1. Greenberg, E. Liza MPH, RN

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Do patients treated by home healthcare agencies get readmitted to the hospital more or less often than patients in skilled nursing facilities? Thirty days after discharge will a home healthcare patient stay out of the hospital longer than the patient discharged from a skilled nursing facility? If you work in home care, you are probably wondering, "How can we compare results from patients in home healthcare to those in skilled nursing facilities when they are so different? Besides, how can an agency influence what happens a month after discharge from home health?" Good questions.


The Centers for Medicare and Medicaid Services (CMS) believes with proper risk adjustment, standardized patient assessments, and standardized measures, they will eventually have the tools in place to evaluate effectiveness and make appropriate comparisons across all types of postacute care settings. Through the "Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014," CMS will develop the tools and performance measures to compare postacute care costs and outcomes. True to its name, the IMPACT Act sets out to transform assessment and performance measurement. It applies to long-term care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, and home healthcare agencies. Ultimately, the new measures and assessments may answer questions about which postacute care providers prevent readmissions and promote community stays most effectively.


The goal of the IMPACT Act is to improve Medicare beneficiary outcomes, improve provider understanding of patient needs and improve coordination of services, and to better evaluate performance of providers and settings. Through a massive reworking of patient assessment data in all four formal postacute care settings, the IMPACT Act will permit tracking of patients' postacute functioning and needs across care settings. CMS also hopes to facilitate research on types of care and practices that result in better patient care.


By the time this article is published, more details should be available on the performance measures to be reported by home healthcare agencies, specifics of the risk adjustment system, and how the new measures will interface with current Home Health Compare reporting. For now, these issues are all work in progress. Time is short. The first postacute care settings begin reporting IMPACT Act measures in October 2016. For home healthcare agencies, the first IMPACT Act performance measures kick in on January 1, 2017 with private reporting to CMS. After a phase in period, all measures will eventually be publicly reported. The first IMPACT Act measures to be rolled out for home healthcare agencies are:


* Estimated Medicare Spending per Beneficiary


* Discharge to community


* All condition risk adjusted potentially preventable hospital readmission rates


* Skin integrity and changes in skin integrity


* Medication reconciliation



On January 1, 2019, three additional measures will roll out for home healthcare agencies. The 2019 new home healthcare agency measures include:


* Incidence of major falls


* Communicating the existence of and providing for the transfer of health information and care preferences


* Functional status, cognitive function, and changes in function and cognitive function



Home healthcare agency public reporting for all measures is targeted for January 1, 2021. Once fully implemented, all postacute care providers will report the same measures, with some differences in the exclusions and risk adjustment factors.


Standardized assessment items for Outcome and Assessment Information Set and tools used by other postacute care providers are also under development to improve continuity of care across postacute care settings. For home healthcare agencies, these will be implemented by January 1, 2019. Assessment domains include:


* Functional status


* Cognitive function and mental status


* Special services, treatments, and interventions


* Medical conditions and comorbidities


* Impairments


* Other domains identified by the Secretary



Visiting Nurse Associations of America (VNAA) fully supports the goals of the IMPACT Act. Nonetheless, the task is enormous and has some potential peril. The rapidity of development, along with the complexity of the measures, raises concerns of unintended consequences.


Through risk adjustment and modified performance measure specifications, CMS hopes to adjust apples-to-oranges differences into apples-to-apples comparisons. VNAA is concerned that risk adjustment methods have not been publicly vetted or tested in all postacute care settings. If risk adjustment isn't done right, it could appear that some providers are doing a worse job when in fact, they have different or more complex patients. Incorrect risk adjustment could impact both public reports to patients and future reimbursement.


Measures reported under the IMPACT Act will likely be used eventually in setting payment rates for postacute care providers. If policy makers use flawed measures to make payment adjustments through mechanisms such as value-based purchasing, postacute care providers could be penalized for events outside of their control. And, some providers may go to extreme lengths to ensure high performance, including "cherry picking" patients most likely to have good outcomes. This could create access barriers to caring for the most vulnerable.


VNAA has urged CMS to move cautiously as it simultaneously changes both patient assessment and provider performance measurement tools. Our healthcare system is in dire need of better-coordinated care and better information to support decision making. The IMPACT Act is spurring important steps in the right direction. CMS should proceed judiciously to ensure that patients and providers are not harmed as we take these steps. Our forward momentum must continue to ensure a robust, high-quality home and community-based care system that can deliver the patient-centered care for which home healthcare agencies are known.


For Further Information:

IMPACT Act of 2014 Data Standardization & Cross Setting Measures:


Text of the IMPACT Act of 2014: