Home Health & Hospice Week

It's not hard to guess where Medicare's home health quality initiative is headed - just take a look at the same initiative for skilled nursing facilities.

The Centers for Medicare & Medicaid Services has expanded the nursing home quality initiative by revising and increasing the number of SNF patient outcomes displayed on its Nursing Home Compare Web site.

"Several of the initial quality measures remain unchanged, others have been revised, and several new clinical topics were added, providing a more comprehensive view of nursing home care," said California Quality Improvement Organization Lumetra in announcing the change.

Nursing Home Compare originally displayed 10 patient outcomes - or "quality measures" as CMS calls them - when it launched in November 2002, while Home Health Compare began displaying 11 outcomes at its debut almost three months ago (see Eli's HCW, Vol. XII, No. 33, p. 258). Nursing Home Compare now boasts 14 outcomes, and HHAs can expect a "parallel" increase, predicts Bob Wardwell with the Visiting Nurse Associations of America.

But those changes probably won't come for another year or so, forecasts Heather Vasek with the Texas Association for Home Care. CMS has said it would review the outcomes annually, so the earliest changes might take place would be next fall, Vasek expects.

If CMS decides to increase the number of patient outcomes displayed on Home Health Compare as it did for nursing homes, it will mean "more of a headache" for beleaguered agencies, Vasek tells Eli. Many agencies already are bewildered by the outcome-based quality improvement process that is supposed to help them improve their patient outcomes, and adding more outcomes to the list will only add to the confusion.

Agencies that fail to master OBQI practices could find they have more than just embarrassing public scores to worry about. In announcing the changes to the nursing home measures, CMS noted that one measure in particular may indicate a quality of care problem among nursing homes.

Nursing homes have worse scores on pressure ulcers in 82 percent of states. "This change may or may not mean that clinical care has deteriorated," CMS says in a release. "CMS and the QIOs are working closely with nursing homes to monitor this, and assure that care does indeed improve."

That probably will mean more intense regulatory scrutiny of the issue, and possible resulting survey crackdowns in the area. If HHAs show declining scores on some of their outcomes, they can expect similar scrutiny, experts warn.

CMS also touted three outcomes that have improved under NHQI - chronic pain, physical restraints and short-stay residents' pain.

Industry Not Sold on HHQI

Adding a few more outcomes to Home Health Compare is unlikely to make determining HHAs' quality of care any easier, says Wardwell, a former CMS official. "Getting at the issue of quality via the Web site is more complicated than most consumers can really digest, particularly when they are in crisis," Wardwell observes. "Moreover, quality certainly cannot be reduced to the handful of measures published for home health to date."

Home Health Compare is merely one tool and is "certainly not comprehensive," he adds.

HHAs haven't exactly embraced the initiative with open arms. For one, very few patients or referral sources seem to use the site, Vasek says. Because it's only been "a little blip on their radar screens," most agencies haven't attached much importance to it.

And agencies have been frustrated by CMS' failure to address the limitations of the system - or at least talk about them. Wardwell is "really disappointed that CMS has not been more open and forthcoming on improvements to the OASIS and the resulting quality measures," he says. "Taking in hundreds of suggestions for OASIS improvement and then giving no feedback for more than a year is probably not the best way to approach the concerns the home health community has expressed," he maintains. v

Editor's Note: A comparison of the old and new nursing home outcomes is at www.cms.hhs.gov/quality/nhqi/Preview.pdf.