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Kathy Green, R.N., of Provider Solutions, has been in home healthcare for the past 15 years. She thanked AHRQ and CMS for making this meeting public. Anxiety in the home healthcare industry can be stabilized by informing industry members of the quality of this discussion.
Because OASIS and OBQI are new, agencies are just learning how to look at the information and select target outcomes. A steep learning curve is involved. The first indicators that are made public must be actionable to reassure the agencies. With its 2 years of data, CMS should be able to determine whether improvement has occurred (before making these measures public). Ms. Green encouraged AHRQ and CMS to analyze these numbers.
Stabilization measures are helpful to identify the poor performers in the industry. Stabilizing patients in the home has value to the consumer.
The measures CMS selects will become the focus of this industry. A CEO and administrator were overheard saying that they wanted to ensure that they did well in the public reporting because, if they did not, they would lose their jobs. The measures should be selected not only on the basis of the statistics, but also on the basis of what is needed to improve homecare.
Discussion
Ms. Bernard asked Ms. Green about the industry's potential response to rotating indicators. Ms. Green believed that these will be necessary. Most agencies, other than the poor performers, will eventually do well on the measures they select. Therefore, continuing to measure those outcomes will no longer have value. It will take 2 years for the agencies to improve, so that the measures should rotate every 2-3 years. Ms. Terry said that the rotation timeframe would be critical. Quarterly reports would be too frequent to show improvement. At least 6 months are needed. The timeframe must be long enough for agencies to be able to respond.
Ms. Bernard was interested to learn that the industry would shift its focus based on the measures selected. Measures in the final set should therefore be based on where practice needs to improve.
Dr. Fitzgerald appreciated Ms. Green's interest in stabilization indicators. Providers will continue to receive the entire 41-indicator set and will be able to focus on stabilization as a target for quality improvement. He asked whether Ms. Green was advocating for their incorporation into the CMS consumer reporting to identify poor performers or suggesting that they continue to be an area of focus. Ms. Green supported the inclusion of the stabilization measures in the CMS public reporting homecare indicators. The consumer has the right to see which agencies are poor performers, and the stabilization measures can identify poor performers in comparison with the improvement measures. An agency not meeting the criteria on three stabilization outcomes would be particularly revealing.
Ms. McCall pointed out that the process uses a positive framework whereas Ms. Green was suggesting that patients whose condition deteriorated be reported. Ms. Green clarified that the positive framework is appropriate. But stabilization measures would be useful for the public to observe whether an agency can stabilize its patients.
Dr. Fitzgerald reported that Delmarva is releasing OBQI on a national level. It has been piloted in five states, led by QIOs in those states. As of August, Delmarva and four other participating states were training QIOs around the country to implement OBQI with home health agencies. This will be ongoing for the next 3 years and will be released to home health agencies that volunteer to participate and learn about this programmatic approach to quality improvement that the University of Colorado researchers designed. Dr. Fitzgerald and his colleagues are very excited to be the lead QIO in this effort and look forward to working with the panel members in its implementation. Ms. Green believed that this presents an opportunity for home health agencies in that they will receive training and support to address quality improvement issues.
Dr. Shaughnessy emphasized how struck he and his colleagues have been by what homecare providers can do, often exceeding their own expectations for what they can accomplish. The OBQI process provides a framework that agencies can use to obtain useful data that shed light on what is happening to patients, and it is remarkable what can be done with those data. This process over time can make a significant difference for homecare. One of the original demonstration home health agencies recently presented the results of its 4 years of OBQI participation. Its most recent outcome report indicated nothing for the agency to address. In just 4 years, agencies can turn their practices around dramatically on all of the indicators.
Dr. Golden pointed out that public performance measures in long-term care have brought about enormous changes in the industry. Conversations and planning are occurring in his state that never would have happened without public reporting, even though the data have yet to be released. This has brought about a positive change in communication.
Dr. Fitzgerald agreed. Nursing homes were very anxious about the possibility of receiving many complaints once the information was made public, but this did not occur once they shifted their focus to quality improvement. Nursing homes addressed what these quantitative measures allowed them to know about where they could improve processes of care and how they could help each other. The effort successfully turned nursing home concerns into a successful focus on quality improvement.
Dr. Sangl asked participants to e-mail any additional comments to her.
Internet Citation:
Technical Expert Panel Meeting on Home Health Measures. October 21-22, 2002. Agency for Healthcare Research and Quality. Rockville, MD.
http://www.ahrq.gov/qual/nhqr02/hhmtep.htm