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Dr. Bartlett reminded panel members that they had deferred discussing the following issues:
Dr. Bartlett asked panel members to discuss these issues and suggest actions that advance the process.
Dr. Golden asked whether the NHQR and CMS public reporting must be based on OASIS. It would be of interest, for example, to know about patients admitted to the hospital within 30 days of discharge from home healthcare. This could be collected administratively. Patients may want to know the no-show rate of the home health personnel, which is a major issue in Dr. Golden's community. Patient/family satisfaction is another important area. Dr. Kosiak replied that AHRQ must be consistent with other measure sets and, in the case of home healthcare, would like to be consistent with what CMS is likely to use, although AHRQ is not constrained by CMS's decision. AHRQ would be interested in learning that no useful measure is available in OASIS or a more useful measure is available from a reliable data source.
Ms. Terry asked about the timeframe for CMS public reporting. Risk-adjustment information should be available for the pilot, because on some of these outcomes, this is needed to show how the agency did in terms of expected/observed outcomes. Ms. Teenier added a request for clarification on the process involved, and whether others will have an opportunity to contribute to that process.
Paul Elstein, Ph.D., replied that CMS plans to select five or six states and is currently developing selection criteria, including geographic variation, participation in the OBQI pilot (although other states will also participate), mix of agencies, and mix of beneficiaries (urban/rural, racial/ethnic groups). The first round will probably take place in early April. CMS would prefer that the measures be risk-adjusted. How CMS will present those measures will require much discussion with many people, including persons at this meeting. With nursing homes, CMS listed the percentage of pressure ulcers and compared that to the state and national rates. With home healthcare, this must still be worked out. One reason why CMS requested this panel was to obtain assistance from people knowledgeable about consumer measurement in selecting measures that meet those criteria. Whatever measures CMS selects will pass through a to-be-determined vetting process. When the public reporting begins next October, CMS may learn things that change some of the measures.
Ms. Fredland pointed out that the discussion did not address wording of the measures. The consumer community ranges from very sophisticated to developmentally disabled, therefore wording is a major issue.
Ms. McCall cited a need to broaden the consideration of homecare issues to the entire long-term care delivery system. Sometimes the focus is only on the service and protecting the industry that provides that service, yet this service is part of a continuum of long term care. Ms. McCall encouraged CMS to keep this in mind as it continues to develop its public reporting system. The focus should be in the whole patient as he or she moves through the health system.
Ms. Scott expressed concern that the consumers who need the information on homecare agencies might not have access to the Internet and therefore CMS public reporting. She was concerned about the difficulty of understanding the measures. Public reporting does create an incentive to make changes, but it must be written in plain language. A provider's ability to use the information to improve patient care will depend on its ability to understand how it is measured.
Home health providers work under the direction of physicians. Each patient has his or her own physician who is responsible for developing a plan of care, including a set of orders to be carried out by agency staff. If home health agencies are not successful in advocating for the patient or encouraging the physician to issue the kinds of orders that the agency knows will make a difference, this may result in suboptimal outcomes for patients and may be reflected in the agency's report cards. As a result, the report cards may diminish access to care.
Dr. Kosiak pointed out that patients do not know who is responsible for particular aspects of care and are only concerned about whether they will receive the care they need from the home health agency. No hand-off measures are available, and several panel members mentioned the ramifications of this. For example, a home health agency might be penalized because of communication problems with the previous provider. Perhaps this issue falls under patient-centeredness, which is of concern to AHRQ. If these issues were measured and improved, this would help patients obtain more seamless care. Dr. Fitzgerald agreed. Transition indicators to assess the move from one delivery modality to another are needed. These would figure most appropriately in the AHRQ report as indicators of global quality. The OASIS indicator set is an appropriate place to start, but the natural evolution of this indicator set would be to address home healthcare discharge, patient satisfaction, and disease-specific process indicators.
Ms. Ketcham would like to see the selected measures lead to funding for research to identify the top performers along these measures, in order to identify best practices to help other agencies.
Dr. Bernard pointed out that a colleague of hers at RTI, Lucy Savitz, gave a presentation at AHRQ on a study to accelerate the cycle of research through integrated delivery systems, focusing on what happens to medications during hand-offs. Information on this study is available to AHRQ.
Dr. Golden agreed that hand-offs are a problem in medicine, period. This is a neglected area in the health system.
Dr. Sangl expressed her appreciation to all of the panel members for their competing views from a wide range of areas of expertise. This was exactly what the sponsoring agencies were seeking for each of the measures. Dr. Sangl expressed special thanks to the researchers from the University of Colorado for their help to panel members in interpreting the measures. AHRQ would prepare a summary report for CMS for consideration in the public reporting measures that it will issue shortly. AHRQ will also use the discussions to help select the best set of measures from existing data for the NHQR and ideas for future research on other measures. AHRQ will solicit public comment on the measures for the NHQR. When AHRQ first issued its entire candidate measure set, the home health section was blank. AHRQ plans to use the opportunity presented by this meeting to obtain public feedback on the home healthcare measures.
Ms. Teenier asked whether the recommendation to CMS would be made public. Dr. Sangl replied that these details have not been worked out yet. Some type of public report will be available. The AHRQ Public Affairs contact is Farah Englert at (301) 427-1865.