How many home health care patients experience improvement in activities of daily living? How many are hospitalized?

Functional outcomes improved for 39 percent to 62 percent of Medicare and Medicaid home health care patients who received services from Medicare-certified home health agencies during 2005, representing an increase of 2 to 6 percentage points from rates in 2002. The hospitalization rate remained constant at 28 percent of these patients from 2002 to 2005.

Why is this important?

Medicare plays an important role in setting quality standards for home health agencies. As a condition of participation in Medicare, home health agencies must undergo periodic quality assurance surveys, develop continuous quality improvement programs, and collect standard patient assessment data for both Medicare and Medicaid patients. The Centers for Medicare and Medicaid Services uses these data to publish comparative agency-specific outcomes of care (CMS 2006a).

In 2004, Medicare and Medicaid paid $30 billion of the $43 billion spent on home health care in the U.S. (Smith et al. 2006). The goal of home health care is to enable homebound individuals to remain as functional and independent as possible, thereby avoiding institutional care (CMS 2003). Covered services may include skilled nursing and aide services, physical and occupational therapy, speech pathology services, and medical social work provided in accordance with a physician's care plan.

Findings

From 2002 to 2005, functional outcomes for adult Medicare and Medicaid patients (ages 18 and older) served by Medicare-certified home health agencies improved steadily but modestly (by 2 to 6 percentage points) across seven publicly reported measures. The proportion of patients whose outcomes improved ranged from 34 to 57 percent in 2002 and from 39 to 62 percent in 2005 (AHRQ 2004; AHRQ 2005; CMS 2006).

• In 2004, the best state performance on any measure was 73 percent for improvement in pain among patients in the District of Columbia. This rate was 14 percentage points higher than the median rate (the state in the middle of the range) and 22 percentage points higher than the rate in Louisiana, the worse-performing state on this measure.
• On the other hand, the best state performance for improvement in locomotion was only 42 percent (South Carolina), which was only 5 percentage points higher than the median rate and 10 percentage points higher than the rate in the worst performing state (Wyoming) on this measure (AHRQ 2005).

The proportion of home health patients who were hospitalized remained constant at 28 percent from 2002 to 2005. Interstate variation in hospitalization rates increased from 13 percentage points in 2002 to 21 percentage points in 2005 as performance in the best state got better and performance in the worst state got worse (AHRQ 2004; AHRQ 2005; CMS 2006).

Implications

Outcome assessment and reporting provide a way to monitor and encourage improvement in the quality of home health care and may be especially important given the incentives for undertreatment inherent in Medicare's prospective payment system (which pays home health agencies a flat fee for an episode of care).

Improvement Ideas and Resources

The Medicare Payment Advisory Commission (MedPAC) recommends that the Medicare program financially reward home health agencies for providing high-quality care or improving their performance (MedPAC 2005). The Commission and others recommend development of process-of-care measures applicable to all home health patients, including those whose function is not improving. For example, MedPAC's analysis suggested the potential for identifying best practices to prevent patient falls and improve wound care (MedPAC 2006).

• Promising technologies that might help improve home health quality include electronic patient records, clinical reminders, and home telehealth monitoring systems to facilitate patient management and patient-provider communication (Feldman et al. 2005; Hersh et al. 2006; McCarthy and Fox 2006; MedPAC 2005, 2006).
• Although hospital admissions are sometimes planned or necessary to provide optimal care, some home health agencies have reduced their occurrence through proactive needs assessment, plans of action, and coordination with the patient's physician to provide timely care interventions (Richard et al. 2000; Shaughnessy et al. 2002a; 2002b).

Measure:

Home health outcome measures have been endorsed by the National Quality Forum (NQF 2005) and the Agency for Healthcare Research and Quality (AHRQ 2005a). The population is adult, nonmaternity patients (ages 18 and older) of Medicare-certified home health agencies whose care was paid for by Medicare or Medicaid. The denominator for each measure is restricted to the applicable subset of the population whose episode of care began and ended in the survey year. Changes in functional outcomes are measured by comparing a patient's assessment at admission (or resumption of care following an inpatient facility stay) to their score at discharge from home care (or admission to an inpatient facility). Measures of improvement exclude episodes of care for patients already at the highest assessment level, since their outcomes cannot improve. Agency rates and state averages are adjusted to account for differences in patient characteristics that can affect patients' likelihood of improvement (CMS 2006a, 2006b).

Limitations:

OASIS data are not representative of all home health care patients. In particular, OASIS excludes private-pay and managed care patients. Different measures have different assessment scales (e.g., a three-point scale for oral medication management versus a six-point scale for bathing), which might influence rates of improvement. Also, "appropriate clinical benchmarks based on best clinical practice for many . . . measures are unknown either on a theoretical basis or in terms of what is clinical achievable" (Sangl et al. 2005).

Source:

The Outcome and Assessment Information Set (OASIS) is "a group of data elements that represent core items of a comprehensive assessment for an adult home care patient. . . . Skilled home health staff gather the information by observing the patient and the patient's home and situation, and by talking with the patient and caregivers" (CMS 2006a). Interrater reliability is substantial to excellent (Sangl et al. 2005). Results are reported by the Agency for Healthcare Research and Quality(AHRQ 2004, 2005b) and the Centers for Medicare and Medicaid Services on the Home Health Compare Web site (CMS 2006a).

References:

* Indicates source of data used in the chart(s).* AHRQ (Agency for Healthcare Research and Quality). 2004. National Healthcare Quality Report, 2004. AHRQ Pub. No. 05-0013. Rockville, Md.: U.S. Department of Health and Human Services.AHRQ (Agency for Healthcare Research and Quality). 2005a. AHRQ Report on Home Health Quality Measures for CMS Public Reporting: Results of Technical Expert Panel Meeting and AHRQ Recommendations. Rockville, Md.: U.S. Department of Health and Human Services. * AHRQ (Agency for Healthcare Research and Quality). 2005b. National Healthcare Quality Report, 2005. AHRQ Publication No. 06-0018. Rockville, Md.: U.S. Department of Health and Human Services.CMS (Centers for Medicare and Medicaid Services). 2003. Medicare Quality Improvement Priorities. CMS Pub. No. 11041. Baltimore, Md.: U.S. Department of Health and Human Services. * CMS (Centers for Medicare and Medicaid Services). 2006a. Home Health Compare. Rockville, Md.: U.S. Department of Health and Human Services. CMS (Centers for Medicare and Medicaid Services). 2006b. Home Health Quality Initiative. Baltimore, Md.: U.S. Department of Health and Human Services. Feldman, P. H., C. M. Murtaugh, L. E. Pezzin et al. 2005. Just-in-Time Evidence-Based E-Mail 'Reminders' in Home Health Care: Impact on Patient Outcomes. Health Services Research 40 (3): 865–85. Hersh, W. R., D. H. Hickam, S. M. Severance et al. 2006. Telemedicine for the Medicare population: Update. Evidence Report/Technology Assessment No. 131. Rockville, Md.: Agency for Healthcare Research and Quality. McCarthy, D., and K. Fox. 2006. Case Study: University of Tennessee Health Science Center's Telehealth Network. Quality Matters (March). New York: The Commonwealth Fund. MedPAC. 2005. Strategies to Improve Care: Pay for Performance and Information Technology. Chapter 4. In Report to the Congress: Medicare Payment Policy, 183–225. Washington, D.C.: Medicare Payment Advisory Commission. MedPAC. 2006. Adding Quality Measures in Home Health. Chapter 5. In Report to the Congress: Increasing the Value of Medicare, 103–113. Washington, D.C.: Medicare Payment Advisory Commission. NQF (National Quality Forum). 2005. National Voluntary Consensus Standards for Home Health Care. Washington, D.C.: National Quality Forum. Richard, A. A., K. S. Crisler, and P. M. Stearns. 2000. Using OASIS for Outcome-Based Quality Improvement. Home Healthcare Nurse 18 (4): 232–7. Sangl, J., D. Saliba, D. R. Gifford et al. 2005. Challenges in Measuring Nursing Home and Home Health Quality: Lessons from the First National Healthcare Quality Report. Medical Care 43 (3 Suppl): I24–32. Shaughnessy, P. W., K. S. Crisler, D. F. Hittle et al. 2002a. OASIS and Outcome-Based Quality Improvement in Home Health Care: Research and Demonstration Findings, Policy Implications, and Considerations for Future Change. Denver, Colo.: University of Colorado Health Science Center, Center for Health Services Research. Shaughnessy, P. W., D. F. Hittle, K. S. Crisler et al. 2002b. Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement. Journal of the American Geriatrics Society 50 (8): 1354–4. Smith, C., C. Cowan, S. Heffler et al. 2006. National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending. Health Affairs (Millwood) 25 (1): 186–96.