
The following suggestion for a patient risk classification system was adapted from the New York State Department of Health three-level structure (6), which uses only "high," "medium," and "low" risk labels. By avoiding numeric labels, the potential for confusion about which level is the highest risk is eliminated.
- High Risk or High Priority. Patients in this category need uninterrupted services and/or are highly unstable; deterioration requiring hospital inpatient admission is likely if these patients are not seen for regularly scheduled visits or if there is failure (including power loss) of life-sustaining equipment.
- Medium Risk or Medium Priority. If services for patients at this priority level are interrupted, mid-level medical management (e.g., nursing home-level care) will be needed. These patients are somewhat medically unstable and required care should be provided on time or within 24 hours. Most of these patients could be temporarily cared for in a special needs shelter, if one is available. These patients do not use life-sustaining equipment or their equipment can be easily moved with them to a special needs shelter.
- Low Risk or Low Priority. The patient's medical condition may be stable. If home and community services are interrupted, the patient can be cared for in alternate housing or a general population shelter. The patient can safely miss a scheduled visit(s) with basic care provided by self or an informal caregiver.
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Standardize Risk Categories Using Commonly Available Data
There is general agreement that standardized data that describes the service and equipment needs of community-dwelling patients would be valuable for estimating the number of these patients who would require hospital/ED admission during a mass casualty event (MCE). One such data source is the Outcomes and Assessment Information Set (OASIS). OASIS is completed upon admission/readmission (and every 60 days) for patients over the age of 18 (excluding maternity patients) who receive skilled services from a Medicare- or Medicaid-certified HHA. Although it provides standardized data, OASIS is not required for non-Medicare/Medicaid-certified agencies. Many patients pay for private nursing, personal care, or housekeeping services from agencies that are not Medicare/Medicaid-certified and thus are not required to complete the OASIS. TEP members pointed out that these individuals' needs are not necessarily any less complex than those of the patients whose care is captured in OASIS, but that these programs are run according to different administrative guidelines. New York City, for example, has 64,000 individuals in its personal care program for whom OASIS data do not exist. In addition, OASIS captures patient data at the point of intake to home care—when patients' needs are most acute. However, OASIS is not a real-time "snapshot" of current patient acuity and needs. Therefore, the investigators determined that OASIS would be insufficient for planning purposes, because so many patients are not captured in this database, and because it might overstate the acuity/needs of the patients that it does capture.
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Incorporate Caregiver Availability
- Low Risk. No assistance is needed or a caregiver currently provides assistance.
- Medium Risk. A caregiver is available, but needs training or support, or caregiver availability is unclear.
- High Risk. Assistance is needed, but no caregiver is available or the caregiver is not likely to provide assistance.
Included with this report is an example of a screening tool that could be used by any home care agency to rate each patient's risk of hospitalization in the event of an MCE. The tool is designed to be used by a health care professional. In three steps, it identifies the treatment/service/equipment needs of the patient (including caregiver availability); leads the clinician to identify the most appropriate locus or level of care if the previously noted treatments/services/equipment are interrupted by an MCE; and asks the clinician to estimate the length of time that the patient could safely remain at home if the usual services/equipment were interrupted by an MCE. This is not a triage tool to be used in the midst of an MCE, rather it is a tool for anticipating the needs of home care patients to aid in emergency planning.
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This tool can be used in paper form, but ideally it would be included as a module in OASIS or some other industry software so that home care agencies could create a small database for storing this information about their patient population. Such a system could also have the capability to aggregate data for planning purposes. Given that the primary focus of this study was to estimate the number of patients who would require hospital/ED admission, an electronic database could focus on the service and equipment needs of patients who require highly skilled medical management. This information could be made available to community and hospital disaster planners for advance planning. In turn, this would give hospital personnel a good estimate of the number of individuals who require highly complex care and who may seek hospital care during an MCE, and what their equipment and care needs may be when they arrive. In the event of an actual MCE, the database information could be immediately forwarded to emergency management and local hospitals and shared with first responders. Information about electricity-dependent patients could also be forwarded to utility companies and first responders (e.g., fire and police departments, emergency medical services).
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