Home Care Under Fire

Benchmarking takes a back seat in home care

Survival is more important to agencies now

(This is the first of a two-part series that looks at benchmarking and quality initiatives in the home care industry. In the first installment, we ask some home care experts how the industry as a whole is using best practices. Next month, we’ll talk to agencies about some of their most recent efforts.)

On the surface, the home care industry, would seem to place a premium on best practices, quality improvement, and benchmarking. The Health Care Financing Administration is asking agencies to provide a new set of data called OASIS (outcome and assessment information set) on Medicare and Medicaid beneficiaries.

This extensive information could be used by the agencies in the future to provide better care. At the same time, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) is pushing for a nearly two-year-old benchmarking initiative called ORYX. In this, agencies pick the performance measures they are interested in and submit them to JCAHO for comparison with other like agencies.

But according to Mary St. Pierre, RN, BSN, the director of regulatory affairs at the National Association of Home Care (NAHC) in Washing-ton, DC, home health care is a beleaguered industry. Many agencies are concentrating harder on making it through the next year, the next month, or even the next week rather than learning how to implement new benchmarking programs and quality initiatives.

As a result of the Balanced Budget Act (BBA) of 1997, agencies are being forced to cap the cost per visit they charge, and also limit how much an agency can spend on any one beneficiary — a per-beneficiary limit which is calculated on an aggregate basis throughout an agency.

"Agencies were caught in a bind," says St. Pierre. "They were trying to lower the number of visits when costs went up, but the cost limits were lowered. They ended up going over their aggregate per-beneficiary limit and ran into financial problems." Some 90% of the home care agencies exceeded one limit or another, she adds. About 2,000 Medicare-certified home health agencies have closed since 1997.

"With all that, who has time to think about benchmarking?" she asks. After much lobbying by the industry and senior groups, there were moves in Congress in the latter part of 1999 to roll back some of the most onerous parts of the BBA and bring some more money into the home care system.

Getting outcomes data for patients

But St. Pierre admits the agencies that have been involved in OASIS, in particular, do understand there is value they can get from the data. "The whole intent is to move toward more outcome-based assessment of home health agencies."

Greg Solecki, vice president for home health care at the Henry Ford Health System in Detroit, agrees that the industry sees itself as "beleaguered" right now, but doesn’t see the situation as being forever bleak. "We are a strong industry, and we have been through a lot in the last two decades," he says. "This isn’t the end of home care, but certainly many agencies will have to close."

His objections to OASIS stem from the large amount of work it has added to agencies that are already cut to the bone. Solecki says OASIS has added "at least 1 million new pieces of paper a year to shuffle. Even as we try to blend our existing clinical database with the OASIS set of questions, and try not to be redundant or duplicative, we found we still have about 27 or 28 pages of paperwork we have to complete on every new home health patient."

Last year, Henry Ford Home Care admitted almost 23,000 new patients, Solecki says, noting that for the average agency the number is about 3,000. "But OASIS is based on an average of some 480 per year. So for us, OASIS has been extremely unwieldy and cumbersome."

Swatting at a mosquito with a blowtorch’

He agrees that home care has "done a poor job in telling its story with data. OASIS may help with that. But I do think we are swatting at a mosquito with a blowtorch. We don’t need all the data Medicare has mandated, and I think we could pare back the questions and make it easier for the clinician."

Kathryn Crisler, MS, RN, assistant director at the University of Colorado Center for Health Services and Policy Research in Denver, says she realizes that there is a lot of "moaning and groaning in the industry."

The center was involved in creating OASIS, and Crisler says that some of the staff who attended the October NAHC conference got an earful of grief from other attendees.

"But I do think that very soon agencies are really going to be able to see what the outcomes of their patients are. What has happened to their patients as a result of receiving home care? And they are going to be able to receive outcome reports that literally do allow them to benchmark against a representative sample of agencies. They will be able to see how they are doing in providing care," she says.

That means they can focus their quality and performance improvement activities where they need to, rather than guessing where they will have the greatest impact, Crisler says. More than 100 agencies were involved in the OASIS demonstration program and received some benchmarking data. "And they have frankly found it to be invaluable," she says.

[For more information, contact:

• Mary St. Pierre, RN, BSN, Director of Regulatory Affairs, National Association of Home Care, Washington, DC. Telephone: (202) 547-7424.

• Kathryn Crisler, MS, RN, Assistant Director, University of Colorado Center for Health Services and Policy Research, Denver. Telephone: (303) 756-8350.

• Greg Solecki, Vice President for Home Health Care, Henry Ford Health System, Detroit. Telephone: (313) 874-6539.

For more information on benchmarking in home care, as well as some actual benchmarking data, visit the NAHC Web site at http://www.nahc.org, or the Center for Health Policy and Research site at http://www.chpr.org.]