1. Greenberg, Liza MPH, RN

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Home healthcare agencies have been measuring patient experiences of home healthcare since 2009, but the stakes are about to get higher. Starting in January 2016, home healthcare agency scores on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Home Health Care Survey will be part of the Centers for Medicare and Medicaid Services (CMS) Star Rating program. According to CMS, star ratings are a tool to provide information on healthcare quality so consumers can make healthcare decisions. Ratings will increasingly be used to drive reimbursement in Medicare and Medicaid value-based purchasing programs (CMS, 2015). For home healthcare agencies, star ratings may influence patient choices as well as contracting decisions of Accountable Care Organizations, health plans, and other purchasers.


For clinicians in home healthcare agencies, the change will likely mean new or reemphasized quality improvement activities. Not only will agencies be working to ensure high-quality clinical care; they will also be developing programs and systems to ensure that patients have a positive experience. This can be a net positive for home healthcare agencies because evidence shows that good patient experience drives retention and loyalty, and is linked to strong financial indicators (Anhang et al., 2014; Browne et al., 2010).


By January 2016 there will be two types of Star Ratings on Home Health Compare: Quality of Patient Care and Patient Survey Star Ratings. Quality of Patient Care star ratings went live in July 2015. These stars reflect a summary score based on 9 of the 26 separate measures of home healthcare agency quality. Now home healthcare agencies are awarded a single-star rating based on their performance on nine measures:


1. Timely initiation of care


2. Patient/caregiver drug education provided


3. Patient received flu vaccine for the current season


4. Patient got better at walking or moving around


5. Patient got better at getting in and out of bed


6. Patient got better at bathing themselves


7. Patient was able to engage in activity with less pain


8. Patient experienced less shortness of breath


9. Patient did not require acute care hospitalization



Patient experience is currently reported on Home Care Compare as a table of individual results. In January 2016, CMS will add a star rating of patient experience. The stars will "roll-up" agencies' performance on the CAHPS Survey into four star measures plus one overall performance measure. These measures describe the patient's experience with:


* The care they received


* Communication with their providers


* Specific issues relating to care


* And their overall rating of their home care



The old adage was "what gets measured gets done." Now, home care clinicians are likely to find that "What gets reported as a star measure gets even more attention." Home healthcare organizations most likely will be focusing attention on ensuring patients have a positive experience in areas known to impact survey responses. Customer service and interpersonal interactions are key drivers of experience. Star ratings are updated quarterly and agencies will be looking for ways to either keep their star ratings high, or improve ratings by the next public report.


Other sectors have gone through this experience. Health insurance plans were first in the health industry to use the CAHPS survey. Health plans quickly realized they couldn't wait for patient reports to roll in. They had to proactively reach out to patients and rigorously monitor their own programs to improve their scores. This change is likely to come to home healthcare as well. Agencies will be reviewing their care and customer service processes to ensure that they close gaps and deliver high-quality and consistent service.


According to Timothy Veach, Compliance Officer for Intermountain Homecare & Hospice in Utah, home healthcare agencies are well positioned to deliver excellent patient experience, and to use star ratings to demonstrate their value to purchasers. According to Mr. Veach, "Home health agencies are fundamentally designed to deliver patient-centered care. But now it isn't just a matter of providing the best care and hoping it works out. Agencies need a tangible action plan to address patient experience. All staff at all levels need to understand what it means to improve patient experience and how staff actions impact CAHPS results." (T. Veach, personal communication, August 17, 2015)


Quality improvement works best when championed by the organization's leadership, but actual quality interactions occur hundreds of times each day as agency staff interact with patients (Browne et al., 2010). Home healthcare agencies need to implement systematic approaches to quality that include training, evaluation, and regular performance assessment (Agency for Healthcare Research and Quality [AHRQ], 2015). Some key improvement strategies that impact patient experience include:


* Improving continuity of care by improving handoffs across staff and ensuring patients understand what is expected to happen at each handoff.


* Improving consistency in patient communications, for example, by standardizing intake communications and phone protocols.


* Reducing the number of ways patient needs can get "lost" in the system, for example, by implementing systematic procedures for returning phone calls or handling patient complaints.


* Making an early, personalized connection with the patient and family. Many agencies handle this with a welcome call and check-in calls periodically to ask if the patient's needs are being met.


* Reviewing patient experience performance data monthly to identify trends early.



Paula Suter, Clinical Director of the Sutter Center for Integrated Care and Sutter Care at Home says that achieving high-quality care delivery consistency across all clinicians and understanding each patient's specific needs and preferences are key to achieving high star ratings. She says, "We focus on ensuring that patients experience smooth care transitions - including the transition from a facility to home, but also transitions in the staff caring for them. We have created an 'always event,' - the opposite of a 'never event.' We always want staff to ask at the beginning of every visit 'what concerns do you have today,' so that we can address the patient's agenda first, before our own. Supervisors are now riding along with staff to observe their interactions and to provide coaching and mentoring to help ensure this happens." (P. Suter, personal communication, August 17, 2015)


Home healthcare personnel work with patients, their families, and caregivers in their own home setting, focusing on priorities established collaboratively with the patient. Agencies are positioned to flourish on measures of patient experience. Our challenge is to ensure that end-to-end quality systems are built for consistency. The net result will be performance ratings that reflect the high-quality, patient-centered care that home healthcare delivers.




AHRQ. (2015). The CAHPS improvement guide. Retrieved from[Context Link]


Anhang Price R., Elliott M. N., Zaslavsky A. M., Hays R. D., Lehrman W. G., Rybowski L., ..., Cleary P. D. (2014). Examining the role of patient experience surveys in measuring health care quality. Medical Care Research and Review, 71(5), 522-554. [Context Link]


Browne K., Roseman D., Shaller D., Edgman-Levitan S. (2010). Analysis & commentary. Measuring patient experience as a strategy for improving primary care. Health Affairs, 29(5), 921-925. [Context Link]


CMS. (2015). Consumer assessment of healthcare providers and systems. Retrieved from[Context Link]