Home Health & Hospice Week

IMPACT Act to make more of an impact.

Home health agencies will start being judged on more factors out of their control if four new quality measures take effect as proposed.

In its July 13 Open Door Forum for home care providers and in the 2017 home health prospective payment system proposed rule published in the July 5 Federal Register, the Centers for Medicare & Medicaid Services gives a run-down of the four new measures that will satisfy IMPACTAct requirements for comparisons across post-acute settings:

Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post-Acute Care Home Health Quality Reporting Program. This measure aims to curb medication errors that cause patients harm and cost the Medicare program money. “Potential medication problems upon admission to HHAs have been reported as occurring at a rate of 39 percent of reviewed charts,” CMS notes in the rule. This measure “provides an important component of care coordination for PAC settings and would affect a large proportion of the Medicare population who transfer from hospitals into PAC settings each year.”

Timeframe: The measure will put agencies under the gun in some instances. It “includes identification of the potential clinically significant medication issues and communication with the physician (or physician designee) as well as resolution of the issue(s) within a rapid time frame (by midnight of the next calendar day),” CMS notes in the rule.

This measure will require three new OASIS items that will replace current items, CMS says in the proposed rule. The items would be collected at the start or resumption of care and the end of care.

Potentially Preventable 30-Day Post-Discharge Readmission Measure for Post-Acute Care Home Health Quality Reporting Program.

This measure will augment Medicare’s longstanding battle against preventable hospital readmissions, which are already reflected in other quality measures.

“Hospital readmissions among the Medicare population, including beneficiaries that utilize PAC, are common, costly, and often preventable,” CMS insists in the rule.

“The proposed measure assesses the facilitylevel risk-standardized rate of unplanned, potentially preventable hospital readmissions for Medicare FFS beneficiaries that take place within 30 days of a HH discharge,” CMS explains in the rule. “The HH admission must have occurred within up to 30 days of discharge from a prior proximal hospital stay.”

Calculation: Readmissions counted in this measure are identified by examining Medicare FFS claims data for readmissions to either acute or longterm care hospitals that occur during a 30-day window beginning two days after HH discharge. More details for how CMS will consider the readmission preventable is in a data specs document on CMS’s website (see link at story’s end), but its three “rationale groupings” are inadequate management of: chronic conditions; infections; and other unplanned events.

This measure is claims-based, requiring no additional data collection or submission burden for HHAs, CMS stresses in the rule. The measure will be based on three years of data and will require a minimum of 20 eligible episodes, CMS details.

Discharge to Community — Post Acute Care Home Health Quality Reporting. “Discharge to a community setting is an important health care outcome for many patients for whom the overall goals of post-acute care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization,” CMS says. “Returning to the community is also an important outcome for many patients who are not expected to make functional improvement during their HH episode and for patients who may be expected to decline functionally due to their medical condition.”

And of course, returning to the community with no hospital readmissions saves Medicare money. “Given the high costs of care in institutional settings, encouraging post-acute providers to prepare patients for discharge to community, when clinically appropriate, may have cost-saving implications for the Medicare program,” CMS notes.

“This proposed measure assesses successful discharge to the community from a HH setting, with successful discharge to the community including no unplanned hospitalizations and no deaths in the 31 days following discharge,” CMS says in the rule.

Take charge: CMS has anticipated HHAs’ concerns that the non-drug measures are largely out of their control. “Discharge to community is an actionable health care outcome, as targeted interventions have been shown to successfully increase discharge to community rates in a variety of post-acute settings,” CMS maintains in the rule. “Many of these interventions involve discharge planning or specific rehabilitation strategies, such as addressing discharge barriers and improving medical and functional status. The effectiveness of these interventions suggests that improvement in discharge to community rates among post-acute care patients is possible through modifying provider-led processes and interventions.”

Total Estimated Medicare Spending per Beneficiary — Post Acute Care Home Health Quality Reporting Program. This measure would be more beneficial to agencies if it counted only the agency’s spending for the patient, but it counts most spending for the patient — including from other providers — during a portion of the MSPB episode (which differs from a home health episode).

Here’s how it works: The MSPB episode will begin at the patient’s admission to an HHA and is comprised of a 60-day “treatment” period and then a 30-day “associated services” period. “The treatment period includes those services that are provided directly or reasonably managed by the HHA that are directly related to the beneficiary’s care plan,” CMS explains. But the post-discharge 30-day period includes most Part A and B services, with a few exclusions. So for example, if your patient gets admitted to a Skilled Nursing Facility within 30 days of discharge from your agency, the SNF costs will go into your MSPB measure. Ditto if the patient gets picked up by another HHA within 30 days, elects hospice, enters the hospital, etc.

PEP and LUPA episodes will be compared only with other PEP and LUPA episodes, not with standard episodes, CMS adds.

Counting all the costs in the 30-day-postdischarge period gives agencies incentives to coordinate care and provide thorough discharge planning, CMS maintains.

Risk Adjustment In Flux

CMS says it will provide preview reports for the claims-based measures. And CMS is withholding a proposal to use socioeconomic and demographic factors to risk-adjust the measures, pending ongoing research on the matter. “We understand the important role that sociodemographic status, beyond age, plays in the care of patients,” CMS says. “However, we continue to have concerns about holding providers to different standards for the outcomes of their patients of diverse sociodemographic status because we do not want to mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations.”

Note: See details about the proposed measures in the document “Proposed Measure Specifications for Measures Proposed in the CY 2017 HH QRP proposed rule” via a link in the “Downloads” box at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.