Home Care Quality

1
Home Care Quality

• Elizabeth A. Madigan, PhD, RN
• Associate Dean for International Health
• Associate Professor
• Bolton School of Nursing

2
Acknowledgement

• Richard Fortinsky, PhD, University of Connecticut
  Center on Aging

3
1998

• Quality activities based entirely on agency
  preference and decisions
• Clinical data collected at the agency level with
  no consistency across agencies
• Payment based on a fee for service approach
• No way for consumers and payers to determine
  agency quality
• Agencies primarily dependent on their own
  resources for quality improvement activities

4
2003

• Clinical data collection involves collection of
  80 standardized items, the Outcomes and
  Assessment Information Set, integrated into
  agency data collection process
• Outcomes based quality improvement
  (OBQI)systematic approach to data collection and
  reporting provided by Centers for Medicare and
  Medicaid Services to agencies
• Outcomes based quality management (OBQM)non-risk
  adjusted case mix and adverse event reports

5
2003 contd

• Payment shifted to Prospective Payment System
  based on Home Health Resource Group
  classificationagencies paid by the episode (not
  to exceed 60 days)
• Public reporting of risk adjusted home care
  outcomes from CMS Home Health Compare
• Quality Improvement Organizations provide
  assistance and consultation for OBQI

6
OASIS as central
OBQI
OASIS
Systematic data collection on admission,
discharge, transfer, death
Public Reporting
OBQM
Case mix
Adverse events
Payment PPS
Quality Improvement Organizations
7
OBQI

• 41 risk adjusted measures focusing on agency
  level performance
• 11 of the 41 are publicly reported
• Primarily functional status orientation (25/41)
• Clinical items (7/41)
• Cognitive/behavioral (6/41)
• Utilization of other services (3/41)

8

• Selected through focus groups of Medicare
  beneficiaries identifying the outcomes important
  to them
• Agencies can pull down reports identifying their
  performance compared to their prior performance
  and the national average
• VOLUNTARY activity at present though regulatory
  changes expected after November election

9
OBQM

• Agency level case mix reports identifying common
  patient characteristics (demographic, functional,
  clinical)
• Adverse event reports13 potential problems
  derived from the OASIS, also not risk adjusted
• Adverse events relatively uncommonaverage
  occurrence 1 across agencies (Madigan, In press)

10
Changes in patients, visits and agencies

• Following the implementation of the 1997 Balanced
  Budget Amendment
• 21 reduction in the number of patients seen by
  home health care agencies
• 40 reduction in the number of visits
• HHC LOS average 31 days with 15 visits
• 33 closure/merger rate among agencies from 1996
  to 2000 (currently 7000 agencies)

11
OASIS reliability and validity

• Functional status items have higher inter-rater
  reliability than other dimensions with the most
  problematic items in the cognitive domain but
  overall reliability is adequate (Madigan
  Fortinsky, forthcoming)
• OASIS validity questionable for cognitive domain,
  particularly depression where mean CES-D score
  for 150 home care patients was 16, indicating
  need for further follow up

12
Important Questions

• Does OBQI result in improved outcomes?
• In a 200 agency demonstration project there were
  improvements in care from use of OBQI process
  (Shaughnessy et al., 2002). For the 6800 other
  agencies, the impact is unknown at present

13
Important Questions

• How accurately do home health care staff record
  OASIS data?
• Preliminary findings suggest that accuracy varies
  but is overall adequate. Anecdotal reports of
  disciplinary differences but not empirically
  validated

14
Important Questions

• What aspects of home care quality are missing
  from the current initiative?
• Patient compliance, the adequacy of patient
  teaching, use of evidence-based clinical
  guidelines to name only a few

15
Important Questions

• How can or should other stakeholders be involved
  in the current quality initiative?
• Physicians, referral sources, state agencies
  providing community-based long term care, other
  payers, patients and family members are not
  integrally involved yet have a stake in the
  outcomes

16
Whats next?

• ? Paying for quality
• ? Access issues for patients at high risk of not
  improving
• ? Many agencies are small and do not have quality
  experts on staff
• ?
• ?