Home Health & Hospice Week

Measure’s facility bias also a concern.

Home health agencies are very concerned about the physician response time component of the new quality measure on medication review. But that’s not the only problem home care providers have with the quality measure.

HHAs commenting on the 2017 Home Health Prospective Payment System final rule shared with the Centers for Medicare & Medicaid Services a number of other concerns about the new measure, including:

• Definitions. The vague definition of “potential clinically significant medication issues,” as well as other terms, worried multiple agencies and their representatives. CMS’s response should allay some of those fears, says OASIS expert Lisa Selman- Holman with Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas (see story, p. 12).
• Lookback. The measure and M2005 require agencies to identify and address issues “at the time of or at any time since the SOC/ROC,” CMS specifies in the OASIS-C2 Guidance Manual Item-by-Item instructions. “This will require a ‘lookback’ review for the discharge OASIS and require the clinician completing the discharge OASIS to complete this review and determine whether medication issues were followed up with the physician by midnight of the next calendar day,” pointed out Lisa Harvey-McPherson with Eastern Maine HomeCare in the agency’s comment letter.

“While this information may be helpful, requiring the clinician to conduct a lookback analysis for each discharge OASIS is unduly burdensome. Clinicians struggle daily with the overarching regulatory burdens required by Medicare,” Harvey-McPherson stressed. “Adding additional burden exacerbates this challenge.”

“This measure creates a significant burden on HHAs to complete [the] ‘look back.’” Unity- Point at Home in Iowa warned CMS in its comment letter. “The clinician workflow will not accommodate this time burden review.”

But CMS dismissed those reservations. “This measure is calculated using items that are already collected in the OASIS and that capture good clinical care,” the agency maintained in the final rule. However, CMS did admit that “the measure may create a new burden for some HHAs.” But that burden is justified, CMS insisted. “The timely review and follow-up of potential clinically significant medication issues at every assessment time period and across the patient’s episode of care is essential for providing the best quality care for patients. Documenting that this review has occurred is an important component of safe and high-quality care.”

• Facility bias. The IMPACT Act measures are supposed to measure care across all post-acute settings. But CMS won’t be getting comparable results with its measure on medication reconciliation, commenters argued.

Big difference: Unlike other facility-based settings, “typically HHAs do not have access to a pharmacist who is considered the most competent to confirm the presence of” the issues referenced in this measure — medication issues, adverse side effects, etc., noted Interim HealthCare in its comment letter. In fact, in the home care setting, “for many patients no single pharmacy may even know all the prescribed medications they have in the home or take,” the company said.

The Visiting Nurse Associations of America “encourages CMS to think critically about the appropriateness of measures on medication reconciliation in home-based settings,” the trade group said in its comment letter. “Whereas other post-acute care settings have near total control of medication usage, the home is a very different environment in which home health providers have limited control over medications.”

Bottom line: “Medication reconciliation in home-based care settings will require different supports and measures to ensure patient safety and will need to be evaluated differently than facility-based care,” VNAA argued.

CMS shrugged off those concerns. “This measure is consistent with standard clinical practice requirements of ongoing review, documentation, and timely reconciliation of all patient medications, with appropriate follow up to address all clinically significant medication concerns,” CMS said in the final rule. “Thus, the documentation of drug regimen review, along with timely follow-up, aligns with professional practice standards expected of all PAC providers to ensure adherence to providing quality care. Further, we wish to note that this measure is based on items that have been modified from existing OASIS items, which have been collected for several years.”

• Lack of NQF endorsement. Many commenters chided CMS for failing to wait for National Quality Forum endorsement of this measure, as well as other new measures adopted for 2017. Interim “is concerned that CMS is going forward with the measure without NQF endorsement,” the company said in its letter.

“None of the proposed measures are NQFendorsed; and for each measure, the MAP recommended continued development,” criticized San Francisco-based health system Dignity Health.

“We strongly recommend that all measures in CMS programs receive NQF endorsement prior to implementation,” stressed the Mayo Clinic in its comment letter.

NQF endorsement of measures is necessary “to ensure adequate testing and confidence in accuracy of measures,” Kindred at Home said in its letter. Kindred recommended “CMS receive NQF endorsement prior to adoption of new measures, and especially prior to the public reporting of measures.” Interim’s Barbara McCann asked CMS not to make public the data from this measure until the NQF has endorsed it.

In the final rule, CMS reiterated its stance that the measure is OK because it’s based on OASIS items “slightly modified for cross-setting purposes.” CMS is seeking endorsement of the measure, it added.

More Medication Measures Ahead?

While CMS is collecting data for the new measure as of Jan. 1 via OASIS-C2, the measure won’t impact your payment determination until 2018, CMS notes in the final rule. And even more medication-related requirements may lie ahead.

“We will take the commenters recommendations into consideration as we continue to develop additional quality measures under the domain of Medication Reconciliation,” CMS said in the final rule.