Application of functional independence measure-function related groups and resource utilization groups-version III systems across post acute settings.

OBJECTIVES: The present study evaluated alternative patient classification systems for skilled nursing facility and rehabilitation facility patients. METHODS: Medicare patients were selected from a random sample of 27 rehabilitation facilities and 65 skilled nursing facilities participating in a national longitudinal study of subacute care. Detailed casemix and resource use data was obtained on 513 patients with hip fracture and 483 stroke patients. The Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system for rehabilitation facilities was replicated on length of stay and tested on resource use for rehabilitation facility patients as well as for skilled nursing facility patients. Modifications to the FIM-FRGs also were tested. The Resource Utilization Groups-Version III classification was tested on rehabilitation facility patients. RESULTS: The FIM-FRGs explained the same amount of variance in length of stay as in the original FIM-FRGs development sample (R2 hip fracture = 0.14, R2 stroke = 0.28), and similar variance in resource use. A modified version of the FIM-FRGs explained more variance in length of stay (R2 hip fracture = 0.19, R2 stroke = 0.39) and resource use (R2 hip fracture = 0.20, R2 stroke = 0.41). Neither model adequately predicted length of stay or resource use in skilled nursing facility patients. The Resource Utilization Groups-Version III rehabilitation groups accounted for little variance in rehabilitation facility patients' per-diem resource use (R2 = 0.11). CONCLUSIONS: The FIM-FRGs are valid for resource use as well as length of stay for rehabilitation facility patients, but are not valid for skilled nursing facility patients. Similarly, the Resource Utilization Groups-Version III system does not apply to rehabilitation facility patients. Related work, however, suggests that development of a single episode-based patient classification system for skilled nursing facility and rehabilitation facility patients is possible and should be pursued.

Outcome-based quality improvement in home health care: the OASIS indicators.

The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized risk-adjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning.

Outcome-based quality improvement in home health care: the OASIS indicators.

The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized risk-adjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning.

Rehabilitation costs: implications for prospective payment.

OBJECTIVE: To obtain information relevant to development of prospective payment for Medicare rehabilitation facilities (RFs) and skilled nursing facilities (SNFs): compares service utilization, length of stay (LOS), case mix, and resource consumption for Medicare patients receiving postacute institutional rehabilitation care. DATA SOURCES/STUDY SETTING: Longitudinal patient-level and related facility-level data on Medicare hip fracture (n = 513) and stroke (n = 483) patients admitted in 1991-1994 to a sample of 27 RFs and 65 SNFs in urban areas in 17 states. STUDY DESIGN: For each condition, two-group RF-SNF comparisons were made. Regression analysis was used to adjust RF-SNF differences in resource consumption per stay for patient condition (case mix) and other factors, since random assignment was not possible. DATA COLLECTION/EXTRACTION METHODS: Providers at each facility were trained to collect patient case-mix and service utilization information. Secondary data also were obtained. PRINCIPAL FINDINGS: RF patients had shorter LOS, fewer total nursing hours (but more skilled nursing hours), and more ancillary hours than SNF patients. After adjustment, ancillary resource consumption per stay remained substantially higher for RF than SNF patients, particularly for stroke. The adjusted nursing resource consumption differences were smaller than the ancillary differences and not statistically significant for hip fracture. Supplemental outcome findings suggested minimal differences for hip fracture patients but better outcomes for RF than SNF stroke patients. CONCLUSIONS: Much can be gained from an integrated approach to developing prospective payment for RFs and SNFs. In that context, consideration of condition-specific per-stay payment methods applicable to both settings appears warranted.

Outcomes across the care continuum. Home health care.

OBJECTIVES: This article describes one approach to measuring outcomes across the continuum of care. METHODS: Development and testing of the outcome-based quality-improvement methodology as developed by the University of Colorado Center for Health Services Research in Denver, Colorado are summarized. RESULTS: Reliable and valid measures for home health care covering end results (pure outcome), intermediate results (instrumental outcome), and use (proxy outcome) were developed and are useful in demonstrating patient improvement or stabilization as well as decline. Further, these measures can be aggregated by agency and, with appropriate severity or risk adjustment, can be used to compare outcomes over time and across agencies. CONCLUSIONS: National testing of the methodology is currently ongoing, with refinements underway in measures, risk adjustment, and operational implementation.

Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings.

OBJECTIVE: To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes. DESIGN: Inception cohort stratified by provider type and followed prospectively for 6 months. SETTING: A total of 92 hospital-based units and freestanding facilities from 17 states. PATIENTS: A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994. MAIN OUTCOME MEASURES: At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments. RESULTS: On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients. CONCLUSIONS: Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.

Stroke Rehabilitation in Nursing Homes.

Increasing numbers of stroke patients with profound functional, psychological, and cognitive impairments are receiving rehabilitation in Medicare skilled nursing facilities. These facilities vary substantially in the patients they admit, the volume and intensity of therapy they provide, and the outcomes they achieve. Facilities with an orientation toward rehabilitation and community discharge providing more intensive therapy services by a wider range of skilled professionals have better outcomes.

Volume/outcome relationships in small rural hospitals.

This article summarizes a study of relationships between hospital volume and patient outcomes for diagnoses commonly treated and procedures commonly performed in smaller rural hospitals. Literature review findings and results of analyses using secondary data for several conditions suggest few if any volume/outcome relationships (with mortality being the main outcome for which data were available). A basic finding of the study is that most conditions and procedures for which volume effects on mortality have been found typically do not pertain to small rural hospitals. However, the available secondary data are weak, and many conditions and procedures have not been studied for small rural hospitals. Therefore, continued monitoring and review are important, as well as improved data systems, further research, and information dissemination on volume/outcome relationships. In particular, examining relationships between volume and outcomes in addition to mortality is critical to a thorough understanding of this topic.

Home care: moving forward with continuous quality improvement.

The utility of examining the effectiveness of home care is illustrated by selected examples and applications. The growth rate of home care over the past decade, questions regarding the possibly substantial differences between the quality of home care in rural and urban America, and empirical evidence that suggests inferior quality of home care for health maintenance organization patients support the need for measuring and monitoring outcomes of home care. The conclusions of a research program targeted at developing a system of outcome measures for home care, and the resulting national demonstration program to implement and refine that system, are summarized.

Case mix of home health patients under capitated and fee-for-service payment.

OBJECTIVE: We compare case mix of Medicare home health patients under HMO and FFS payment. STUDY DESIGN: A pseudo-experimental design was employed to study case mix using three types of Medicare-certified home health agencies (HHAs): HMO-owned agencies, pure FFS agencies that admit few Medicare HMO patients (less than 5 percent of admissions are Medicare HMO patients), and mixed (or contractual) agencies that admit at least 15 Medicare FFS patients and 15 Medicare HMO patients per month. SAMPLES OF PROVIDERS AND PATIENTS: Random samples of Medicare-aged patients (> or = 65 years) were selected at admission between June 1989 and November 1991 from the 38 study HHAs. Sample sizes by agency type were: 308 patients from 9 HMO-owned agencies; 529 patients from 15 pure FFS agencies; and 381 HMO patients and 414 FFS patients from 14 contractual agencies. DATA: Primary longitudinal data were prospectively collected at admission for all patients on health status indicators, demographics, admission source, and home environment. MEASURES: The most important case-mix measures were functional and physiologic indicators of health status, including (instrumental) activities of daily living ([I]ADLs). Selected indicators of demographic variables, prior location, living situation, characteristics of informal caregivers, mental/behavioral factors, and resource needs were also used. PRINCIPAL FINDINGS: (a) The case mix of Medicare FFS patients compared with Medicare HMO patients was more intense in terms of impairments in ADLs, IADLs, and various physiologic conditions. Pressure ulcers as well as neurological and orthopedic impairments requiring rehabilitation care were also more prevalent among FFS patients. (b) Relative to HMO patients admitted to contractual agencies, HMO patients admitted to HMO-owned agencies were moderately more dependent in ADLs and IADLs. However, only 62 percent of HMO patients admitted to HMO-owned agencies, in contrast to 77 percent of HMO patients admitted to contractual agencies, had been hospitalized during the 30 days prior to home health admission. (c) In all, the case mix of patients receiving care from HMO-owned agencies is more heterogeneous than the case mix of HMO patients receiving care from contractual agencies. CONCLUSIONS: The case-mix (and selected utilization) findings indicate that HMOs use home health care differently than does the FFS sector. The greater diversity of case mix for HMO-owned agencies and the narrower or less diverse case mix that characterizes HMO patients receiving home care on a contractual basis point to the likelihood of cost differences among the two types of HMO patients and FFS patients, and raise the question of possible outcome differences.

Analytic framework for evaluation of telemedicine.

This paper discusses two conceptual models intended to facilitate research on the effects and effectiveness of telemedicine. The first is a conceptual framework to study the efficacy of telemedicine as a diagnostic medium. Using conditions that are carefully chosen to serve as indicators of effectiveness, we recommended the analysis of sensitivity and specificity to establish the accuracy of telemedicine in relation to conventional health care delivery. Suggested guidelines for interpretation of the results are discussed. The second model is a scheme for classification of telemedicine applications that is based on processes of care rather than on specialties or disorders. The purpose of this classification scheme is to facilitate research on such variables as costs, access, acceptability, and effects on practice patterns.

Patient-level cost of home health care under capitated and fee-for-service payment.

This article examines costs for a national sample of 1,260 Medicare patients receiving home health care from 38 home health agencies. It uses data from a study that compares home health care provided to Medicare beneficiaries in health maintenance organizations (HMOs) and the traditional fee-for-service (FFS) system. The major findings indicate significantly lower costs, based on fewer home health visits, for HMO patients compared to FFS patients, even after adjustment for case mix and other factors. However, FFS patients also attain better outcomes, suggesting that HMOs may provide too few visits to home health patients. At the same time, the number of visits to FFS patients may be greater than is necessary to achieve the better FFS outcomes.

Outcome-based quality improvement in home care.

A system of outcome measures of service quality was developed and tested. The findings of this project will provide a framework for moving forward with outcome-based quality improvement in home care. Using outcome measures will permit agencies to analyze their performance in terms of effectiveness of care.

Home health agency quality: Medicare certification findings compared to patient outcomes.

As part of an evaluation of the Medicare certification program for home health agencies (HHAs), we examined the extent to which certification findings were related to patient outcomes. In a previous study, we collected longitudinal patient data for a national sample of 42 HHAs and developed precise patient outcome measures. In this study, the outcome measures were compared to certification findings for the same HHAs and time period (1991-93). We found relatively little association between the two sets of measures. The findings indicate that the Medicare HHA survey process does not yet successfully incorporate patient outcomes.

Effects and effectiveness of telemedicine.

The use of telemedicine has recently undergone rapid growth and proliferation. Although the feasibility of many applications has been tested for nearly 30 years, data concerning the costs, effects, and effectiveness of telemedicine are limited. Consequently, the development of a strategy for coverage, payment, and utilization policy has been hindered. Telemedicine continues to expand, and pressure for policy development increases in the context of Federal budget cuts and major changes in health service financing. This article reviews the literature on the effects and medical effectiveness of telemedicine. It concludes with several recommendations for research, followed by a discussion of several specific questions, the answers to which might have a bearing on policy development.

Home health care outcomes under capitated and fee-for-service payment.

In this article, case-mix-adjusted outcomes of home health care are found to be superior for Medicare fee-for-service (FFS) patients relative to Medicare health maintenance organization (HMO) patients. The superior outcomes for FFS patients were accompanied by higher utilization and cost of home health services, suggesting a volume-outcome (or dose-response) relationship that was further substantiated by within-HMO and within-FFS analyses. The findings suggest that greater attention should be paid to both outcome-based quality assurance and managed care practices that may be overly restrictive in terms of the use of home health services.

Measuring and assuring the quality of home health care.

The growth in home health care in the United States since 1970, and the exponential increase in the provision of Medicare-covered home health services over the past 5 years, underscores the critical need to assess the effectiveness of home health care in our society. This article presents conceptual and applied topics and approaches involved in assessing effectiveness through measuring the outcomes of home health care. Definitions are provided for a number of terms that relate to quality of care, outcome measures, risk adjustment, and quality assurance (QA) in home health care. The goal is to provide an overview of a potential systemwide approach to outcome-based QA that has its basis in a partnership between the home health industry and payers or regulators.