Carolyne E. Adams

The study purpose was to determine if health status differed between rural versus urban home health patients and to identify if locale was a significant predictor of home health direct care time. Implemented in October 2000, the Medicare home health prospective payment system (PPS) made only temporary allowance for differences in cost of delivering home health services in rural versus urban environments. However, past research documented differences in health status and service utilization between rural and urban home health patients. Data were collected retrospectively on a convenience sample of 2,788 patient episodes of care. Patient health status was measured using items form the Outcome Assessment and Information Set (OASIS). Obtained from itinerary records, direct care time was the time clinicians spent in the home. The results showed significant differences in rural versus urban patients health status, with urban patients being healthier than rural patients. Consistent with poorer health status, rural patients received more RN direct care time. Other study factors being equal, living in a rural locale increased total direct care time by 150 minutes over living in an urban environment. Given the poorer health status and increased time requirements for rural patients, the results support assertions that Medicare per episode reimbursement should be higher for rural than for urban home health patients.

As home health reimbursement moves from fee-for-service to prospective payment, data describing the relationship between service utilization and patient outcomes will be the basis for planning services. The investigators measured the relationship between service utilization and generic patient outcomes for 1,704 home health episodes of care. Few significant relationships were found. The average study patient received 17 visits, well below the average number for the state and nation. Investigators suggested the possibility that visit numbers were too low to stimulate improvement in outcomes and that when services are curtailed, home health staff may do well to focus quality improvement efforts on condition-specific patient outcomes rather than generic outcomes.

This article describes the evolution of a collaborative model of quality improvement between an HMO and six contracted home health agencies using OASIS items to measure patient outcomes. The results showed that when agencies completed quality improvement activities independently, HMO patients' outcomes did not improve substantially. In contrast, when the HMO and agencies collaborated, patient outcomes improved as much as 19% in 1 year. This collaborative model can help purchasers and providers to share responsibility for improvement in patient outcomes.

The study purpose was to determine if use of the Outcome-Based Quality Improvement (OBQI) model, including a subset of the outcome Assessment and Information Set (OASIS), enhanced outcomes for health maintenance organization (HMO) patients referred for care to six contracted home health agencies (HHAs). After four quarters of data-driven quality improvement activities, the improvement scores of the patients were not changed significantly from the baseline period. Stabilization scores increased significantly for two of the five outcome measures. Use of OASIS and the OBQI model for HMO patients referred to multiple HHAs requires that contracted HHAs share outcome results and quality improvement conclusions.