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n February of 2006, President Bush signed the Deficit Reduction Omnibus Reconciliation Act of 2005 into law, making pay-for-performance (P4P) for home healthcare a reality. This legislation establishes home health P4P reporting. Voluntary reporting of quality measures (QMs) determined by the Centers for Medicare & Medicaid Services (CMS) for P4P begins in 2007. Home health agencies that do not report the measures will receive a reduction of 2% from the annual market basket.
       What will this really mean for home health? Let us start with the basic purpose of the P4P system: to create collaboration between providers and other stakeholders, ensure that valid QMs are used and providers are not being pulled in conflicting directions, and ascertain that the measures actually improve the quality of care.
       To develop and implement these initiatives, then, CMS is collaborating with a wide range of other public agencies and private organizations with a common goal of improving quality and avoiding unnecessary healthcare costs. The Quality Improvement Organizations (QIOs) will also provide technical assistance to a range of healthcare providers.
       Three types of measures are being evaluated by CMS: outcome, process, and structure. Outcome measures should be familiar to everyone in home healthcare. They are changes in patient health state between 2 points in time (eg, from admission to discharge). The Outcomes-Based Quality Improvement (OBQI) process uses a set of outcome measures based on the Outcome and Assessment Information Set (OASIS) data submitted by every home healthcare agency in the United States.
       Any outcome measure used for P4P must be adjusted for risk. This ensures that variations in patient populations served by 2 home healthcare agencies are considered when their outcome measures are compared. If one agency’s patients were older than the other, for example, it would impact outcomes and should be adjusted for when comparing the 2 agencies.
       The next type of measures being evaluated is process measures. They focus on whether a specific service was provided and can be used to assess the agency’s adherence to evidence-based guidelines. An acute care example is, “Did each patient seen in the hospital with an acute myocardial infarction receive aspirin within 6 hours of arrival?” An example in home healthcare is, “Was each patient assessed for risk of falling on admission?” The advantage of this type of measure is that risk adjustment is not needed, as this would be considered a standard of care for every patient (or at least all patients with specific diagnoses).
       The third type being considered is the structure-based measure. It describes features of the healthcare organization related to its capacity to provide care. Examples of structure-based measures in home healthcare may include, “Is the home healthcare agency available to meet patient care needs 24 hours a day, 7 days a week?” and, “What is the nurse/patient ratio in the home healthcare agency?” The agency is also considering a patient experience or satisfaction measure, which would be consistently used to measure patient satisfaction.
       How about payment impact? The Medicare Payment Advisory Commission (MedPac) has made recommendations on how P4P should compensate providers. MedPac suggests that evidence-based measures must first be identified by CMS. Then, they should be acceptable to independent quality experts and organizations, private and public sector payers, providers, and consumer organizations. Any process measure chosen should demonstrate that its implementation will lead to better outcomes.
       Next, MedPac suggests that the collection and analysis of the data should not be overly burdensome for either CMS or providers. Using data that are being collected to OBQI measures would meet this requirement. Where quality information is not being collected, the long-term gain should be weighed against the burden of collection. It may also be reasonable to change claims reporting to gather the data during the submission of claims rather than adding manual reviews later on. The benefits of any additional reporting must be balanced against the cost of additional claims data collection. There should also be adequate risk adjustment to deter providers from avoiding patients who might lower their quality scores.
       Finally, providers should be able to improve quality on the measures chosen. The more providers who can be compared on a QM, the greater the potential impact for beneficiaries. To be fair to providers, the measure must be something they control, and it should be something that needs improvement.
       What does this mean to the OASIS data set? MedPac states, “Researchers conclude that the OASIS items used to determine OBQI scores reliably measure the clinical and functional condition of patients.” This suggests that OASIS-based measures are meaningful; therefore, accurate completion of OASIS has renewed importance.
       There are many things home healthcare agencies can do now to start preparing. First, ensure that everyone admitting patients has had adequate training in the completion of OASIS. Chapter 8 of the CMS Implementation Manual provides detailed instructions for the completion of each OASIS question as well as detailed assessment strategies for each question. The agency has also developed OASIS web-based training available at http://www.oasistraining.org. Many home healthcare agencies perform peer-to-peer mock evaluations to improve inter-rater reliability in performing OASIS assessments. Others use physical therapists (PTs) and occupational therapists (OTs) to support training of registered nurses (RNs) in how to gather assessment data for answering the functional OASIS questions, RNs to support training for PTs and OTs on medication and incontinence issues.
       Many home healthcare agencies find that it also helps to establish a culture that supports quality improvement (QI). Is performance improvement just a task that must be performed quarterly to meet regulations? Reinforce the collection and evaluation of data to determine areas requiring improvement. Devise an action plan to help meet that improvement. Finally, be sure that someone is regularly “working the plan.” Writing an improvement action plan is only the first step. The steps identified in the plan must actually be put into place, and they must be monitored and evaluated to determine if they are having the desired result. One person should be ultimately accountable for the completion of the action plan.
       An agency can start the process today using current OBQI outcome measures. If measures chosen by CMS are different from what your agency selected in its improvement plan, you have still created a culture of QI, and it should be easy to change the focus of the plan to different measures. Many details of how P4P will be implemented by CMS are unknown, but the clock is ticking.

Questions and Answers

       Question: I recently admitted a patient for cardiac care and found a blister on her right posterior heel. The Wound, Ostomy and Continence Nurses (WOCN) Society OASIS Guidance Document states that a stage 2 pressure ulcer may present as a blister. Is it a stage 2 pressure ulcer? Also, is it appropriate to stage all blisters?
       Answer: If, after consultation with the physician, this wound was determined to be a pressure ulcer, then yes, you should classify it as a stage 2 pressure ulcer when answering M0445 (Does this patient have a Pressure Ulcer), M0450 (Current Number of Pressure Ulcers at Each Stage), and M0460 (Stage of Most Problematic [Observable] Pressure Ulcer). But no, not all blisters should be staged—just stage those that are pressure ulcers. And if a blister is due to something else, it should not be staged.
       Question: One of my patients has had an implanted infusion device for total parenteral nutrition (TPN) for several months. The incision line has healed closed, and there are no signs or symptoms of infection. I understand that it should be considered a surgical wound when answering M0482 (Does this patient have a Surgical Wound), but how about its status? How should I answer M0488 (Status of Most Problematic Surgical Wound)?
       Answer: We are not sure what others would say, but in our opinion, if the surgical insertion site were completely epithelialized, there were no signs of infection, and a healing ridge was present (or a healing ridge had been present and has resolved), we would describe it as “Fully Granulating” for M0488.
       Question: When a stasis ulcer is repaired with a skin graft, does the wound become a surgical wound for OASIS questions, or does it remain a stasis ulcer?
       Answer: It remains a stasis ulcer.

Got a Question?

       If you have a question you would like addressed in “OASIS: More Than Just an Assessment,” contact Managing Editor Ryan Dougherty at ryand@hmpcommunications.com, and we will address it in a future issue of ECPN.