The outcomes vanguard is spreading into home health.
In late July the Joint Commission on Accreditation of Healthcare Organizations published the schedule for home health and behavioral health companies to start collecting outcomes data for the Oryx project. Hospitals and nursing homes already are gearing up to meet the Oryx requirements. Behavioral health and home care are the fourth and fifth JCAHO accreditation programs to begin integrating outcomes measures into the process.
By the end of December of this year, home health agencies are supposed to notify the Joint Commission which two clinical measurements they've selected to submit. By March 31, 2000, agencies must send their data to the Joint Commission. Each succeeding year, organizations must add more clinical measures, until they cover a given percentage of patients.
At the same time, HCFA is getting ready to publish rules that will eventually require home health agencies to incorporate the Outcome and Assessment Information Set into their patient assessments. Under development since 1988, OASIS is part of HCFA's effort to improve outcomes in home health.
"We're waiting any day for publication of a final rule that mandates Medicare-certified home health agencies to collect this data set," says Alexis Wilson, founder and chief research officer of Seattle-based Outcome Concept Systems. The data set consists of 79 items assessing such factors as the patient's age, level of pain and activities of daily living.
Because of all the questions home health caregivers must ask patients to complete the data set, OASIS is labor-intensive and adds a fair amount of time to the clinician's initial visit. It also will add costs to agencies already squeezed hard by the rollbacks in home health reimbursements contained in last year's balanced-budget law, observers say.
"The mandate is pretty clear," Wilson says. "Congress is wanting to decrease the cost of home health, not increase it. That's the bad news.
"The good news is, finally we will have a means to do comparable evaluations. This will give us the ability to do apples-to-apples comparison," Wilson adds.
The big question hanging over home health is, do fewer visits mean worse outcomes? Why, for instance, do Medicare home health providers make about 130 visits per case in Louisiana while those in Washington state make about 34?
No one has a good answer for that.
This enormous variation in utilization only raises eyebrows in Congress, which is trying to contain home health expenditures before they burst through the budget.
The OASIS data set, which many in the industry say offers exemplary comparability of outcomes among providers, should allow researchers to analyze resource consumption against outcomes. That, put into a rigorous quality-improvement framework, should bring about better care, for less money-hence, better value.
Still, it's going to take some time. Agencies fear the additional cost-"not only for the amount of time the clinician will spend in the home, but the added cost of having someone put the data into the computer to get it to state agencies, which is supposedly what they have to do by January 1999," Wilson says. The state agencies are supposed to send it on to HCFA.
Originally agencies were supposed to start collecting the data Oct. 1. But that doesn't seem likely at this point.
In the meantime, Congress decided to pursue a prospective payment system for home care. But it can't set that up without a risk-adjustment methodology. That task, too, was layered onto the OASIS data set. Early data submissions will give researchers the raw material they need to develop the risk adjustments.
Like Wilson, Yvonne Santa Anna, vice president for education and disease management at Columbia Homecare Group in Dallas, understands these concepts in principle and thinks they're the right way to go. But she is worried that the new OASIS requirements, coupled with the Joint Commission's Oryx initiative, could overtax seasoned home health nurses to the point that they leave the field.
"We need to decrease the burden of paperwork on clinicians," she says. "The people who come into home care are the best clinicians. You have to be; you're on your own. They're not going to put up with this."
For agencies to stay in the game, they're going to have to figure out how to integrate the OASIS reports they get back from HCFA, which compare their outcomes with those of other agencies, into a comprehensive outcomes improvement process. Wilson says that's where individual agencies must find their strategic advantage.
But Santa Anna believes it's going to be harder than anyone imagines. She designs the forms for Columbia home health agencies nationwide, and she has tried to incorporate the OASIS elements into a standard assessment tool.
That's challenge enough. But adding in Oryx is "a double whammy," Santa Anna says. "The government says you will do OASIS. Then you have Oryx saying almost the identical things. They're asking you to select a tool that the JCAHO has sanctioned. The (home health) agencies are spinning their heads. Someone needs to think about, it's either/or, not both."
Al Buck, M.D., executive vice president at the Joint Commission, says he doesn't see much divergence between OASIS and Oryx. In fact he expects them to "converge" somewhere in the future. "Some if not all of the OASIS set would become a part of this repertoire" of performance enhancement, he says.
That raises the question, if HCFA is going to require agencies to collect OASIS data, why does the Joint Commission require them to submit Oryx data, too? Why couldn't they simply submit OASIS data to JCAHO?
That might be a possibility, Buck says. "We would want to be sure that the OASIS measures fit the criteria and attributes. If they do, they certainly would satisfy the requirement."
Santa Anna has little patience with that argument. "This is redundant. It's costing people a lot of money, and we're not getting more quality."
So why not dispense with Joint Commission accreditation entirely if your agency is handling the OASIS directives well enough?
It's not that simple, Santa Anna says. "The community at large sees the Joint Commission accreditation as a sanction of your quality. So the community is requiring it of our agencies if we're to get other contracts besides Medicare. You've got to have JCAHO accreditation, and the JCAHO knows that."