Home Health & Hospice Week

Beware hidden costs of process measures.

Process-based quality measures could become part of home health agencies' pay for performance framework, if the Medicare Payment Advisory Commission gets its way.

The influential advisory body to Congress is considering recommending in its June report that lawmakers mandate new process-based measures for HHAs, according to the Commission's meeting this month. That's opposed to the current patient outcome measures, which gauge a home health patient's condition rather than steps the agency took.

Process-based measures that focus on safety are necessary because they measure what is under an HHA's control, rather than a patient outcome influenced by many factors not under the agency's control. For example, "it was difficult for some agencies to concede that a fall that happened on a Wednesday when their nurse hadn't been there all week could really be directly attributed to the quality of their fall prevention practices," MedPAC staffer Sharon Cheng said in the meeting.

Agencies vary widely in practices, and process measures could help standardize those. Process measures would also encourage evidence-based practices, Cheng said.

Some of the specific process measures MedPAC favors would also encourage providers to adopt new technology. And MedPAC would like to see broader quality measures in place for home health when P4P is implemented, Cheng added.

Standardized Assessments Recommended

An expert panel convened by the commission focused on two areas for process measures: fall prevention and wound care.

Recommended process measures for fall prevention include a standardized fall risk assessment tool applied to all patients, "validated techniques" to measure risk assessment, and linking the risk assessment to followup. Examples of validated techniques are measuring postural hypotension and asking a patient to stand on one foot for 10 seconds.

Recommended process measures for wound care include a standardized wound assessment for all patients, taking wound images, pressure wound clinical techniques, an infection control strategy and standardized wound bed preparation, MedPAC staffer Sarah Friedman noted in the meeting.

Wait a minute: But whether MedPAC will actually recommend those measures is still unclear. Commissioners expressed concerns about endorsing more quality measures for HHAs.

MedPAC hasn't "gotten into the business of developing process measures or practice guidelines," Commissioner Alan Nelson noted in the meeting. Developing such measures would be more appropriate for the Centers for Medicare & Medicaid Services, the HHS Agency for Healthcare Research and Quality or the home health community, Nelson suggested.

Bob Wardwell with the Visiting Nurse Associations of America agrees. Home health trade groups "are working very hard to develop principles and specific recommendations on P4P quality measures," says Wardwell, a former top CMS official. "If CMS will work cooperatively with the home health community, we can move to a set of measures that most folks will find satisfactory."

Safety surrounding wounds and falls is very important, says consultant Regina McNamara with Kelsco Consulting Group in Cheshire, CT. But many of these measures would impose new documentation requirements on HHAs without improving care quality.

Hidden costs: And some of the measures, such as maintaining wound images, would require pricey new equipment, McNamara points out. That's "an added expense when many agencies are struggling with low margins," she observes.

Working toward evidence-based practices is good, but labeling one set of processes as "best practices" with a quality measure can be dangerous, McNamara warns. Not all practices suit every agency, patient or situation. HHAs need to have flexibility to come up with the processes that work the best for their specific circumstances, she maintains.

Focusing on process measures also fails to give patients responsibility for their outcomes, McNamara protests.