OASIS Alert

The devil is in the details when it comes to quality.

Proposed new measures to track rehospitalization and emergency department use are raising eyebrows in the home health industry.

Many commenters voicing their opinions of the home health prospective payment system proposed rule published in the July 3 Federal Register accept the need to track this data. But the details about collection and measurement of the data cause concern.

In a nutshell: The Centers for Medicare & Medicaid Services wants to add two new quality measures for home health agencies — “Rehospitalization during the first 30 days of HH” and “Emergency Department Use without Hospital Readmission during the first 30 days of HH.” CMS would apply the measures to patients who had an acute inpatient hospitalization in the 5 days before the start of a HH stay. CMS would base both measures on claims, not self-reported data.

“We recognize that reduction in unplanned hospitalization and emergency room use are important factors in the reduction of costs to the Medicare program,” said Margaret Fanckhauser, RN, MS, MPH, with Central New Hampshire VNA and Hospice in a comment letter. “We support the use of claims-data (rather than OASIS data) to measure this standard because it is standardized and independent of agency manipulation.”

But Fanckhauser goes on to point out several “caveats to CMS so that home health agency performance is not inappropriately interpreted” including:

• “Home Health Agencies alone are not 100% responsible for a patient’s return to an ER or inpatient acute care facility. CMS requires that agencies deliver care under the orders of a physician. If a patient under care is deteriorating, the skilled homecare clinician appropriately contacts the physician for direction, and the physician directs the patient to go to the hospital, it must be understood that the agency does not have the authority to override that decision. CMS does not allow the homecare agency to initiate orders on its own.”
• “Current homecare rules require that agencies discharge patients from the Medicare home health program when a patient is a) no longer homebound and/or b) no longer in need of skilled services. Therefore, even when an agency clinician believes a patient is fragile and might benefit from continued home health monitoring, the agency is compelled to discharge the patient if the patient stops meeting those criteria. If the patient then returns to an ER or hospital within 30 days, the agency is held accountable for the outcome even if the patient was no longer under their care. We advise that, if CMS continues to use the 30 day criterion, all patients who were discharged because they were no longer homebound or no longer had a skilled need be dropped from the calculation.”

The proposed plan to use claims data to drive these measures was also a source of concern. “In general, [Gentiva Health Services Inc.] supports the addition of two new claims-based measures ...,” said John R. Hamilton III, Gentiva’s chief compliance officer, in a comment letter. “We believe such measures based on claims data are appropriate,” he says.

But Hamilton goes on to suggest that including OASIS data could foster greater accuracy for risk adjustment purposes. OASIS data could provide “validated information about additional functional, medical, cognitive and social support of individuals that could make the quality measure risk adjustment factors richer,” he says. “OASIS data can also function as a good predictor of re-hospitalization.”

Another area of concern was whether the proposed measure will consider observation status.

“Any acute care hospitalization measure derived looking at just inpatient readmissions will fail to take into consideration any patient who was admitted to acute care for observation status,” said Paula A. Bussard with The Hospital and Healthsystem Association of Pennsylvania.

“Failure to account for the significantly increased use of observation status may artificially result in some home health agencies looking like they have lower acute care hospitalization rates …” Bussard said. “HAP strongly recommends that CMS develop acute care hospitalization measures to measure: (1) the rate of admission from home health to observation status; (2) the rate of admission from home health to inpatient hospital admission status; and (3) an overall rate of acute care hospitalization that includes a roll-up of both inpatient observation and inpatient admissions status.”

The emergency department use quality measure also needs some fine-tuning, commenters said. “[I]n many areas of the country, the opening of urgent care centers has literally exploded,” Bussard said. “In areas of the country where this has not occurred, home health patients may seek care from a hospital emergency department, and these agencies may look like they have more persons using the emergency department for urgent care than those agencies in areas that have a high penetration of urgent care centers.” This could skew the results of the measure across different agencies across the country, she said.

Note: The proposed rule is at www.gpo.gov/fdsys/pkg/FR-2013-07-03/pdf/2013-15766.pdf. To read the 96 comment letters submitted, go to www.regulations.gov/#!docketDetail;D=CMS-2013-0140 and scroll down to the “Comments” section.