Peter W. Shaughnessy

The Increased Needs of Patients in Nursing Homes and Patients Receiving Home Health Care

To evaluate the effects of Medicares prospective payment system and Medicaids preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicares prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaids policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.

Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement

OBJECTIVES: To evaluate effects on patient outcomes of Outcome‐Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC).

A study of reliability and burden of home health assessment using OASIS.

ABSTRACT The Outcome and Assessment Information Set (OASIS) is used for outcome reporting, quality improvement, and case mix adjustment of per-episode payment for home health care. The research described here addresses interrater reliability of OASIS items and compares clinician time required to complete patient assessment with and without OASIS. Interrater reliability for OASIS data items was estimated using independent assessments by two clinicians for a sample of 66 patients. Incremental assessment time due to OASIS was estimated using interview data from two agency-matched groups of clinical care providers-one group who used OASIS in the assessment and a second group whose assessment did not include OASIS items. Interrater reliability is excellent (kappa > .80) for many OASIS items and substantial (kappa > 0.60) for most items. The reported time required to complete an assessment with OASIS did not differ from the time required for a comparable assessment without OASIS. The results of this study are being used to guide developmental efforts to improve OASIS items. They can also be informative to home health care agencies when interpreting OASIS-based outcome and case mix reports.

Outcomes across the care continuum. Home health care.

OBJECTIVES This article describes one approach to measuring outcomes across the continuum of care. METHODS Development and testing of the outcome-based quality-improvement methodology as developed by the University of Colorado Center for Health Services Research in Denver, Colorado are summarized. RESULTS Reliable and valid measures for home health care covering end results (pure outcome), intermediate results (instrumental outcome), and use (proxy outcome) were developed and are useful in demonstrating patient improvement or stabilization as well as decline. Further, these measures can be aggregated by agency and, with appropriate severity or risk adjustment, can be used to compare outcomes over time and across agencies. CONCLUSIONS National testing of the methodology is currently ongoing, with refinements underway in measures, risk adjustment, and operational implementation.

Assessing and Assuring the Quality of Home Health Care: A Conceptual Framework

Increased use of home care services, and the provision of more sophisticated care to acutely ill patients, have prompted concern about quality assurance in home settings. A conceptual framework is proposed to assess home health-care quality based on two premises: outcome, process, and structural measures, first, are required to evaluate quality accurately; classification of patients into quality indicator groups (QUIGs), second, permits specification and use of more practical and valid quality measures. The framework may prove useful because measures are related directly to patient conditions, services rendered, and treatment objectives. Further reliability and validity testing of the QUIGs and a system of operational quality measures are currently underway.

Multiple Runs Distributions: Recurrences and Critical Values

Abstract Most traditional applications of runs tests have entailed bivariate runs distributions. Extensions to more general runs tests for randomness have been hindered by the lack of exact critical values for distributions with more than two kinds of elements. Combinatorial recurrences that can be used to compute exact significance levels for small sample sizes are presented for runs distributions for ν ≥ 2 kinds of elements. Critical values for small sample sizes are tabled for ν = 2(1)6. More extensive tables are available from the author.

Outcome-based quality improvement in home health care: the OASIS indicators.

The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized risk-adjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning.

Outcome-Based Quality Improvement in the Information Age

The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized riskadjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning.

We've collected the OASIS data, now what?

The OASIS data set provides home care agencies with well-tested items for the collection of patient health status and outcome data. Illustrative examples of some of the OASIS-derived reports that agencies participating in demonstration projects received are presented. By understanding these reports, clinicians can see how the information they collect is presented in reports and can better understand the importance of collecting complete and accurate data.

Outcome-based continuous quality improvement as a financial strategy for home health care agencies

Rapid growth in home health care has led to heightened attention by third-party payers and regulators. Increasingly home health agencies (HHAs) must demonstrate the value of their serv ices. A major concurrent trend within the industry and at the federal level is toward incorporat ing standardized outcome measures in the continuous quality improvement (CQI) programs in HHAs. We suggest that in addition to improving quality, outcome-based CQI can help a HHA demonstrate the value of its services, improve the cost-effectiveness of its care provision, and thereby strengthen its financial viability. Key words: continuous quality improvement, finan cial strategy, outcome measurement