Home Health & Hospice Week

Home care is not the same as inpatient care, commenters told CMS.

Many commenters on the 2016 home health PPS proposed rule support Medicare’s intention to add a pressure ulcer quality measure. But home health agencies do want to see some important changes.

The Centers for Medicare & Medicaid Services is “considering whether body mass index (BMI) should be used as a covariate for risk-adjusting NQF #0678 in the home health setting, as is done in other post-acute care settings,” the agency said in the proposed rule.

In a draft of the OASIS changes necessary for the measure, height and weight are included in a new M item: “Height and Weight — While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up.”

Part A of the draft item states “Height (in inches). Record most recent height measure since the most recent SOC/ROC.” Part B says “Weight (in pounds). Base weight on most recent measure in last 3 days; measure weight consistently, according to standard agency practice (e.g., in a.m. after voiding, before meal, with shoes pounds off, etc.).”

How To Measure?

Obtaining weight presents a much bigger challenge in home care than other settings, commenters told the agency. The pressure ulcer measure “is a great tool for CMS to use on MDS assessments for SNFs and LTCs, but it is not appropriate for Home Care providers unless the requirement for an accurate height and weight is removed,” said Marlene Seerup from Minnesota in her comment letter. “As a home care provider, I know that it is often difficult if not impossible to obtain an accurate height and especially weight on a patient who is confined to their home and at the greatest risk of developing pressure ulcers. If they are in a wheelchair and/or bedbound, the only way to obtain a weight is if the patient has a scale on their bed which is very unusual,” she said.

“In a facility, they have access to w/c scales and scales on hoyer lifts. Home Care patients do not have these options,” Seerup continued. “The majority of the time, if the patient has a transfer lift device, it is a hand-cranked device with no scale.” Patients often aren’t able to leave their homes for physician appointments, “so they do not have the option of being weighed there either,” she added. “This is just not a feasible expectation for Home Care patients.”

If a patient’s medical condition “does not support a need for ongoing assessment of weight, the absence of a scale would not be addressed as part of the plan of care,” pointed out a letter from St. Joseph’s Home Care in New York.

Clinicians can ask patients their height or consult the medical record, St. Joseph’s noted. “‘Reported’ heights would likely be documented for many patients but the reliability of the reports is questionable, especially as patients’ age increases and they suffer from both spinal compression and memory deficits.”

Wrinkle: “I am not clear what is meant by ‘base weight’” in Part B of the draft item, the rep from St. Joseph’s said. “I would want to be very clear with staff about the expectation for recording a weight which is measured during the visit versus a weight which could be reported by the patient based on an ‘in home’ measurement or based [on] a recent MD appointment or hospitalization.”

Dump The Items, HHAs Urge

Multiple providers suggested scrapping the height and weight requirements altogether. “I do like the overall concept of the proposed change, but in order for it to be successful, CMS does need to remove the BMI requirement,” Seerup said.

Alternative: The items “may provide much benefit,” said Bay Area Hospital Home Health in Oregon, in its comment letter. CMS could make them workable by adding “an option/box to allow for those patients who cannot be weighed (unable to bear weight, bedbound, etc.). Additional boxes might include ‘unable to weigh;’ ‘not addressed’ or ‘other.’”

Suggestion: The new items are valuable, because “the correlation of low BMI and incidence of pressure ulcers is inarguable,” said Barbara Dale of Tennessee in her comment letter. “However, I  would urge the consideration of a high BMI to be included in the OASIS data set. Numerous articles are available with good quality evidence that a BMI above 40 can also increase the risk of pressure ulcers.”

Note: See the draft OASIS changes at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-January_2017_July2015.pdf.