Home Health & Hospice Week

Number of process-based measures would replace patient outcomes.

An organization you may never have heard of could be deciding the fate of your Home Health Compare rating -- and whether a huge new burden will be placed on home health agencies.

The National Quality Forum has tentatively agreed on 29 new quality measures for home health agencies -- 22 for public reporting via Home Health Compare and seven for internal quality improvement purposes (see box, next page). The Centers for Medicare & Medicaid Services and HHAs will have to adopt the quality measures if the forum finalizes them under its consensus-building procedures, according to NQF spokesperson Phil Dunn.

NQF is an organization whose stakeholder members discuss and endorse quality measures for health care providers. They have already done so for provider groups such as hospitals and nursing homes, Dunn explains.

NQF doesn't develop the measures, but rather accepts submitted measures. For the home care measures, CMS, the National Hospice and Palliative Care Organization and Assessing Care of Vulnerable Elders were among those who submitted measures for consideration.

But CMS and NQF appear to disagree on whether Medicare really has to adopt the endorsed measures, says Bob Wardwell with the Visiting Nurse Associations of America. "The 64-dollar question is how many of the new measures will be required by Medicare," says Wardwell, a former CMS top official. "NQF and CMS seemed to be saying different things." And most agencies have no idea that their quality improvement workloads and ratings are hanging in the balance. Whether it means to or not, NQF "is flying under the radar," says Brian Ellsworth of the Connecticut Association forHome Care.

If NQF endorses and CMS adopts many of the existing OASIS-based measures plus the 11 new process measures, it could add up to "a big new burden on HHAs," Wardwell worries. If CMS decides to add all the new proposals on top of the existing quality measures, agencies will pay the price.

Although it may endorse the non-OASIS measures, NQF appears to think it is up to CMS to figure out how to implement them -- possibly including "an additional reporting burden" for agencies, Ells-worth cautions.

The home care industry has had a voice in the NQF process, with a number of providers and industry representatives on the home health steering committee. And interested parties will have plenty of chances to make comments on the proposed measures, Dunn points out.

The industry would welcome many changes to the current quality measures, Wardwell and Ellsworth agree. The steering committee proposes to dump four of the 11 current Home Health Compare measures -- upper body dressing, bathing, toileting and confusion frequency. Agencies have railed against those Home Health Compare items and other outcome-based quality improvement (OBQI) measures, saying there was little they could do to influence those outcomes.

"There was a clear concern by the committee about measures that were not 'actionable,'" says Ellsworth, who attended the July 21 NQF meeting. The committee didn't want to hold agencies responsible for outcomes they could do little to improve.

"The discussion and process should put some pressure on CMS to fix the problems with the OBQI measures that we have been complaining about for two years to no effect," Wardwell cheers. "Some of the measures that failed did so because they were widely known to be problematic and not resolved."

Many questions remain about the newly recommended measures, and the process is in its early stages. More details about the new non-OASIS measures will be provided in NQF's forthcoming report, Ellsworth notes.

And NQF proposed measures for HHAs, hospices and infusion providers all together, Wardwell points out. "The question of what standards will apply to whom and when" must be answered, he says.

Editor's Note: A description of the home care project and list of steering committee members is at www.qualityforum.org/txhomehealthNQFprojsummaryFINAL+SCroster.pdf