Public to get access to home health quality information thanks to CMS

Review indicators and start preparing now

Nursing homes have been living with public reporting of quality information by the Centers for Medicare & Medicaid Services (CMS) since November. Now, home health agencies will undergo the same type of public scrutiny.

In April 2003, a pilot project testing quality indicators and pubic reporting mechanisms will begin in six states. While those states had not been chosen as of press time, Florida most likely will be at the top of the list, according to CMS.

Other states quite possibly could include Virginia, Missouri, Tennessee, South Carolina, Massachusetts, Oregon, Texas, Iowa, Pennsylvania, or Wisconsin, says Ann B. Howard, director of federal policy for the Ameri-can Association for Homecare in Alexandria, VA. "National implementation is scheduled for October or November of 2003," she says.

While the indicators chosen for nursing home public reports were chosen with no input from the nursing home industry, CMS did include home health representatives on the technical panel that chose the initial quality indicators for home health, Howard says. The 11 indicators have created concern for some agencies, but overall, most seem to be pleased with the clinical indictors chosen, she says. The indicators had not been finalized as of press time, but Howard expects all 11, perhaps with minor changes, to be approved.

The biggest concern for many agencies will be the number of indicators that are related to improvement and the public’s ability to understand the information, says Kathy Green, RN, vice president of product strategy for Healthcare Quality Solutions, a Tampa, FL-based software company that specializes in home health products. "When we look at benchmarking information for our customers, we see that for all outcomes, there is generally improvement in 50% to 58% of all patients," she says. "This means that any home health patient has a 50-50 chance of improving with any agency."

What the public doesn’t understand is that the goal of home health is to stabilize and prevent deterioration of a patient’s condition in most cases, Green says. "Most often, home health patients improve as much as possible in the hospital. Once in home health, some patients, such as stroke patients, are expected to show improvement, but a cardiac patient is not likely to improve."

It will be hard for the general public to understand why patients don’t improve because the indicators imply that all home health patients should improve, she adds. "What the public won’t see with these quality indicators is that we all do a great job stabilizing patients." In fact, Green’s company’s data show that home health agencies effectively stabilize 80% to 90% of their patients.

Even with this concern, Green says home health agencies have an opportunity to show improvements in all indicators and to greatly improve care to patients. Six of the 11 proposed indicators are related to rehab therapy, she says.

"I think it is exciting that there is an emphasis on rehab therapy because the information from our database shows that patients who receive rehab therapy have better outcomes than patients who don’t receive therapy," she says.

In geographic areas where rehabilitation therapists are in short supply, the therapy-related quality indicators will be a problem, says Phyllis W. Fredland, RNC, BSN, executive director of Health Personnel Inc., a home health agency based in McKees Rock, PA.

"Most of the complaints I hear from other agencies is how long they have to wait for therapists to see patients and how hard it is to coordinate care with therapists," Fredland says.

For an agency to show improvement in the rehab-related indicators, its manager will have to make sure that care between nurses and therapists is coordinated closely and improvements are documented and reported, she adds.

Another approach to addressing patients’ needs for therapy is to incorporate rehab nursing into an agency’s services, Green suggests. "I don’t believe that most home health agencies think in terms of rehab nursing to address simple therapy needs, but it can be an effective approach."

By training nurses to recognize therapy needs and implement activities to address the needs, home health agencies can help patients who may not qualify for therapy visits, she adds.

Incremental progress not measured

Some home health managers have pointed to the lack of specificity and clear definition of some of the indicators as a problem, Howard says.

"For example, the indicator related to improvement in pain is very general and may not reflect true improvement," she says.

Fredland agrees. "The question related to pain asks if the patient has no pain, pain that does not occur daily, daily pain that is not constant, or constant pain. I might have a patient who experiences pain six times each day initially, but then progresses to experiencing pain only twice each day. The way that the question is asked does not enable me to demonstrate improvement with this patient even though the amount of pain is decreased to one-third of the original pain."

The same problem arises with the indicator related to ambulation, she adds. "Even if my patient improves the ability to walk with a walker from 15 feet to 200 feet, there is no change in his or her condition according to the question which combines all walking with a device in the same category," Fredland says.

Howard also has heard many agencies express concern that not all indicators are risk-adjusted. "Some managers whose agencies take the sickest patients are worried that their care will seem less effective because they have patients who won’t show improvement." Another concern expressed by many agencies is that some home health agencies will be reluctant to accept very frail, old, or sick patients, she adds.

Statistically, agencies that are larger and accept sicker patients also may have the greatest opportunity, Green points out. "The more acute patient has more opportunity to improve than the less acute patient," she says.

Focus on quality indicators

"The best advice for home health managers is to teach [their staff according] to the test," Howard emphasizes.

"Focus on the quality indicators when the final list is approved because these are the indicators that will focus upon best practices," she says.

In fact, start looking at your outcomes for each of the indicators now, even if you are not located in one of the pilot states, Green suggests. "If you are low in any of the categories, or even average, look at ways to improve," she says.

All home health agencies can expect to see a 5% increase in all scores by the time CMS publicizes the results nationally, she adds. This will be the result of many agencies focusing upon the indicators and addressing ways to improve.

"This means that if you are average now, but do nothing to improve your outcomes, you’ll drop below average as everyone else improves," she explains.

Streamlining your systems, care mapping based on outcomes related to these quality indicators rather than just diagnoses, and teaching staff members the basics of outcomes-based quality improvement will help your agency as "scores" are publicized, Green says.

Although this may seem like one more burden to handle along with reimbursement cuts and staffing challenges, it is an opportunity for home health agencies to demonstrate to the public and to potential employees how well they care for patients, Green says. "We all want to provide better quality care, and this is one more tool we can use to help us achieve our goal."

[For more information about CMS’ publication of quality indicators, contact:

  • Ann B. Howard, Director of Federal Policy, American Association for Homecare, 625 Slaters Lane, Suite 200, Alexandria, VA 22314-1171. Telephone: (703) 535-1891. Fax: (703) 836-6730. E-mail:
  • Phyllis W. Fredland, RNC, BSN, Executive Director, Health Personnel Inc., 1110 Chartiers Ave., McKees Rocks, PA 15136. Telephone: (412) 331-1042. Fax: (412) 331-2774. E-mail:
  • Kathy Green, RN, Vice President of Product Strategy, Healthcare Quality Solutions, 200 S. Hoover Blvd., #205, Tampa, FL 33609. Telephone: (800) 850-0018 or (813) 282-3303, ext. 273. E-mail:]