Benchmarking data for home care are scarce
Initiatives promise national databases by 2000
With an upcoming prospective payment system, home health, once the undisputed cash cow of the health care industry, is being squeezed by the same pressures as acute care hospitals.
"Home health is also facing a increased regulatory pressures and competition from managed care all of which are demanding cost and quality information," says Alexis Wilson, founder and chief research officer of Outcome Concept Systems, one of the pioneers in home health outcomes and benchmarking in Seattle.
Yet unlike acute care, home health lags in its ability to compare national and regional performance. Unless agencies pay to join benchmarking consortia or proprietary measurement systems, home health benchmarking is a patchwork of resources at best.
But that is about to change. In Nov. 1997, home care became the fourth accreditation program of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, to be required to integrate an outcomes measurement system into its accreditation process. By Dec. 31, 1998, home care agencies must select a vendor that offers a JCAHO-approved measurement system as well as at least two clinical or patient perception of care measures. (See list of approved vendor systems for home care, pp. 20-22.)
Agencies must start submitting initial performance data by March 31, 2000, a year after acute and long-term care facilities are scheduled to begin electronic reporting of outcomes through the new ORYX program. Eventually, agencies will be able to use the accreditation database for external benchmarking.
Closer on the home health horizon is the Outcomes and Assessment Information Set (OASIS), the minimal data set the Health Care Financing Administration will use in its prospective payment system. If HCFA’s proposed rule becomes a regulation this summer, agencies must begin using the 79-question tool to track demographics and clinical and functional data elements.
Although many home care agencies regard the lengthy instrument as jumping through another regulatory hoop, some experts say OASIS may become the envy of the benchmarking industry. Lou Anne Koch, president of Eldermanage Inc. in Atlanta, calls it "the most creative thing to happen to home care benchmarking. . . . Every staff member at every home health agency will be making the same comparisons with the same indicators. That’s why these outcomes will be so valuable."
About 50 agencies already are benchmarking against each other and generating their own quality improvement goals through the OASIS demonstration project. (See related story, p. 23.)
But, cautions Kathy Krisler, such a comprehensive data base will not be available immediately in the early stages of compliance with OASIS. "First of all, the final version of OASIS isn’t expected until 1999. Then, the next step is that HCFA will establish criteria for data submission and then, like ORYX, vendors will have to comply," says the senior research analyst at the Center for Health Policy and Research, which developed the instrument with HCFA.
Such OASIS data also may be used to satisfy the ORYX requirements, says Deborah Nadzam, PhD, RN, vice president of performance measurement at JCAHO.
However, Koch advises benchmarking professionals not to wait for OASIS or ORYX to provide those essential outcomes measurements. "Home health agencies are getting all wrapped up in meeting the regulatory and accreditation parameters and don’t realize what OASIS can do for them right now," she warns. She says agencies can begin using OASIS to pave the way for internal benchmarking by making data gathering more efficient. "First, form a leadership team representing both clinical and administration; don’t just hand the project off to your QI person." Representatives should include staff from management information as well as field clinicians.
This core group examines the current assessment process, including admission, recertification, and discharge. "Most agencies don’t know how long it takes to do these assessments as well as what it includes; yet in home health, it is this process that generates all subsequent care," she says.
After outlining the assessment process and the accompanying forms, the team can begin streamlining. She cites the example of a corporate health care organization that was able to give up 16 forms after it incorporated other assessment tools into OASIS. "We questioned every question by asking, Why do we need this data?’" she says.
The team then can structure the comprehensive assessment so it actually becomes the guide for a patient-specific care plan. "You can restructure the assessment to build in trigger points that highlight the care plan," she says. For example, if a patient is experiencing no problem in a particular area, it is left blank. If a patient and/or family can handle the problem, it is marked "MP," for managed problem. But if not, it is marked "P." "When you flip back through the assessment, you see the elements of the care plan immediately."
Such consistent presentation of data makes setting internal benchmarking targets much easier. "Most agencies don’t know what the top three or four most common admitting diagnoses much less what the quality improvement issues are in those diagnoses," Koch says.
Yet in the rush to benchmark clinical performance, home health agencies shouldn’t lose sight of the fact that ultimately they must please the payer as well as accreditation or regulatory bodies. "Accreditation agencies are looking for outcomes measures that reflect whether your interventions are appropriate and effective, but the payers want to know the cost," Wilson warns. "So make sure your system includes efficiency measures such as cost per visit and staff productivity."
Historically, home health primarily has tracked billing data, Koch explains. "But today we need the kind of data that tells us how we are functioning clinically and financially."
For more information, contact Lou Anne Koch, President, Eldermanage Inc., 1341 North Crossing Drive NE, Atlanta, GA 30329. Phone: (404) 329-1533. Alexis Wilson, Outcome Concept Systems Inc., 2719 East Madison St., Suite 201, Seattle, WA 98112. Phone: (206) 325-3396. Web site: www.ocsys.com.
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