Contents
Participants
Welcome, Introductions, and Purpose of the Meeting
Background, Context, Measure Review Criteria, and Review Process
OASIS Measures Development and Use in Quality Improvement
Overview of OASIS Measure Properties
Review of the Measures
Outstanding Issues Regarding Individual Participants' Prioritization of Measures
Individual Participants' Prioritization of the Measures
Outstanding Issues Raised During the Course of the Meeting
Public Comment
Participants
Panel Members
Shulamit Bernard, Ph.D., R.N., RTI International
Suzanne Clark, R.N., Office of Health Care Quality, State of Maryland
Julie Crocker, M.S.N., R.N., Delmarva Foundation for Medical Care (by telephone)
Carol Cronin, M.S.W., M.S.G., Annapolis, MD
Matthew Fitzgerald, Ph.D., Delmarva Foundation for Medical Care
Phyllis Fredland, R.N., Health Personnel, Inc.
William E. Golden, M.D., F.A.C.P., University of Arkansas for Medical Sciences
Rhonda Ketcham, R.N., Christiana Visiting Nurse Association
Brian W. Lindberg, M.M.H.S., Consumer Coalition for Quality Health Care
Nelda McCall, M.S., Laguna Research Associates
Jeanne McGee, Ph.D., McGee & Evers Consulting, Inc.
Christopher Murtaugh, Ph.D., Visiting Nurse Service of New York
Mary Nguyen, R.N., Welcome Homecare
Frances B. Petrella, R.N., Outcome Concept Systems, Inc.
Robin E. Remsburg, Ph.D., R.N., National Center for Health Statistics
Debra Saliba, M.D., M.P.H., RAND
Linda Scott, M.S.H.A., R.N., Johns Hopkins Home Care Group
Pamela Teenier, R.N., Gentiva Health Services
Margaret Terry, R.N., MedStar Health Visiting Nurse Association
Speakers
Kathy Crisler, R.N., M.S., University of Colorado
Margaret Gerteis, Ph.D., BearingPoint (formerly known as Barents)
David Hittle, Ph.D., University of Colorado
Pete Shaughnessy, Ph.D., University of Colorado
Agency for Healthcare Research and Quality
Carolyn Clancy, M.D., Acting Director
Judith Sangl, Sc.D., Health Scienctist Administrator, Center for Quality Improvement and Patient Safety
Edward Kelley, Ph.D., Senior Service Fellow, National Healthcare Quality Report
Beth Kosiak, Ph.D., National Healthcare Quality Report
Centers for Medicare & Medicaid Services
Paul Elstein, Ph.D., Deputy Director, Quality Measurement and Health Assessment Group
Barbara Paul, M.D., Medical Officer, Center for Medicare Management
Armen Thoumaian, Ph.D., L.C.S.W.,Health Program Evaluation Officer
Mary Wheeler, M.S., R.N., Project Officer
Facilitator
Larry Bartlett, Ph.D., Health Systems Research
Carolyn Clancy, M.D., welcomed participants to the Technical Expert Panel Meeting on Home Health Measures. Dr. Clancy expressed her excitement at collaborating with colleagues from CMS on this important initiative. As interest in quality of care grows and intensifies, it raises many questions about how to ensure that quality is high and which measures are the right ones to use. Secretary of Health and Human Services Tommy Thompson and Tom Scully of CMS are intensely interested in these issues and are clearly not alone. This is the context for this meeting.
Although AHRQ does not run programs, it has made important contributions to the support and development of measures and often seeks opportunities to share the results of its research with colleagues from CMS and others in the Department. Within a year, AHRQ will produce the first-ever National Healthcare Quality Report (NHQR), which will provide the Nation with a picture of the healthcare system's current status. Home healthcare measures will be a component of the report. CMS plans to use the measures even before the report is completed. AHRQ is excited about these parallel efforts and the resulting collegial activity.
This is a public meeting that will offer an opportunity for public comment. The summary of the discussions at the meeting will be available for public input.
Dr. Clancy noted the impressive mix of expertise around the table and thanked the expert panel members for the hard work they would do over the course of the meeting. She predicted that participants would leave the meeting knowing that they have contributed to something important.
Dr. Clancy's opening remarks were followed by introductions by the expert panel members and other meeting participants.
The National Healthcare Quality Report
Ed Kelley, Ph.D., thanked the organizers of the meeting for their hard work to ensure that the appropriate people were selected for the panel.
The NHQR was mandated by Congress in the Healthcare Research and Quality Act, and will:
Before embarking on this initiative, AHRQ sought assistance from the Institute of Medicine (IOM) to establish boundaries. The resulting report, Envisioning the National Healthcare Quality Report, provided a framework that included a matrix incorporating consumer perspectives on healthcare needs (staying healthy, getting better, living with illness or disability, and coping with the end of life) and measures from the IOM's "Chasm" report (effectiveness, safety, timeliness, and patient-centeredness). Equity and efficiency would be addressed throughout the NHQR.
With this guidance from the IOM and Congress, AHRQ began to flesh out the NHQR framework. Dr. Kelley and his colleagues identified key aspects of care and issued a call for measures to populate this framework, which they reviewed according to the criteria in the IOM report. AHRQ wanted the national report to be based on an open process and consensus on measurement so that when it came out, the reactions would focus on content, rather than on whether the measures were appropriate. The clinical areas for measurement in the NHQR are based on the areas identified in Healthy People 2010, which include long-term care. Although homecare might fit into many categories in the NHQR, it is discussed under long-term care.
The need for home health quality measures in the NHQR is acute. AHRQ issued a call in the Federal Register on August 19 for measures and held a public meeting sponsored by the National Committee on Vital and Health Statistics. The agency also received input from the IOM committee and other experts. Dr. Kelley emphasized that the report that will be issued in September 2003 will be an initial report, and he expects the process of developing the NHQR to be refined over time.
AHRQ had not originally planned to include homecare in the first report because the measure development is not complete, but feedback emphasized the importance of including this important area. Therefore, AHRQ plans to address home healthcare in the first report.
CMS Public Reporting Activities/Review Criteria
Barbara Paul, M.D., added her thanks to AHRQ and CMS staffs that planned this meeting.
CMS uses many strategies to purchase high quality healthcare with taxpayer dollars. These include establishing and enforcing standards; providing plans, physicians, and providers with technical assistance; promoting or creating collaborations and partnerships; giving consumers assistance and information to help make choices; structuring coverage and payments to improve care; and rewarding desired performance. CMS has found that these strategies improve performance and improving performance improves the quality of the care delivered.
CMS launched Managed Care Plan Compare on its Web site in January 1999, Dialysis Facility Compare in January 2001, and Nursing Home Compare this year. The home healthcare quality initiative will be launched in 2003. The measures that the expert panel members help prioritize will assist CMS in deciding which measures to use in Home Healthcare Compare. These measures will be used by CMS to report on the quality of care provided by home healthcare agencies across the Nation.
The CMS home healthcare agency initiative has four parts:
CMS expects to meet with experts again in a year to take into account lessons learned from this process and decide which measures should become standard in homecare.
Armen Thoumaian, Ph.D., discussed the Outcome and Assessment Information Set (OASIS), an instrument created over a 14-year period to measure functional outcomes for improving quality of care. It was developed through a scientific process, using input from the home healthcare industry, and was tested for validity and reliability. The instrument was implemented nationwide in October 1999.
Outcome-Based Quality Improvement (OBQI) reports based on the OASIS measures assist healthcare agencies in quality improvement for Medicare beneficiaries and all patients. Home healthcare agencies use the reports to target outcomes for improvement, compare the behaviors they use to treat patients with best practice behaviors, identify the behaviors they need to change for improvement, develop and implement plans, and assess their improvement rates over time.
Dr. Thoumaian hoped that the expert panel members would develop a list of measures that provide meaningful information to consumers in deciding where to obtain the highest quality home healthcare services. The measures chosen should provide a fair and equitable view of the quality of care provided by the home health agency, be easy to interpret by the public, and not be open to misinterpretation. In addition, the public disclosure of the measures should not unfairly harm home health agencies or compromise the reporting of accurate OASIS data. Finally, the measures chosen should help provide home health agencies with incentives to use the outcomes of the measurement to improve quality of care.
Discussion
Focus groups conducted by Nelda McCall indicated that the physician usually decides which home health agency to use. Educating consumers is important, but they rarely make decisions about agencies. Dr. Paul added that CMS also learned from focus groups that patients seek advice from their physicians in selecting a hospital. Dr. Kelley called for the NHQR measures to address all aspects of quality of care and be meaningful. The meaningfulness and robustness of the measures should address multiple constituencies.
Larry Bartlett, Ph.D., pointed out that the measure review criteria include policymakers and consumers as targets for meaningfulness and consider whether policymakers include providers. Dr. Paul suggested that providers are consumers in the sense that they consume information. This category can also include nurses, potential patients, and others. Pete Shaughnessy, Ph.D., added that the OASIS consensus panels were multidisciplinary and many physicians had input into these measures.
Jeanne McGee, Ph.D., asked about CMS plans for the reporting and distribution of a report oriented toward a consumer audience. Dr. Paul replied that CMS will offer this information through a Web site (Medicare.gov), as it did with Nursing Home Compare. The agency might also purchase advertisements.
Suzanne Clark, R.N., noted that, in many cases, neither the patient nor the physician has much choice about agencies, because the insurer dictates who will provide the homecare service. Moreover, the homecare services that are provided are often very brief. Experts need to keep this in mind in deciding how to improve the care that patients receive.
Dr. Bartlett emphasized that this expert panel is not a formal federal advisory committee, and AHRQ and CMS would not seek consensus. At the end of the second day, the panel members would be asked to bring together their values, insights, and knowledge about measures to provide input to AHRQ, which will provide input to CMS. OASIS includes 41 measures, all of which are strong, and expert panel members would need to pick the top 12 or 13 of these for the NHQR and the top 12 or 13 for CMS public reporting. These two lists might or might not overlap.
Margaret Terry, R.N., asked whether the criteria for the measures included reliability, which was listed in the IOM report but not in the notebook, unless it falls under scientific soundness. Dr. Bartlett said that reliability belongs under scientific soundness. Dr. Kelley added that a great deal of work went into developing OASIS and making sure that its measures are valid and reliable. But this does not mean that panel members should not consider reliability in making their choices.
Carol Cronin, M.S.W., asked about the total number of measures in the OASIS set. Dr. Thoumaian replied that the 41 measures to be considered by the panel are a subset of the 54 measures in OASIS. CMS and AHRQ are focusing on the 41 measures because they assess long-term quality improvement issues that every home health agency should address, and are applicable to much of the home health care patient population. The other 13 measures are fairly rare events.
Rhonda Ketcham, R.N., asked whether the reporting will be in the form of general measures or based on specific diagnoses. A consumer needing bypass surgery, for example, would be interested in outcomes related to recovery from bypass surgery, not generic measures. Matthew Fitzgerald, Ph.D., asked whether the 41 OASIS measures represent the universe of potential measures for public reporting. Quality improvement has seen advocacy for outcome measurement but, as a result, process measures have been all but forgotten. OASIS does not have clinically specific process-of-care measures related to specific clinical areas that are actionable. Often, when outcome measures are used in quality improvement, process-of-care measures are used to identify tangible steps that providers can take to achieve the desired outcomes.
Dr. Thoumaian replied that the OASIS measures are not specific to particular diagnoses. The functional outcomes they measure apply to many diagnoses. Ambulation, for example, is important in many diagnoses. Perhaps in a few years, with advances in research, disease-specific measures may be added. Dr. Bartlett said the focus at the meeting would be on existing OASIS measures.
Christopher Murtaugh, Ph.D., pointed out that the nursing home quality indicators include a set for chronic care long-term patients and a set for post-acute, short-term patients. He asked whether AHRQ and CMS have considered arranging the measures in a similar way. Dr. Paul replied that CMS has no such plan. The 41 OBQI indicators are considered a starting point, and represent a different model than that used for nursing homes. Dr. Thoumaian added that long-term care is a continuum. A primary aim of homecare is rehabilitation, and chronic patients are not always eligible for Medicare homecare. In the future, the measures may distinguish between patients who shift from homecare to a nursing home and patients who are rehabilitated. Dr. Murtaugh pointed out that goals for post-acute care patients and chronic care patients are different.