Home Health & Hospice Week

New OASIS-based measures likely to see quick implementation.

The National Quality Forum may be making home health agencies an offer they can't refuse regarding quality measures.

NQF spells out its 28 proposed quality measures for home health in a report recently posted to its Web site. The list is almost the same as the 29 measures NQF's home health steering committee recommended after a July meeting (see Eli's HCW, Vol. XIII, No. 27, p. 211). It includes seven measures already publicly reported under Home Health Compare.

NQF dropped "ADL/Rehab Potential and No Therapies" from the list because the developer withdrew it, the report explains. The developer likely withdrew it because it was the only measure out of a 22-item set to be chosen for inclusion.

Another change is that NQF decided to make the entire list of 28 measures recommended for public reporting. Previously, the NQF home health steering committee had recommended designating the outcome-based quality monitoring (OBQM) items, i.e. adverse events, for internal quality improvement purposes only.

NQF is now collecting comments from the public and its members on the measures. NQF members will vote on a revised ballot of measures in November and December, and NQF will forward its final recommendations to the Centers for Medicare & Medicaid Services at the beginning of 2005.

CMS has noted in an open door forum that it isn't required to automatically adopt the measures NQF proposes. But the agency will have to report on why it doesn't adopt them, according to law.

That means CMS is likely to adopt quickly the new measures based on OASIS data - the seven OBQM measures plus Improvement in Status of Surgical Wounds, Improvement in Urinary Inconti-nence, Improvement in Dyspnea, and Discharged to the Community. Relatively quick implementation is probable because the data-gathering and reporting systems already are in place for those measures, notes Bob Wardwell with the Visiting Nurse Associations of America. If CMS didn't adopt the OASIS-based measures, it would have to justify why in a public report.

The agency may hold off a while on implementing the 10 measures not based on OASIS data, predicts Brian Ellsworth of the Connecticut Association for Home Care. Some major data collection and reporting overhauls will have to take place to make these measures, many of them process-based, possible.

With CMS' other burdens required by the Medicare Modernization Act, namely implementing the prescription drug benefit, the agency may easily justify why it isn't ready to adopt new non-OASIS measures.

Major OASIS Overhaul Ahead

But CMS won't be able to put off the non-OASIS measures forever. The changes to capture data for those measures are likely to add a significant new burden to HHAs' workloads, Wardwell and Ellsworth worry.

The NQF report implies OASIS would have to be enlarged to collect all the data required for measures ranging from Comprehensive Geriatric Assessment to Risk Assessment for Pressure Ulcers. "You could be talking about a monster OASIS form," Ellsworth warns.

"This could be an incredible burden," Ward-well agrees. "This is real life," he stresses. Clinicians have to walk into a patient's home and complete this paperwork, and adding numerous OASIS items to capture these measures could make that nearly impossible.

There is a way to adopt the new measures and limit the additional burden: cutting OASIS items and measures NQF didn't endorse.

The Forum rejected many outcome-based quality improvement measures because they didn't hold up to scrutiny, Ellsworth notes. That includes three measures CMS currently displays as part of Home Health Compare - items on confusion, toileting and getting dressed.

Streamlining opportunities are present, especially since CMS is looking to revise the OASIS tool anyway under the OASIS Technical Expert Panel's forthcoming recommendations, Ellsworth points out. And NQF provides the rationale for rejecting each of the items in its report.

There is little question at least some of the non-OASIS measures will eventually take effect, experts say. The question is whether a crushing new burden will accompany them.

In its contract with NQF, CMS specified that recommendations must "be based on data that are currently reported such that it is feasible for home health agencies to collect the data consistently and with no added burden," the report acknowledges. But NQF decided to "expand the scope" of its recommendations by using non-CMS funds, and thus many of its recommendations do involve added burden.

Don't Miss Your Chance To Comment

Home health agencies seem to have little say in the matter. Some HHA members were on NQF's steering committee that chose the recommendations, but they were not encouraged to object to measures just because they added to agencies' burdens or weren't well defined, observers claim.

NQF is taking public comment on the measures, but it warns "that your comments must be specific. General comments directed to tone, themes, or philosophy are less useful in providing information to NQF staff and other NQF Members about what the final consensus document should state."

Many agencies have no idea their future workload is depending on this NQF recommendation, Ellsworth laments. "Given its level of importance, this should be very high on everyone's priority list," Ellsworth urges.

But HHAs have only until Oct. 6 to submit comments. And some observers question how much NQF will heed them anyway.

NQF spokesperson Phil Dunn insists NQF is soliciting input on the measures. "NQF staff has reached out to many potentially interested parties," Dunn tells Eli. "We have also sought to reach out to the community through the press."

Wardwell worries comments that criticize recommended measures will be viewed as "self-serving defensiveness."

CAHC will submit specific data to support its claim that two currently used outcomes are inappropriate for inclusion in NQF-endorsed measures, Ellsworth says (see next article). 

Editor's Note: The NQF report, supporting materials and instructions on submitting comments are at www.qualityforum.org/home_health_measures_public.html.