Home Health & Hospice Week

CMS fast-tracking measures across post-acute settings.

You may see your referrals affected much more by your patients’ hospital readmission rates under the IMPACT Act passed last fall.

Why? IMPACT requires the Centers for Medicare & Medicaid Services to standardize certain core data collection and reporting across four post-acute provider types: home health agencies, skilled nursing facilities (SNFs), long-term care hospitals (LTCHs), and inpatient rehabilitation facilities (IRFs). And CMS has decided to start with a claims-based data element that cuts across all settings: hospital readmissions within 30 days.

“The idea is to create a shared accountability for excessive rates of readmissions so that both providers are motivated to work with one another to enhance the coordination of care during those transitions,” said CMS’s Joel Andress in a Feb. 25 Special Open Door Forum about the IMPACT Act. “Both providers involved in that transition of care are responsible in some ways to the quality … whether or not that patient is readmitted,” he said in the question-and-answer portion of the call.

But that readmission measure won’t be quite what you’re used to. “Because of the timeline we’re operating under … we presented the readmission measures that we currently have available for each of these four settings,” Andress said. But “what we’re going to be doing over the course of the next year is making modifications to them, so that they are potentially preventable. Their current forms are not.”

Look for: CMS will finalize the IMPACT measures via formal rulemaking, noted CMS’s Stella Mandl in the forum.

CMS is looking to minimize burden on providers and avoid duplication, Mandl added in the forum. That’s one reason the agency is starting out with measures that are already approved by the National Quality Forum and used in all four provider settings, and that are claims-based.

But in the future, you can expect changes to OASIS. “The IMPACT Act requires specific measure domains to have data submitted from the OASIS instrument and it requires certain domains to be standardized across the settings,” Mandl explained to a caller from Marshall Medical Center’s home care program in Alabama.

At first, CMS will give HHAs their data in private reports. But by IMPACT’s implementation date of January 2019 for HHAs, CMS will report the data publicly. (The other providers’ deadline is October 2018). Data collection must start in 2017 to hit those deadlines, notes the National Association for Home Care & Hospice.

Low Readmission Rates Will Make You An Attractive Partner

A question from one hospital during the forum illustrates why this measure will be important for HHAs. “With the transition to more shared accountability between providers like home health and acute care hospitals, what direction can be given to hospitals if higher readmission rates are identified to be associated with a select group of home health agencies in our community … when we are bound by the patient’s choice condition of participation?” asked a representative from West Jefferson Medical Center in the New Orleans area.

Reminder: Under the Hospital Readmissions Reduction Program passed in the Affordable Care Act, CMS fines hospitals up to 3 percent for “excessive” readmissions in certain DRGs. The policy began in 2012. See more details at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html.

“Our encouragement would be that communication with those home health agencies should certainly be increased,” Andress responded. “The main thing to encourage in home health agencies, especially when they’re becoming responsible for these kinds of quality indicators, is to demonstrate to them that you know there’s a consequence if they choose not to engage in coordination of care with the hospital.”

The poor outcomes measures will affect agencies as well, Andress emphasized. “That really is kind of the focus of shared accountability; that if [agencies] fail to coordinate care appropriately for their patients, then their readmission rates will increase,” he said. “While that may have some impact on the hospital’s readmission rate, it is most heavily going to affect the home health agency’s readmission rate. It’s reported and is publicly available information and that’s the purpose of the quality reporting program in the first place.”

Do This: “Agencies should definitely start paying attention to their readmission rates by comparison to their competing agencies,” urges Pat Jump with Acorn’s End Training & Consulting in Rice Lake, Wis. “Hospitals will be looking at this and will want to work most closely with home care providers who work with them successfully to keep patients from being readmitted,” Jump tells Eli.

Readmissions Out Of Agencies’ Control

Home care and other providers often protest that hospital admissions are frequently unrelated to the care they furnish. “Nowhere do we make the patient responsible for following through with any of the education that’s been provided in any of the settings,” said a representative from Stillwater Medical Center in Oklahoma. “When you get into the home and you’re seeing them three times a week for three hours total, the other hours of the day rely on the patient following through with what they’ve been educated about … or their planned medication regimen or any of the other treatment plans.”

“We need to do something to hold the patient accountable for their engagement and their healthcare choices,” the rep told CMS.

“You have to look at the readmission measures as they interact with other domains of quality measures as well,” Andress said. “Certainly we’re highlighting CMS patient engagement measures.”

A lot of the IMPACT measures’ value will be relative. “We know that some percentage of readmissions should not be occurring, but there isn’t a clear standard of how many readmissions should be occurring,” Andress admitted. Instead, the measures are designed to let referral sources and patients compare providers and see where they fall in the spectrum of admission rates.

But experts worry that sort of comparison may discourage HHAs from taking on the sickest patients needing home care. v

Note: To access a transcript or recording of the call, click on the ZIP file at www.cms.gov/ Outreach-and-Education/Outreach/OpenDoor Forums/ODFSpecialODF.html in the “Downloads” section. The slides are in the “Downloads” section at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html.