Home Health Workgroup of the
Long-Term Care Interest Group
Academy Health
nd
April 5, 2006 – 2 Conference Call
Workgroup chair: Eliot Fishman
Participants: Linda Bergofsky, Valerie Cheh, Eliot Fishman, David Hittle, Alene Hokenstad,
Susan Horn, Patricia MacTaggart, and Suzanne Tamang.
Staff: Kristine Metter, Christal Stone
Summary
a. Two Measures Proposed for Public Home Health Reporting
[1] Timeliness measure: Initial visit within 24 hours of case opening.
[2] Frequency of care measure: 5 or more direct nurse visits and/or telemonitoring in first two weeks after discharge for patients with specific
diagnoses.
[3] Next steps: Finalizing two measures, marshalling provider organizations
for support with regulatory agencies.
Table 1. Quality Improvement in Home Care Consensus Standards for Home Health Come
Framework Domain
Measure
Description
Category: Outcome Measures
Timeliness
1. Initiation of home care
services within 24 hours
Frequency
1. Frequency of Nursing Visits
Percentage of patients who
received home health services
within 24 hours of case
admission.
Percentage of patients with
diagnosis of hip fracture,
diabetes, hypertension, and CHF
who received five or more direct
nursing contacts and/or telemonitoring within 2 weeks of
admission.
b. Disposition of Other Measures Discussed
[1] Measurement of adequate discharge planning and adequacy of staffing
are longer-term goals that would require expanded/improved data
collection.
[2] Technical expert panel is actively considering Access to Therapies with
measurement population based on either diagnosis or risk of falls.
Purpose of the Call:
a. Workgroup Focus: Establishing a workgroup in which providers, researchers, and
regulators collaborate on recommendations regarding home health care quality
measurement, possibly contributing to CMS’ ongoing discussions regarding home care
quality and pay for performance.
b. Proposed Initiative: An important gap in existing publicly reported measures is the
process of care, and particularly access to adequate levels of home care service.
c. The objective of this meeting was to follow up regarding several specific measures
discussed in our first call.
Five categories were under consideration:
i. Timeliness – The current CMS regulation requires initiation of service
delivery within 48 hours of opening a home care case. As a provisional
standard, we would propose initiation of services within a specific
timeframe as a quality measure.
ii. Frequency – Existing research indicates there is a relationship between the
frequency of direct nursing contact and poor outcomes. This measure
would assess nurse contact within two weeks post-discharge for specific
diagnoses.
iii. Staffing adequacy – System-wide staffing constraints are a critical area of
measurement. Documenting staffing measures on the OASIS may
facilitate a policy response in this measurement area.
iv. Access to therapy – This measure would define a population and
determine if they have received appropriate treatment for new disease
related functional impairments.
v. Appropriateness of discharge –This measure would assess the percent of
discharges into community with significant ADL limitations and without
in-home paid or informal support.
Meeting Outcomes:
a. Consensus was achieved in favor of two process measures:
i. Timeliness: initiation of care within 24 hours
1. Clear ties to patient satisfaction and quality
2. Non-contentious standard
a. Possible resistance from providers in low staffing resource
settings
ii. Frequency: Five direct nursing contacts within 2 weeks post-discharge for patients
with hip fracture, diabetes, hypertension, and CHF.
1. Those with tele-monitoring in care plan would be excluded because their
care may be manageable with fewer in-home visits.
2. Reasonable standard that reflects adequacy of services
3. Research by Mathematica and Fazzi suggest importance of initial postacute period.
a. Cheh: The Phillips work was a small pilot project that did not
develop into a larger study
b. Transitional care research is a growing body of work and Fishman
will check the literature to see what can be used for frequency data
b. Three measurement areas would need better assessment data and/or research:
1. Access to Therapies: This is under consideration for a new round of
publicly reported measures by the Technical Expert Panel, but it is not
their highest priority in the short term
a. Would it be possible to define a measurement population with a
Dx of CVA tied to recent functional impairment(s)?
i. Hittle: Alternative is to define measurement populations
around assessment of falls risk. OASIS collects many
aspects of falls risk and can develop a good assessment but
does not capture history of falls, balance, or foot pain. In
addition, medication review is not recorded on the OASIS,
but is on the initial assessment.
ii. Using an approach that is an alternative to a set of specific
diagnoses, Connecticut is leading the way on fall risk
assessment.
iii. There is interest within CMS on the issue.
2. Appropriate discharge to community: A longer-term objective on the
workgroup’s agenda.
a. Currently, OASIS does not capture detailed or accurate
descriptions of informal and formal support post-discharge. Better
capacity to measure, i.e. improving OASIS, is going to have to
come along before this measure will be ready for public reporting.
3. Staffing: ratios or hours of care
The workgroup discussed several reasons that this is a complicated
area of measurement but one that is worth ongoing attention.
a. Hittle: It is unclear how to define or risk-adjust a measurement
population for staffing ratios? May be too subjective to get
concrete thresholds.
b. Staffing measures should be sensitive to different models of care
such as emerging technologies like tele-monitoring.
c. What is the evidence that direct nursing contact makes a
difference?
i. Horn: (Presenting some evidence from NH research)
Recent research1 in nursing home facilities on RNs, LPNs,
CNAs showed that while care time of LPNs and CNAs had
a threshold for quality, it was less strong than direct care
time by RNs. (Hours of direct care were captured through
pay stubs.) Lower direct nursing time in NH was found to
increase health complications: pressure ulcers. Study
1
Lower RN direct care leads to increase in health complications and hospitalizations for nursing home patients November 2005 -- From the
abstract: "more RN direct care time per resident per day...was associated with fewer pressure ulcers, hospitalizations, and [urinary
tract infections]; less weight loss, catheterization, and deterioration in the ability to perform [activities of daily living]; and greater use
of oral standard medical nutritional supplements." Susan Horn, Peter Buerhaus, Nancy Bergstrom & Randall Smout (Nov 2005).
"RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as
RNs spend more time on direct patient care," American Journal of Nursing, 105 (11), 58-70; quiz 71. see the article...
calculated direct nursing hours by subtracting
administrative time and non-RN hours.
II.
Immediate Steps
a. Eliot will Draft proposal for two proposed domains (see Table 1.):
[1] Timeliness - Initiation of home care services within 24 hours
[2] Frequency* - Frequency of nursing visits within 2 weeks of home care
admission
b. Research the evidence base behind these proposals, tying quality of care in the
home care setting and transitional care frequency data for nurse contact.
Table 1. Quality Improvement in Home Care Consensus Standards for Home Health Come
Framework Domain
Measure
Description
Category: Outcome Measures
Timeliness
1. Initiation of home care
services within 24 hours
Frequency
1. Frequency of Nursing Visits
III.
Percentage of patients who
received home health services
within 24 hours of case
admission.
Percentage of patients with
diagnosis of hip fracture,
diabetes, hypertension, and CHF
who received five or more direct
nursing contacts and/or telemonitoring within 2 weeks of
admission.
Intermediate Term
a. Update on Technical Panel.
b. Marshalling provider organizations for support – an important next step in
interfacing with the regulatory agencies
c. Continue to explore measures of staffing adequacy, access to therapy and
discharge planning.