Home Health & Hospice Week

Quality Improvement Organizations swear they aren't tattletales for surveyors, but home health agencies still aren't so sure they trust them. HHAs that have survived Operation Restore Trust, overzealous surveyors and the interim payment system aren't the trusting souls they used to be; they raise an eyebrow at anyone who says, "We're from the government and we're here to help you."

The Centers for Medicare & Medicaid Services issued a "roles paper" delineating QIO versus surveyor roles in the Home Health Compare project, where HHAs' patient outcomes are publicly compared in newspapers and on a new CMS Web site. QIOs are charged with helping agencies improve their patient outcomes through outcome-based quality improvement. When CMS issued the roles paper, legal experts warned the QIOs have wide latitude to report agency activities to surveyors "in situations where there is a need to protect against a substantial risk to the public health" (see Eli's HCW, Vol. XII, No. 9, article "Quality Improvement"). And HHAs were little reassured by comments from CMS and QIO representatives at the National Association for Home Care & Hospice's annual policy conference. In an April 7 CMS presentation on surveys, an attendee raised a concern about QIO-surveyor interactions in the question-and-answer session following the talk. CMS official Heidi Gelzer deferred some of the response to a QIO rep in the audience. "We are responsible to the Medicare beneficiary," the rep stressed.

"Appropriate referrals" are made back and forth between QIOs and surveyors, Gelzer added. Agencies found more reassuring the QIO rep's promises that the organizations make referrals only for "egregious" situations. "We're not looking for it, but if it's observed we will report it," the rep explained. Likewise, American Health Quality Association spokesperson Dave Adler insists QIOs will report only "gross and flagrant" violations to surveyors. The AHQA represents QIOs. Also reassuring were comments from CMS official Barbara Paul the next day in a panel on home care quality. Information given to a QIO is a "privileged, protected, confidential communication between you and the QIO," she stressed to NAHC conference attendees. The problem with those assurances, say legal experts, is that they aren't written down anywhere. Instead, the roles paper vaguely sets out that the supposed risk to public health "might involve occurrences which any individual citizen would find unacceptable" or "might be understood as unacceptable by someone with clinical experience."

But Paul dismissed that provision as a "legal gobbledy-gook out clause for that rare situation that we hope none of us will ever see."

Adler also notes it's very unlikely that QIOs would be in a position to witness any violations at all. Much of the OBQI help is classroom training and follow-up phone calls. Adler stresses the [...]