The 2017 Final Rule makes significant changes to the Home Health Quality Reporting Program (HHQRP), including changes to both publicly reported quality indicator items and items included in the monitoring of agency quality outcomes scores. As part of the Triple Aim of healthcare for Medicare beneficiaries, quality monitoring continues to be a focus of CMS and the Office of the Inspector General. The overall goal is that every home health agency will be responsible for its own quality monitoring and improvement, as agencies have been given an expanding arsenal of tools and data with which to plug into its robust Outcomes Based Quality Improvement (OBQI) program.
The new regulation focuses on finding the correct quality measures to measure performance and outcomes, both internally and comparatively between agencies. Changes to the quality reporting program also allows compliance with implementation of Improving the Medicare Post-Acute Care Transformation Act (IMPACT) of 2014. IMPACT serves to align quality measures and quality data comparison between post-acute care settings, including home healthcare, long-term acute care hospitals, and skilled nursing and inpatient rehabilitation facilities.
Quality Data Is Critical
Quality has been a focus in home healthcare for many years. The OASIS data set was created to ensure a standardized set of metrics for comparison of beneficiary outcomes and agency performance. The Social Security Act and Conditions of Participation (CoPs) for home health require agencies submit OASIS data for quality measurement .
Quality Episode Standards
A complete quality episode must be submitted to calculate quality measures from OASIS data. Unlike a 60-day payment episode, quality episodes have a start and end of care. The start of a quality episode begins with either a Start of Care (SOC) or a Resumption of Care (SOC) following an inpatient stay OASIS, and the end of a quality episode is defined by either a Transfer (T/F) or Discharge (DC) OASIS. Failure to submit sufficient OASIS assessments to allow accurate calculation of quality measures, which includes both T/F and D/C OASIS assessments, is a failure to comply with the CoPs for home health.
Every agency is expected to submit a minimum of two matching OASIS assessments for each patient admitted to the agency, as the two matching OASIS assessments are requested for a quality episode.
Quality Reporting Compliance
In the 2015 Final Rule, CMS established a Pay-for-Reporting performance requirement to measure compliance, and while only 70 percent threshold was finalized, the schedule for reaching at least 90% compliance is outlined below.
|
Episode Timeline |
Compliance Score Threshold |
Year of Applied 2% Reduction to Market Basket |
| Episodes beginning July 1, 2015 and before June 30, 2016 |
70% |
2017 |
| Episodes beginning July 1, 2016 and before June 30, 2017 |
80% |
2018 |
| Episodes beginning July 1, 2017 and before June 30, 2018 |
90% |
2019 |
According to the Pay-for-Reporting initiative, non-compliant agencies who do not meet the directive to submit quality data may face a reduction in payments of 2 percent, for up to one year, in the annual market basket percentage increase.
Agencies meet the quality data reporting requirements are eligible to receive the full home health market basket percentage increase of 2.5 percent, whereas those who do not meet the quality requirements will only receive 0.5 percent of the increase. In 2017, the 2.5 percent market basket increase consists of 2.8 percent market basket increase with a 0.3 percent annual private non-farm business multi-factor productivity rate (MFP) decrease factored in to equal 2.5 percent.
The ultimate goal is to require all agencies to achieve a quality reporting compliance rate of 90 percent or more so CMS can determine the extent to which agencies meet federal reporting requirements , and oversee the accuracy and completeness of submitted OASIS.
The quality reporting compliance rate is calculated by the following Quality Assessments Only (QAO) formula:
QAO = ____# Quality Assessments X 100_____________
# Quality Assessments + # Non-Quality Assessments
Changes in Quality Reporting
As part of the 2016 HHPPS Final Rule, CMS removed six process measures from the HHQRP:
- Pain Assessment Conducted
- Pain Interventions Implemented during All Episodes of Care
- Pressure Ulcer Risk Assessment Conducted
- Pressure Ulcer Prevention in Plan of Care
- Pressure Ulcer Prevention Implemented during All Episodes of Care
- Heart Failure Symptoms Addressed during All Episodes of Care
Additionally, CMS is adding four measures to meet the “Medication Reconciliation” and “Resource Use and other Measures” domains of the IMPACT Act :
- Total Estimated Medicare Spending Per Beneficiary
- Discharge to Community
- Potentially Preventable 30-day Post-Discharge Readmission Measure
- Drug Regimen Review Conducted with Follow Up for Identified Issues
Changes to Reporting Pressure Ulcers
CMS has significantly changed the suggested reporting instructions and classification of Closed Stage 3 and Stage 4 Pressure Ulcers, and pressure ulcers when a graft is applied.
Per current OASIS C1 guidance, Stage 3 and 4 Pressure Ulcers are considered “closed”, but not “healed”, when complete epithelialization has occurred. As defined, Stage 3 and 4 Pressure Ulcers are marked as though the ulcers never heal, but are “newly epithelialized”, at best.
However, this guidance changes according to the new OASIS-C2 Guidance Manual. Although closed Stage 3 and 4 Pressure Ulcers have 80 percent tensile strength, compared to normal tissue ,and are thus always prone to breakdown, to properly answer OASIS-C2 Pressure Ulcer questions, Stage 3 and 4 Pressure Ulcers are now considered “healed” when they are “closed” or “newly epithelialized.” In addition, new OASIS-C2 Pressure Ulcer criteria account for risk adjustment, such as height and weight.
Classification of ulcers with surgical flap or graft intervention has changed. According to OASIS-C1 guidance, pressure ulcers that are treated by flap procedures (such as a muscle flap) are considered surgical wounds post-procedure, while pressure ulcers treated by skin graft procedures remain pressure ulcers for the sake of OASIS. However, in OASIS-C2, both flap and skin-graft procedures change the pressure ulcer to surgical wounds for the sake of OASIS . This information needs to be relayed to clinical staff so that beginning on OASIS-C2 guidance is followed.
In part six, we will continue to explore the HHQRP, HHCAHPS changes and other Final Rule changes, which became effective January 1, 2017.
