Alternative Risk-Adjustment Approaches to Assessing the Quality of Home Health Care: Final Report. Technical Advisory Group (TAG) Meeting


A TAG meeting was conducted in Washington, DC, on August 20, 2004. Members of the TAG, which included industry representatives, were experts in home health care quality, risk-adjustment, and home health policy. The TAG made a number of comments and recommendations based on a review of preliminary analysis results and other background documents.

Strong support was expressed for identifying a core set of risk-adjusters (for statistical reasons as well as for face validity and interpretation of risk-adjustment models). TAG members agreed that the original file of risk-adjusters obtained from the University of Colorado had some limitations and that additional OASIS data should be requested to allow further development of three types of risk-adjusters: diagnoses, social support, and payer. Diagnoses were aggregated into broad body system categories on the original file. With the specific diagnosis information collected on OASIS, it will be possible to specify diagnoses that occur frequently in the home care population (e.g., diabetes) as well as conceptually important medical conditions. It was pointed out that some important diagnoses typically are recorded as secondary, not primary, diagnoses (e.g., multiple sclerosis) and that diagnosis risk-adjusters should take OASIS secondary diagnoses into account.

The TAG also recommended further examination of living arrangement and social support risk-adjusters after the original OASIS variables are obtained because of their high face validity for clinicians. There was a discussion about more detailed living arrangement data and whether knowing that the patient lives with his or her spouse, as opposed to other family members, is likely to perform better as a risk-adjuster. TAG members pointed out that it is possible that too much assistance could delay improvement in some activities. Also, it was suggested that the project team think about whether it is possible to identify spouses who can help with care versus those who cannot or who may require their own care.

There was a discussion of the original payer data (M0150) as well. Medicaid as a payer is to some extent an indicator of economic status. It also is likely to be an indicator of more permanent disability and/or chronic disease. One of the industry experts also suggested that agency staff completing OASIS assessments tend to check Medicare as a payer if there is any chance that the episode might be billed to Medicare. A very large share of episodes (greater than 94%) on the file obtained from the University of Colorado report Medicare as a payer. In addition to home health agency coding practices, this is partly due to the way episodes of home health care are selected for OBQI outcome analysis. All episodes must start and finish in the calendar year. This eliminates many long episodes that are more likely to have Medicaid as the payer including episodes where home health was provided the entire year but admission and discharge are outside the calendar year.

The rationale for examining the baseline therapy measures (i.e., oxygen therapy, IV/infusion therapy, enteral/parenteral nutrition, and ventilator) separately from other clinically relevant risk-adjusters was discussed by the TAG. The risk-adjustment experts agreed that it generally is a bad idea to include actual services in payment or outcome risk-adjustment models since it may encourage inappropriate use of the services. The clinical and industry experts, however, pointed out that these services were invasive and would not be initiated without very clear clinical indications and medical orders. These measures generally had little impact on the explanatory power of the 11 HHQI risk-adjustment models but may be appropriate as outcome-specific risk-adjusters in some cases.

One TAG member indicated that sensory measures (e.g., vision, speech) tend to vary in their relationship with outcomes and that the project team may want to consider dropping them from the core set of risk-adjusters and including them as outcome-specific risk-adjusters when appropriate. It also was suggested that “Life Expectancy” be dropped from consideration since agencies questioned its reliability and it is unclear whether it will be included in future versions of OASIS.

Overall, there was agreement that the sequential model building approach used by the project team was logical. There also was agreement that LOS should not be included as a risk-adjuster. Members of the TAG also agreed that agency-level analyses are an important part of the assessment of differences between current and alternative risk-adjustment models.

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