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Service Delivery Innovation Profile

Formalized Communication Between Rural Home Health Agency Nurses and Physicians Leads to Increased Use of Home Health Services, Fewer Inpatient Admissions

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A rural home health agency formalized oral and written communication processes with physicians, using specific communication tools to ensure that ongoing patient needs are being met. The program led to improved communication, increased use of home health services (due to physicians' increased confidence in the home health agency), and a concomitant decline in inpatient admissions among home health patients. In January 2009, the agency became free standing from the hospital and is now called Berwick Home Health & Hospice.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on home health admissions, inpatient admissions, communication scores, and patient satisfaction, along with additional anecdotal evidence related to physician satisfaction.
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Developing Organizations

Berwick Hospital Home Health Care
Berwick, PAend do

Date First Implemented

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Patient Population

Vulnerable Populations > Rural populationsend pp

Problem Addressed

The lack of clear and formal communication between physicians and home health agencies leads to patients unnecessarily being admitted to the hospital when they could have been effectively cared for at home.
  • Many hospitalizations among home health patients: Each year, roughly 30 percent of the approximately 3.88 million episodes reported by 8,600 home health agencies result in hospitalizations; this figure translates into approximately 1.1 million hospitalizations annually.1
  • Home care is preferable and often safer: Most patients prefer to remain at home if at all possible; in addition, hospitalizations can result in complications such as nosocomial infections and medical errors, and, for older patients, lead to delirium and functional decline.2
  • Importance of communication: Many home health agencies identify physician communication as a significant factor affecting the need for hospitalization; thorough, consistent communication can ensure that home health services are viewed by physicians as a viable alternative to hospitalization when appropriate.1

What They Did

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Description of the Innovative Activity

Berwick Home Health & Hospice uses specific communications tools to formalize the communication process and to remind home health nurses to provide consistently all relevant information when telephoning physicians about patient care. The agency also formalized its communication process for sharing care plans with hospitalists and community physicians and implemented technologies to facilitate communication between nurses and agency staff. Key elements of the program include the following:
  • Emphasis on staying home if possible: Home health nurses are taught to focus their communication on what can be done (given the patient's situation) to keep the patient at home. Nurses remind physicians that patients want to stay at home and that home health care is more efficient for the physicians than visiting patients in the hospital.
  • "SBAR" framework for communication: The agency adopted the SBAR (Situation, Background, Assessment, Recommendation) tool originally used by the nuclear submarine service. Nurses use a one-page SBAR form (adapted to the home health arena) that is designed to address common physician questions; the form prompts nurses to provide the following information:
    • Situation: The nurse provides the name of the patient and the reason for the call.
    • Background: The nurse describes the history of the patient so that the physician has all relevant information, including primary diagnosis, pertinent medical history, most recent findings, mental status, neurological changes, temperature, blood pressure, pulse rate/rhythm, respiratory rate/quality, lung sounds, pulse oximetry, gastrointestinal status/changes, wound status, pain level, musculoskeletal changes, and/or do not resuscitate status.
    • Assessment: The nurse provides his or her assessment of the current problem or, if the problem is not determined, notes that the patient’s status is deteriorating.
    • Recommendation: The nurse provides his or her recommendation for patient care, prompted by a checklist that offers suggestions such as an as-needed visit, a change in the recommended frequency of visits, a physician office visit, a physician or nurse home visit, telemonitoring, diagnostic testing options, medication changes, wound care changes, dietary/fluid changes, and/or other recommendations.
  • "CUS": Home health nurses use another tool, known as "CUS" (Concerned, Uncomfortable, Safety), when they feel that their communication is not effectively conveying the situation. This second layer of communication helps nurses speak more firmly with physicians when advocating for a patient. CUS reminds nurses to speak up when they are concerned about the patient’s situation; uncomfortable with the patient’s current assessment; and/or worried about the patient's safety.
  • Communication with hospitalists: The home health agency formalized the communication process between the agency staff and hospitalists when home health patients are admitted to and discharged from the hospital.
    • Admissions: Agency staff place physician-generated orders in a designated location in the hospital so that hospitalists can access this information easily.
    • Discharges: The hospitalist faxes a patient status report with care recommendations to the home health agency on patient discharge. The agency sends an initial home health care plan to the hospitalist for signature and also provides an informational copy to the patient's primary care physician. Any further orders or questions about patient care are sent directly to the primary care physician.
  • Implementation of communication technologies: The agency also improved direct e-mail and telephone access between nurses in the field and office staff members.

Context of the Innovation

In January 2009, Berwick Home Health & Hospice became a free-standing agency. Originally, it was the home health agency of the Berwick Hospital Center, a 101-bed community hospital in Berwick, PA. Berwick is a small rural community located in north-central Pennsylvania. The majority of Berwick Home Health & Hospice's patients are elderly and on a fixed income, with a socioeconomic status of lower middle class or below. Most patients are covered by a Medicare or a Medicare+Choice insurance product.

Berwick Home Health & Hospice worked with Quality Insights of Pennsylvania, the national Medicare Quality Improvement Organization coordinating center for home health care quality improvement, on an initiative to reduce hospitalizations and the incidence of dyspnea among home health patients. As part of the initiative, the agency targeted organizational culture change, and, as a part of this process, the issue of communication with physicians surfaced, spurring agency leaders and staff to identify best practices in physician relationships and communication.

Did It Work?

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The program has led to better communication, increased use of home health services, and a concomitant decrease in inpatient admissions among home health patients.
  • Fewer hospitalizations: Acute care hospitalizations among home health patients dropped significantly. During 2005 (before the program was implemented), 29 percent of home health patients were hospitalized; by 2008, that figure had fallen to 22 percent.
  • Increased use of home health services: Physicians are clearly turning to home health services as a substitute for inpatient care where appropriate. Home health admissions increased from 40 per month to more than 60. This increase appears to be due to physicians' high level of confidence in the home health agency (see the information below on physician satisfaction).
  • Improved communication: Over approximately 15 months, the agency's communication score on the Home Health Quality Culture Survey, developed by the Medicare Quality Improvement Organization Program as part of its Eighth Scope of Work, increased from 2.09 to 3.83 (on a scale of 5). (Note: The survey instrument measured home health agency staff perception of the agency's performance with regard to teamwork, communication, leadership, and care coordination.)
  • Anecdotal reports of high levels of physician satisfaction: Anecdotal information indicates that physicians are satisfied with the communication between themselves and the home health agency. Although the agency has not received feedback from physicians specifically about the revised communication processes, it has received comments that physicians are pleased that their patients are being kept at home, that home care has been managed very well, and that they want to replicate this kind of care with other patients. Physicians also report that good working relationships with home health nurses have led to better clinical outcomes for patients.
  • Maintenance of high levels of patient satisfaction: Home health patient satisfaction scores have remained high since the program was implemented.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on home health admissions, inpatient admissions, communication scores, and patient satisfaction, along with additional anecdotal evidence related to physician satisfaction.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Identification of tools and resources: As part of a comprehensive planning process for the program, the agency worked with Quality Insights of Pennsylvania to identify tools and other resources that could assist in improving communication processes.
  • Training via module-based workbook: One identified resource was a Communication Workbook with five modules that agency staff worked through. The five modules are described below:
    • Module 1: Staff members provided insight on organizational strengths and weaknesses, including those surrounding communication.
    • Module 2: Staff examined and defined organizational, team, and individual communication roles.
    • Module 3: Staff reviewed agency systems for rewarding and recognizing employees and reviewed the mission and vision for the organization.
    • Module 4: Staff conducted an indepth examination of communication processes, including the ways that the agency communicated interpersonally and with physicians, and how staff members used available technology; during this module, the issue of communicating with physicians became a main focus of improvement.
    • Module 5: Staff learned about performance measurement as it relates to communication processes.
  • Development of communication tools and strategies: The agency adapted the SBAR form to fit patient needs and trained nursing staff how to use SBAR and CUS. The agency also formalized a communication plan to guide patient handoffs to and from hospitalists and primary care physicians.
  • Coaching: Nurses received coaching during actual physician phone calls to improve their communication skills. The coach (a nurse practitioner in the agency) made notes during the call, which was held on speaker phone; after the call, the coach and the nurse discussed alternative communication strategies that could have been used.
  • Technological improvements: The agency set up a direct phone line so that nurses in the field could reach nurse managers directly.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as home health nurses incorporate new communication strategies and skills into their daily activities.
  • Costs: Program costs are minimal, as tools were available free of charge from Quality Insights of Pennsylvania. Minor expenses were associated with the introduction of new technologies, such as the new phone line.
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Funding Sources

Berwick Hospital Home Health Care
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Tools and Other Resources

Various tools, including the SBAR form, are included in the Best Practices Intervention Tools for Physician Relationships, which is available free of charge from the Home Health Quality National Campaign at

The Home Health Quality Culture Survey may be requested through Quality Insights of Pennsylvania:

Adoption Considerations

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Getting Started with This Innovation

  • Enlist staff assistance: Ask nurses to identify both problem areas and strengths in the current communication process, and then solicit ideas for improving problems while maintaining the strengths. This input is highly informative and will lead to greater success than will a top-down directive strategy.
  • Examine communication comprehensively: Consider interpersonal communication as well as communication with other clinicians and organizations.
  • Carefully map out the communication process: All participants need to understand their roles and expectations.
  • Formalize the "obvious": SBAR and CUS help clinicians specify the elements of communication, even when these elements seem obvious; this helps clinicians communicate thoroughly in all situations.
  • Use available tools: There is no need to "reinvent the wheel," as adaptable tools are available through Home Health Quality Improvement (
  • Obtain commitment from top leadership: Adopting communication improvement processes requires support from the director of the home health agency. This high-level commitment helps unify and motivate staff.

Sustaining This Innovation

  • Continually reevaluate communication processes to ensure high standards.
  • Obtain feedback from physicians regarding communication processes.

Additional Considerations

  • Although improving communication is easier when the home health agency and hospital are part of the same organization, more formalized communication is possible even if the home agency is independent.

More Information

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Contact the Innovator

Kathy Carper, RN, BSN
Clinical Supervisor
Berwick Home Health and Hospice
6850 Lows Road
Suite 102
Bloomsburg, PA 17815
Phone: (570) 416-0561
Fax: (570) 380-1258

Innovator Disclosures

Ms. Carper has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.


1 Esslinger E. Reducing acute care hospitalization: the Home Health Quality Improvement (HHQI) National Campaign.
2 Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143(11):798-808. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 23, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 23, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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