Home Health & Hospice Week

Even more measures may be on the way.

Get ready for your publicly reported patient outcomes to increase by more than a third - at least.

After months of deliberations, the National Quality Forum has endorsed 15 quality measures for home health agencies. And the Centers for Medicare & Medicaid Services has accepted them, a CMS spokesperson tells Eli.

Seven of NQF's endorsed measures already are included in Home Health Compare, CMS' online outcomes comparison Web site. But eight measures have never been made public before (see next article).

Where's the fire?: CMS will include most of the new measures in a HHC update later this year, the CMS rep says. The quick adoption shows CMS' eagerness to embrace quality progress - the agency already announced in December that it would drop four measures and replace them with then-proposed NQF measures (see Eli's HCW, Vol. XIII, No. 45).

In addition to endorsing the 15 OASIS-based measures, NQF is still considering six measures (see box, next page), and has dropped seven measures altogether.

Ding Dong, the ACOVE Measures are Dead

HHAs are probably happiest about those measures that NQF dropped off its list, notes Chicago-based consultant Rebecca Friedman Zuber. Many provider groups roundly criticized the seven process-based measures proposed under the ACOVE (Assessing Care Of Vulnerable Elders) set.

The ACOVE standards, which included items such as "Comprehensive Geriatric Assessment" and "Asking About Falls," would have added a huge new data collection and reporting burden to HHAs, notes John Beard, president of Alacare Home Health & Hospice based in Birmingham, AL.

And the process-based ACOVE measures had only ever been tested in a managed care setting, Zuber notes.

"I'm relieved that the ACOVE measures went away for now," cheers Bob Wardwell with the Visiting Nurse Associations of America. They contained "just too many unknowns," says Wardwell, a former CMS top official.

New Outcomes Better, But Not Perfect

The new 15-measure set "will be an improvement over existing Home Health Compare measures," believes Stephen Connor, vice president of the National Hospice and Palliative Care Organization. Under the new arrangement, some of the current OASIS-based measures will be swapped out for better ones, says Connor, who serves on NQF's Home Health Steering Committee.

But HHAs still have plenty of bones to pick with certain measures. "There are a couple [endorsed measures] agencies won't be thrilled about," Zuber predicts.

For example, all of the emergent care and acute hospitalization outcomes shouldn't be publicly reported because they haven't been risk adjusted, Beard protests. Without risk adjustment, the measures "present the consumer with an inaccurate picture as to the quality of care." And they are misleading if a provider has programs attracting "the sickest of patients," Beard tells Eli.

Even the risk-adjusted outcomes make HHAs nervous, Wardwell says. "Everyone in the field wishes that they could have a greater degree of confidence in the risk adjustment methodology," he laments. CMS' reassurance that the risk adjustment methodology is good enough, but not perfect, "has to raise concerns."

HHAs also aren't happy with the urinary in-continence measure, Zuber adds. If agencies follow the OASIS manual instructions to the letter, "just about every patient you see will have urinary incontinence," Zuber criticizes.

Penalty: Because the instructions are confusing, agencies that complete the OASIS item correctly may end up looking like they have patients with a higher incidence of incontinence. And a usual home health episode rarely gives patients time to improve their in-continence, Zuber complains. Thus the measure doesn't really reflect what agencies are doing to improve patient outcomes.

Are More Outcomes Ahead?

Agencies will be happy that NQF seems to be heeding their concerns about three troublesome OASIS-based measures. Because the measures weren't approved by the requisite ratio of NQF members, the forum will take another close look at outcomes regarding oral medications, discharges and nursing home admissions (see box, next article) before voting on them again.

Three measures regarding hospice care are also on hold for now (see box,next article) NHPCO proposed the measures, which are not based on currently collected data. It appears NQF plans to address the measures in a separate project it's developing just for hospice providers, Connor reports.

Because the government has shown high interest in instituting patient outcomes, the hospice industry wants to make sure it comes up with its own measures, rather than having an outside party impose them, Connor says.

If enough NQF members approve the six measures under consideration in the general re-vote, the measures go back before the NQF Board of Directors for finalization, explains NQF spokesperson Phil Dunn. So, NQF could approve - and CMS could accept - a potential six more outcomes before the process is through.

NQF plans to update the home health measures every three years after endorsing the final measures this year, Dunn says.

Wait a minute: And while the already en-dorsed measures look like a pretty sure thing, any party can request a reconsideration of the recommendations until March 9, NQF notes in a release. 

Editor's Note: More information on the project is at www.qualityforum.org.