Implementing a Home Health Outcome-Based Quality Improvement Pilot Project

Say Goodbye to Wet-to-Dry Wound Care Dressings

The home health agency (HHA) market has seen increasingly more change in ownership transactions. Little is known about the organizational characteristics and quality of care of HHAs after ownership has changed. To examine whether an HHA change in ownership was associated with different quality-of-care outcomes, patient volume, and staffing levels. Using current HHA change of ownership files linked to publicly available Medicare HHA data, this staggered difference-in-differences analysis evaluated ownership change transactions of Medicare-certified HHAs from quarter 1 of 2016 to quarter 4 of 2019. Pretransaction and posttransaction HHA characteristics and quality-of-care outcomes were compared between HHAs that changed ownership and up to 8 matched controls. The transactions in the main analysis included (1) when an HHA remained as for-profit with a change in ownership and (2) when an HHA changed from nonprofit/public to for-profit ownership. The data were analyzed between November 2023 and September 2024. The primary outcomes were HHA-quarter measures of star ratings, the individual quality measures that compose the star ratings based on the Outcome and Assessment Information Set, and claims-based quality metrics, such as hospitalizations and emergency department visits. The secondary outcomes included HHA year measures of Medicare patient volume, per capita payments, and staffing levels (full-time equivalents and minutes per visit). The main dataset included 294 Medicare-certified HHAs that changed ownership, matched with 2330 controls. In 3 years after an ownership change, quarterly star ratings increased by 0.18 (95% CI, 0.05-0.31) relative to matched controls, with greater increases among HHAs that converted from nonprofit/public to for-profit. No significant improvement was observed in the 60-day rates of hospital admissions or outpatient emergency department visits. Further, no significant changes were observed in the number of Medicare beneficiaries, but per capita payments increased within 2 years post-ownership change. Significant reductions were observed in full-time equivalents of registered nurses (-17% [95% CI, -31% to -3%]) and home health aides (-26% [95% CI, -39% to -13%]), as well as per-visit minutes for skilled nursing care (-5% [95% CI, -9% to -1%]), physical therapy (-3% [95% CI, -5% to 0%]), and home health aide care (-11% [95% CI, -15% to -6%]). In this difference-in-differences analysis of Medicare-certified HHAs, ownership change was associated with higher star ratings and Medicare per capita payments, but not with claims-based quality measures. Reduction in staffing levels after ownership change raises concerns about implications for quality of care.

Telehealth is a tool being considered by home health agencies (HHAs) to help manage costs. Most HHAs in the United States rely on Medicare reimbursement as their primary revenue source. With the implementation of a new payment system in October 2000, HHAs went from a cost-based, fee-for-service payment to a per episode prospective payment reimbursement model. For HHAs, the revenue goal changed from maximizing the number of visits under feefor- service to maximizing the number of patients and managing the episode within the prospective payment reimbursement formula. This paper addresses whether or not there is a financial business case for telehealth in HHAs. For this research effort, building a business case involved identifying and measuring the factors that contribute to the financial effectiveness of the home health organization. Utilizing a return on investment breakeven analysis model, we investigated the financial impact of telehealth, utilizing data from 32 HHAs in the Commonwealth of Pennsylvania. The breakeven analysis demonstrated that telehealth can have a positive impact on the HHA's financial position. Results indicate that HHAs should seriously consider the use of telehealth as part of their agency's care delivery model.

Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.

To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Not Applicable. We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

LTC-Vital Medicaid Is on the Bargaining Table

Home health care serves over 5 million Americans “aging in place”. In January 2016, home health value-based purchasing model (HHVBP) was introduced and piloted in 9 states in the US with a purpose of improving care quality and efficiency, and expanded nationwide in 2023. This study aimed to examine the impact of HHVBP on business operation of home health agencies (HHA), including ownership changes. This is a longitudinal study using 7 years (2013-2019) of data from two national data sources. A dummy variable was used to indicate whether an HHA is in a state with HHVBP or not. Ownership measures included both the type and changes of ownership between 2013-2017. A total of 14,334 HHAs (95,137 agency-years) were included in analysis. Of the 14,334 agencies, about 19% were in HHVBP states, 88% continued business in all study years, 1679 were new agencies and 49 agencies discontinued business. In HHVBP states, 363 out of 2781 (13%) were newly added, compared to 1316 out of 11,553 (11%) in non-HHVBP states. Agencies in HHVBP states were more likely to be public agencies (e.g., 6.08% vs. 4.97% in 2013; 5.62% vs. 4.60% in 2018), though it slightly decreased over time; and experience changes in ownership and particularly the years after the implementation of HHVBP (e.g.,2.44% vs. 2.38% in 2013; 7.03% vs. 4.39% in 2018). The HHVBP can have a significant impact on the operation and ownership type of home health agency, which in turn may impact availability and quality of home health care.

This study by Baier et al.1 sought to illustrate the decision-making process that occurs in hospital discharge planning when case managers engage with patients and families in selecting a home health agency. Case managers and home health consumers were qualitatively asked about their respective roles in the decision process, as well as their knowledge of existing public home health quality reports. No participants were aware of public quality reports. Case managers described presenting a list of available home health agencies to consumers, who in turn generally felt they had little information to guide their decision and often asked case managers for a recommendation. However, case managers felt unable to assist further in the process, citing federal laws protecting freedom of patient choice2 as preventing them from doing so. The major limitation in this study is the unexpected fact that none of the participants were aware of public quality reporting for home health agencies, effectively truncating the discussion to observations about how uninformed the decision-making process was and conjectures about how public quality reports might be used. While it is tempting to attribute case managers’ limited helpfulness in home health agency selection to the federal laws guaranteeing freedom of patient choice, the more immediate obstacle is a lack of awareness about the availability of a neutral source of quality reporting that consumers could directly access online. Other limitations include the lack of generalizability since participants were drawn solely from Rhode Island, and the relative lack of participants who were patients rather than family members. Not to its detriment, this study raises more questions than it answers. Future work could seek to test interventions in which quality reports are provided to home health consumers prior to their selection of an agency, with various patient-level and system-level outcomes3 compared against a control. In the larger context of transitional care,4 the relative importance of higher quality home health agency selection for patients post-discharge remains to be seen. Likely, the most effective interventions protecting patients in the transient period of increased vulnerability following hospitalization5 will be multifaceted.

Postacute Care: A Guide for People With Dementia and Their Caregiver

Hospitalizations and 30-day readmissions fell for Medicare patients in 14 communities when providers there worked with local quality improvement organizations (QIOs)to smooth and coordinate transitions between care settings, researchers from the Colorado Foundation for Medical Care and the Centers for Medicare & Medicaid Services reported in JAMA.The communities that participated in the 2-year CMS project saw mean reductions of 5.74% in hospitalizations and 5.70% in 30-day readmissions per 1,000 Medicare fee-for-service patients during 2009-2010. Fifty control communities saw smaller reductions: 3.17% in hospitalizations and 2.05% in readmissions (JAMA 2013;309:381-91).“Our results provide evidence of a … significant association between care transitions improvement interventions initiated by 14 [QIOs] and reductions in rehospitalizations and hospitalizations” as well as “evidence of a background national decline in hospitalizations and rehospitalizations for Medicare beneficiaries since 2008,” the researchers said.CMS left it up to each community to decide how best to improve transitions. QIOs guided the efforts and worked with local health care facilities and providers to improve a range of areas, including discharge standardization, medication reconciliation, chronic disease care planning, palliative care counseling, elder care services, and patient self-management. “Local community context was clearly relevant,” the investigators said.Each community used three or more evidence-based approaches such as Interventions to Reduce Acute Care Transfers, Re-Engineered Discharges, Transitional Care Nursing, the Care Transitions Program, and the Best Practices Intervention Packages on transitional care. The agency spent on average about $12 million annually to support the QIOs' efforts to coordinate improved care transitions.“Attempts to optimize care transitions will need to recognize that there is no single solution to address all the issues contributing to patient rehospitalization,” wrote Dr. Mark V. Williams, chief of the division of medicine–hospital medicine at the Northwestern University, Chicago, in an editorial (JAMA 2013;309:394-6). Hospitalizations and 30-day readmissions fell for Medicare patients in 14 communities when providers there worked with local quality improvement organizations (QIOs)to smooth and coordinate transitions between care settings, researchers from the Colorado Foundation for Medical Care and the Centers for Medicare & Medicaid Services reported in JAMA. The communities that participated in the 2-year CMS project saw mean reductions of 5.74% in hospitalizations and 5.70% in 30-day readmissions per 1,000 Medicare fee-for-service patients during 2009-2010. Fifty control communities saw smaller reductions: 3.17% in hospitalizations and 2.05% in readmissions (JAMA 2013;309:381-91). “Our results provide evidence of a … significant association between care transitions improvement interventions initiated by 14 [QIOs] and reductions in rehospitalizations and hospitalizations” as well as “evidence of a background national decline in hospitalizations and rehospitalizations for Medicare beneficiaries since 2008,” the researchers said. CMS left it up to each community to decide how best to improve transitions. QIOs guided the efforts and worked with local health care facilities and providers to improve a range of areas, including discharge standardization, medication reconciliation, chronic disease care planning, palliative care counseling, elder care services, and patient self-management. “Local community context was clearly relevant,” the investigators said. Each community used three or more evidence-based approaches such as Interventions to Reduce Acute Care Transfers, Re-Engineered Discharges, Transitional Care Nursing, the Care Transitions Program, and the Best Practices Intervention Packages on transitional care. The agency spent on average about $12 million annually to support the QIOs' efforts to coordinate improved care transitions. “Attempts to optimize care transitions will need to recognize that there is no single solution to address all the issues contributing to patient rehospitalization,” wrote Dr. Mark V. Williams, chief of the division of medicine–hospital medicine at the Northwestern University, Chicago, in an editorial (JAMA 2013;309:394-6).

This study focused on home health agency characteristics and evidence-based practices that could have an impact on the ability to improve the home health outcome-based quality improvement measure: improvement in the management of oral medications. The findings of this Quality Improvement Organization-approved study suggest that there are organizational characteristics and evidence-based practices associated with better rates for this outcome measure. Organizational characteristics include belonging to a healthcare system that is hospital based, not-for-profit part of a network focused on quality, and intentionally working on the oral medications outcome. Evidence-based practices include use of reminder strategies, phone follow-up interventions, repeat patient education about medications at subsequent home care visits, and use of medication simplification strategies for patients receiving multiple medications.

Home Health Agency Patient Experience Measures and Their Relationship to Joint Commission Accreditation.

A ROUNDUP OF NEWS AND INFORMATION FROM OUR COMMUNIT

This study explores the emerging conflict and cooperation between two types of organizations providing home health care to chronically ill and terminal patients--the hospice and the home health agency. Exploratory results suggest that the variables of size (terminal patient load), and competition (the number of other home health agencies in an area) influence relationships between home health agencies and hospices. It is also suggested that recent Medicare regulations may encourage mergers between agencies and hospices in addition to the existing modes of cooperation and referrals.

To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively). Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.