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Importance: The home health agency (HHA) market has seen increasingly more change in ownership transactions. Little is known about the organizational characteristics and quality of care of HHAs after ownership has changed., Objective: To examine whether an HHA change in ownership was associated with different quality-of-care outcomes, patient volume, and staffing levels., Design, Setting, and Participants: Using current HHA change of ownership files linked to publicly available Medicare HHA data, this staggered difference-in-differences analysis evaluated ownership change transactions of Medicare-certified HHAs from quarter 1 of 2016 to quarter 4 of 2019. Pretransaction and posttransaction HHA characteristics and quality-of-care outcomes were compared between HHAs that changed ownership and up to 8 matched controls. The transactions in the main analysis included (1) when an HHA remained as for-profit with a change in ownership and (2) when an HHA changed from nonprofit/public to for-profit ownership. The data were analyzed between November 2023 and September 2024., Main Outcomes and Measures: The primary outcomes were HHA-quarter measures of star ratings, the individual quality measures that compose the star ratings based on the Outcome and Assessment Information Set, and claims-based quality metrics, such as hospitalizations and emergency department visits. The secondary outcomes included HHA year measures of Medicare patient volume, per capita payments, and staffing levels (full-time equivalents and minutes per visit)., Results: The main dataset included 294 Medicare-certified HHAs that changed ownership, matched with 2330 controls. In 3 years after an ownership change, quarterly star ratings increased by 0.18 (95% CI, 0.05-0.31) relative to matched controls, with greater increases among HHAs that converted from nonprofit/public to for-profit. No significant improvement was observed in the 60-day rates of hospital admissions or outpatient emergency department visits. Further, no significant changes were observed in the number of Medicare beneficiaries, but per capita payments increased within 2 years post-ownership change. Significant reductions were observed in full-time equivalents of registered nurses (-17% [95% CI, -31% to -3%]) and home health aides (-26% [95% CI, -39% to -13%]), as well as per-visit minutes for skilled nursing care (-5% [95% CI, -9% to -1%]), physical therapy (-3% [95% CI, -5% to 0%]), and home health aide care (-11% [95% CI, -15% to -6%])., Conclusions and Relevance: In this difference-in-differences analysis of Medicare-certified HHAs, ownership change was associated with higher star ratings and Medicare per capita payments, but not with claims-based quality measures. Reduction in staffing levels after ownership change raises concerns about implications for quality of care.

Objectives: To develop person-centered integrated care quality indicators for home health agencies in Shanghai, China., Design: The study combined the Delphi method and the analytic hierarchy process (AHP)., Material and Methods: The Delphi consultation questionnaire was distributed to experts in home healthcare in Shanghai, China. A panel of experts with experience in home healthcare in Shanghai, China, was selected. Purposive sampling was used to choose experts. In this study, ten experts were selected from within sub-fields of home healthcare, including nursing, health policy, quality improvement, person-centered care (PCC), and integrated care., Results: The authority coefficient (Cr) in this study was 0.835. The coordination degree of experts' opinions, which is expressed by Kendall coordination coefficient W (a higher value, better coordination of the item), ranged from 0.352 to 0.386 (p < 0.001). The consistency ratio (CR) values for each level were less than 0.1. The quality indicator system included three first-level indicators, 15 second-level indicators, and 56 third-level indicators., Conclusions: A person-centered integrated care quality indicator system was developed for home health agencies. The findings from this study enable nurses, managers, and policymakers in home and community-based settings to evaluate person-centered integrated care quality using a robust framework. In addition, these indicators can also be used as a standardized tool to guide the development of long-term care services and supports (LTSS) for home-bound elderly., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection., Data Sources: We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website., Data Collection/extraction Methods: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users., Study Design: This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs., Principal Findings: The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries., Conclusions: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection., (© 2021 Health Research and Educational Trust.)

Background: The Centers for Medicare & Medicaid Services (CMS) Home Health Quality Reporting Program (HHQRP) uses performance measurement to spur improvements in home health agencies' (HHAs') quality of care. We examined quality improvement (QI) activities HHAs reported making to improve on HHQRP quality measures, and whether reported QI activities were associated with better measure performance., Methods: We used responses (N = 1052) from a Web- and mail-based survey of a stratified random sample of HHAs included in CMS Home Health Compare in October 2019. We estimated national adoption rates for 27 possible QI activities related to organizational culture, health information technology, care process redesign, provider incentives, provider training, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance. We used multivariate linear regression to examine the associations between HHA characteristics and QI adoption, and between QI adoption and CMS Home Health Quality of Patient Care Star Rating., Results: HHAs reported implementing an average of 16 QI activities (interquartile range 11-19 activities). Larger HHA size was associated with adopting 1.6 additional QI activities (p < 0.001). HHAs with higher proportions of disabled, black, or Hispanic patients adopted QI activities at similar or higher rates as other HHAs. Of the 27 QI activities, 23 were considered helpful by more than 80% of adopting HHAs. Compared with adopting 44% of QI activities (10th percentile among HHAs), adopting 89% of QI activities (90th percentile) was associated with a 0.4-star higher Star Rating (95% confidence interval 0.2-0.6)., Conclusions: HHAs report implementing a significant number of QI activities in response to CMS measurement programs; implementation of a greater number of activities is associated with better performance on publicly reported measures. To guide future HHA QI investments, work is needed to identify the optimal combination of QI activities and the specific QI activities that yield the greatest performance improvements., (© 2021 The American Geriatrics Society.)

Background: Home health care is a rapidly growing healthcare sector worldwide. Home health professionals face unique challenges related to preventing and controlling infections, which are likely to amplify during an infectious disease outbreak (e.g. SARS-CoV-2). Little is known about the current state of infection prevention and control-related policies and outbreak preparedness at U.S. home health agencies., Objectives: In this study, we conducted a national survey to assess infection prevention and control-related policies, infrastructure, and procedures prior to the SARS-CoV-2 pandemic., Design: Cross-sectional study., Setting/participants: Using a stratified random sample of 1506 U.S. home health agencies, we conducted a 61-item survey (paper and online) from November 9, 2018 to December 31, 2019., Methods: Survey data were linked to publicly-available data on the quality of patient care, patient satisfaction, and other agency characteristics. Probability weights were developed to account for sample design and nonresponse; Pearson's χ2, Fisher's exact, t-tests or linear regression were used to compare the universe of agencies/respondents and urban/rural agencies., Results: 35.6% of agencies responded (n = 536). Most home health personnel in charge of infection prevention and control have other responsibilities; one-third have no formal infection prevention and control training. Rural agencies are more likely to not have anyone in charge of infection prevention and control compared to those in urban areas. About 22% of agencies implement recommended guidelines when administering antibiotics. Less than a third (26.4%) report that their staff vaccination rates were higher than 95% during the last flu season. Only 48.1% of agencies accept patients requiring ventilation, and of those, 40.9% located in rural areas do not have specific infection prevention and control policies for ventilated patients, compared to 20.8% in urban areas (p < 0.001). Only 39.7% of agencies provide N95 respirators to their clinical staff; rural agencies are significantly more likely to provide those supplies than urban agencies (50.7% vs. 37.7%, p = 0.004). Lastly, agencies report their greatest challenges with infection prevention and control are collecting/reporting infection data and adherence to/monitoring of nursing bag technique., Conclusions: Prior to the SARS-CoV-2 pandemic, we found that infection prevention and control was suboptimal among U.S. home health care agencies. Consequently, most agencies have limited capacity to respond to infectious disease outbreaks. Staff and personal protective equipment shortages remain major concerns, and agencies will need to quickly adjust their existing infection prevention and control policies and potentially create new ones. In the long-term, agencies also need to improve influenza vaccination coverage among their staff. Tweetable abstract: Infection prevention and control infrastructure, policies and procedures and outbreak preparedness at U.S. home health agencies was found to be suboptimal in nationally-representative survey conducted just prior to the COVID-19 pandemic., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: To examine the growth and evolution of the home health agency (HHA) market and to compare quality performance across HHA ownership categories., Data Source: Agency characteristics were extracted from Medicare cost reports and Provider of Services file. Quality of care and patient characteristics were extracted from Quality of Patient Care Star Ratings and HHA Public Use File., Study Design: Agency- and state-level analyses were conducted to describe HHA market trends. Patient characteristics and quality measures were compared across ownership categories of interest., Data Collection/extraction Methods: All Medicare-certified HHAs in operation, 2005-2018., Principal Findings: Over the study period, the HHA sector grew substantially, increasing from 7899 to 10 818 agencies, and chain-owned HHAs doubled in number from 903 (11.4% of all agencies) to 1841 (17.0%). In 2018, across agency types, for-profit nonchain agencies were the largest category both in the number of agencies (67.8%) and the number of Medicare enrollees served (40.7%). Additionally, for-profit nonchain agencies grew most in total number, from 4293 (54.3%) to 7337 (67.8%), while for-profit chain agencies grew most in the number of Medicare enrollees served, from 439 998 (12.9%) to 1 082 385 (28.3%). Regarding patient composition, for-profit nonchain agencies served the highest proportion of dual eligible beneficiaries (42.2%) and African-Americans (27.9%) among all agency types. Regarding quality performance, a higher star rating is significantly (P < .01) associated with chain agency status. Moreover, chain HHAs performed better on self-reported process measures, and risk-adjusted self-reported outcome measures; however, they performed worse on risk-adjusted claims-based outcome measures. These results were similar across for-profit and nonprofit chain agencies., Conclusion: Chains play a growing role in the home health sector. Substantial differences in geographic distribution, patient composition, and quality performance were observed between chain- and nonchain HHAs. Examining the growth and performance of multi-agency chains can help inform quality reporting and monitoring, assess payment adequacy, and facilitate greater transparency and accountability within the HHA marketplace., (© Health Research and Educational Trust.)

We linked the Medicare Provider Utilization and Payment Data for Home Health and the Home Health Compare data for the year 2016 to identify home healthcare agency (HHA) characteristics associated with acute care hospitalization (ACH) or emergency department (ED) use. The study cohort consisted of 9,800 HHAs. Beta regression was used to examine the association between average age, race/ethnic composition, number of skilled nursing visits, number of therapy visits, percentage of dual eligible patients, HHA ownership, HHA location, Medicare tenure, proportion of patients with a diagnosis of schizophrenia, stroke, diabetes, depression, chronic obstructive pulmonary disease (COPD), heart failure, cancer and Alzheimer disease, and ACH or ED use. After controlling for HHA-level characteristics, variations in HHAs' ACH and unplanned ED visits were found. For-profit HHAs were significantly less likely to have patients with ACH. (Odds ratio = -0.05, p = 0.020), HHAs in the Midwest, South, and West had lower odds of ACH. HHAs that serve more than 50% Black patients had significantly decreased odds (β = -0.16, p < 0.001) of ACH. A 1-unit increase in the proportion of patients with a diagnosis of schizophrenia, COPD, stroke, heart failure, and Alzheimer disease was associated with increased odds of hospitalization. For each unit increase in the number of skilled nursing visits, the odds of ACH increased by 0.02 (p = 0.001). For-profit and nonprofit HHAs had a significant decrease in the odds of unplanned ED visits (p < 0.05). An increase in the proportion of patients with COPD was associated with increased odds of unplanned ED visits (p < 0.001). HHA characteristics are associated with hospitalization and ED use without hospitalization. These characteristics point to variation in quality of care measured by ACH and ED use.

Importance: Medicare Advantage (MA) enrollment is increasing, with one-third of Medicare beneficiaries currently selecting MA. Despite this growth, it is difficult to assess the quality of the health care professionals and organizations that serve MA beneficiaries or to compare them with health care professionals and organizations serving traditional Medicare (TM) beneficiaries. Elderly individuals served by home health agencies (HHAs) may be particularly susceptible to the negative outcomes associated with low-quality care., Objective: To compare the quality of HHAs that serve TM and MA beneficiaries., Design, Setting, and Participants: This cross-sectional, admission-level analysis used data from 4 391 980 home health admissions identified using the Outcome and Assessment Information Set (most commonly known as OASIS) admission assessments of Medicare beneficiaries in 2015 from Medicare-certified HHAs. A multinomial logistic regression model was used to assess whether an association existed between the Medicare plan type and HHA quality. The model was adjusted for patient demographics, acuity, and characteristics of the zip codes. Sensitivity analyses controlled for zip code fixed effects. The present analysis was conducted between October 2018 and March 2019., Exposures: Home health users were classified as TM or MA beneficiaries using the Master Beneficiary Summary File. The MA beneficiaries were further classified as enrolled in a high- or low-quality MA plan on the basis of publicly reported MA star ratings., Main Outcomes and Measures: Quality of HHA derived from the publicly reported patient care star ratings: low quality (1.0-2.5 stars), average quality (3.0-3.5 stars), or high quality (≥4.0 stars)., Results: Of 4 391 980 admissions, most (75.5%) were for TM beneficiaries (mean [SD] age, 76.1 [12.2] years), with 16.6% of beneficiaries enrolled in high-quality MA plans (mean [SD] age, 77.8 [10.0] years) and 7.9% in low-quality MA plans (mean [SD] age, 74.4 [11.4] years). Individuals enrolled in low-rated MA plans were most likely to be nonwhite (percentages of nonwhite individuals in TM, 14.3%; in high-quality MA, 19.8%; and in low-quality MA, 36.5%) and dual Medicare-Medicaid eligible (percentages for dual eligible in TM, 30.5%; in high-quality MA, 19.5%; and in low-quality MA, 43.3%). Among TM beneficiaries, 30.4% received care from high-quality HHAs, whereas 17.0% received care from low-quality HHAs. Compared with TM beneficiaries, those in a low-quality MA plan were 3.0 percentage points (95% CI, 2.6%-3.4%) more likely to be treated by a low-quality HHA and 4.9 percentage points (95% CI, -5.4% to -4.3%) less likely to be treated by a high-quality HHA. The MA beneficiaries in high-quality plans were also less likely to receive care from high-quality vs low-quality HHAs (-2.8% [95% CI, -3.1% to -2.2%] vs 1.0% [95% CI, 0.7%-1.3%])., Conclusions and Relevance: Compared with TM beneficiaries, MA beneficiaries residing in the same zip code enrolled in either high- or low-quality MA plans may receive treatment from lower-quality HHAs. Policy makers may consider incentivizing MA plans to include higher-quality HHAs in their networks and improving patient education regarding HHA quality.

This cross-sectional study examines factors associated with the CMS Summary Star Ratings in Home Health Agencies (HHA). Using Home Health Compare, medical claims, and census data, negative binomial regression analysis was conducted at the HHA level. Positive associations were found between Summary Star Ratings and beneficiary age, the number of claims, the proportion for specific diagnoses, the agency being hospital based, HHA age since establishment, patient retainment, improved walking/moving/bathing, and homeownership. Negative associations were found for specific ICD diagnosis proportions, HHAs serving special populations, the rate of non-white patients, patients transferred to different HHAs, income, and marital status in the coverage area. These findings are relevant to both practitioners and policymakers, in that they highlight major non-service factors associated with perceived quality of care.

Objectives: To understand the association between agency-level CMS Hierarchical Condition Categories (HCC) risk scores and patient experience measures for home health., Study Design: This was a cross-sectional study., Methods: We extracted variables from the 2014 Medicare Provider Utilization and Payment Data for Home Health Agencies and Home Health Compare file. We applied fixed-effects models for the analyses. Our dependent variables included both global and composite patient experience measures. The 2 global patient experience measures were the patient's overall rating of care provided by the agency (rating) and the patient's willingness to recommend the home health agency to others (recommendation). The 3 composite patient experience measures were how often the patient felt the provider gave care in a professional way (professional way), how well the home health team communicated with the patient (communication), and whether the home health team discussed medicines, pain, and home safety with the patient (discussion)., Results: Increased agency-level CMS HCC risk scores were negatively associated with all patient experience measures: rating (-2.04; P ≤.001), recommendation (-2.75; P <.001), professional way (-1.56; P <.001), communication (-1.67; P <.001), and discussion (-1.69; P ≤.001). Several covariates, including the percentage of racial/ethnic minority beneficiaries, ownership of the agency, and number of tenured years with the Medicare program, were significantly associated with patient experience measures., Conclusions: A negative association exists between CMS HCC risk scores and patient experience measures. To avoid unintended consequences, patient experience measures need further risk adjustment under the CMS 5-star patient survey rating system and the Home Health Value-Based Purchasing pilot program.

This integrative review analyzes research on the relationship of Home Health Care (HHC) to readmissions, specifically, identifying moderating and mediating factors and measurement constraints influencing effectiveness evaluations of HHC in reducing readmissions. HHC patients' readmission rates are higher than patients not receiving home health services but measurement of effectiveness is confounded by both practice variation and comparisons using noncomparable control groups. Effectiveness evaluations of HHC in reducing readmission requires attention to sample comparability and control for mediating variables. Establishing evidence of effectiveness clarifies the utility of HHC as a strategy to reduce readmissions.

Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies.

Objective: To examine associations between organizational characteristics of home health agencies (eg, profit status, rehabilitation therapy staffing model, size, and rurality) and quality outcomes in Medicare beneficiaries with rehabilitation-sensitive conditions, conditions for which occupational, physical, and/or speech therapy have the potential to improve functioning, prevent or slow substantial decline in functioning, or increase ability to remain at home safely., Design: Retrospective analysis., Setting: Home health agencies., Participants: Fee-for-service beneficiaries (N=1,006,562) admitted to 9250 Medicare-certified home health agencies in 2009., Interventions: Not applicable., Main Outcome Measures: Institutional admission during home health care, community discharge, and institutional admission within 30 days of discharge., Results: Nonprofit (vs for-profit) home health agencies were more likely to discharge beneficiaries to the community (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.33) and less likely to have beneficiaries incur institutional admissions within 30 days of discharge (OR, .93; 95% CI, .88-.97). Agencies in rural (vs urban) counties were less likely to discharge patients to the community (OR, .83; 95% CI, .77-.90) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.24; 95% CI, 1.18-1.30) and within 30 days of discharge (OR, 1.15; 95% CI, 1.10-1.22). Agencies with contract (vs in-house) therapy staff were less likely to discharge beneficiaries to the community (OR, .79, 95% CI, .70-.91) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.09; 95% CI, 1.03-1.15) and within 30 days of discharge (OR, 1.17; 95% CI, 1.07-1.28)., Conclusions: As payers continue to test and implement reimbursement mechanisms that seek to reward value over volume of services, greater attention should be paid to organizational factors that facilitate better coordinated, higher quality home health care for beneficiaries who may benefit from rehabilitation., (Copyright © 2017 American Congress of Rehabilitation Medicine. All rights reserved.)

This study explored patient experiences in home health care through a literature review, focus groups, and interviews. Our goal was to develop a conceptual map of home health care patient experience domains. The conceptual map identifies technical and personal spheres of care, relating prior studies to new focus group and interview findings and identifying the most important domains of care. Study participants (n = 35) most frequently reported the most important domain as staff who are caring, supportive, patient, empathetic, respectful, and considerate (endorsed by 29% of participants). The conceptual map includes 114 discrete domains.

The onset of depressive symptoms is common in home care clients and their caregivers. Understanding the experience of the informal caregiver can assist clinicians in providing services to maximize the well-being of both the client and their caregivers. The objectives of this article are to examine risk factors for the development of depressive symptoms. A longitudinal analysis design was completed for clients with 2+ assessments. The development of depressive symptoms was defined as a Depression Rating Scale score of 3+ on re-assessment. The results-overall, 10.7% of clients experienced new depressive symptoms and clients with a caregiver who was feeling distressed, angry, or depressed were 45% more likely to develop symptoms.

Objectives: To evaluate home health agency quality performance., Design: Observational study., Setting: Home health agencies., Participants: All Medicare-certified agencies with at least 6 months of data from 2011 to 2015., Measurements: Twenty-two quality indicators, five patient survey indicators, and their composite scores., Results: The study included 11,462 Medicare-certified home health agencies that served 92.4% of all ZIP codes nationwide, accounting for 315.2 million people. The mean composite scores were 409.1 ± 22.7 out of 500 with the patient survey indicators and 492.3 ± 21.7 out of 600 without the patient survey indicators. Home health agency performance on 27 quality indicators varied, with the coefficients of dispersion ranging from 4.9 to 62.8. Categorization of agencies into performance quartiles revealed that 3,179 (27.7%) were in the low-performing group (below 25th percentile) at least one time during the period from 2011-12 to 2014-15 and that 493 were in the low-performing group throughout the study period. Geographic variation in agency performance was observed. Agencies with longer Medicare-certified years were more likely to have high-performing scores; agencies providing partial services, with proprietary ownership, and those with long travel distances to reach patients had lower performance. Agencies serving low-income counties and counties with lower proportions of women and senior residences and greater proportions of Hispanic residents were more likely to attain lower performance scores., Conclusion: Home health agency performance on several quality indicators varied, and many agencies were persistently in the lowest quartile of performance. Still, there is a need to improve the quality of care of all agencies. Many parts of the United States, particularly lower-income areas and areas with more Hispanic residents, are more likely to receive lower quality home health care., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Home health care is an essential service for home-bound patients in Thailand. In this action research study, we used the International Classification of Functioning, Disability and Health (ICF) framework to modify home health care services provided by a university hospital. Staff responsible for delivering the services (physical therapist, nurses, and Thai traditional medicine practitioners) participated in the development of an ICF-based assessment tool and home health care service procedure. After an 8-month trial of implementing these changes, professional satisfaction and empowerment were high among the home health care team members. Patients and their caregivers were also satisfied with the services. In conclusion, the ICF is an effective means of guiding home health care.

The United States resettles close to 70,000 refugees each year more than any other country in the world. Adult refugees are at risk for negative health outcomes and inefficient health resource use, and meeting the multiple health needs of this vulnerable population is a challenge. The purpose of this study was to assess the impact of a home health care (HHC) pilot project on meeting the needs of older adult refugee patients. A retrospective chart review of 40 refugee adult patients who participated in an HHC pilot was done to analyze their health outcomes using OASIS-C data. Participants' pain level, anxiety level, medication management, and activities of daily living management all significantly improved over the course of their HHC episode. Results of this study indicate that HHC has great potential to improve the health of vulnerable refugee populations and assist the families involved in their care.

We examined the effects of provider characteristics on home health agency performance on patient experience of care (Home Health CAHPS) and process (OASIS) measures. Descriptive, multivariate, and factor analyses were used. While agencies score high on both domains, factor analyses showed that the underlying items represent separate constructs. Freestanding and Visiting Nurse Association agencies, higher number of home health aides per 100 episodes, and urban location were statistically significant predictors of lower performance. Lack of variation in composite measures potentially led to counterintuitive results for effects of organizational characteristics. This exploratory study showed the value of having separate quality domains.

The Improving Medicare Post-Acute Transformation (IMPACT) Act of 2014 will set the course for much of postacute care well into the next decade. It (1) authorizes a uniform method of patient assessment in postacute care; (2) sets a timetable for developing, implementing, and reporting quality measures; and (3) lays the groundwork for future payment reform in postacute care. This article places the IMPACT Act into the larger arc of health care reform and change. It summarizes the law's key provisions and presents a contrarian analysis of this much-heralded bipartisan legislation. The Affordable Care Act (ACA) of 2010 already gives the Centers for Medicare and Medicaid Services the authority to implement what the IMPACT Act requires. The IMPACT Act may even slow down the changes envisioned in the ACA. The article concludes by noting the implications for occupational therapy both as a practice and a profession., (Copyright © 2016 by the American Occupational Therapy Association, Inc.)

Objective: To determine the agreement of measures of care in different settings-hospitals, nursing homes (NHs), and home health agencies (HHAs)-and identify communities with high-quality care in all settings., Data Sources/study Setting: Publicly available quality measures for hospitals, NHs, and HHAs, linked to hospital service areas (HSAs)., Study Design: We constructed composite quality measures for hospitals, HHAs, and nursing homes. We used these measures to identify HSAs with exceptionally high- or low-quality of care across all settings, or only high hospital quality, and compared these with respect to sociodemographic and health system factors., Principal Findings: We identified three dimensions of hospital quality, four HHA dimensions, and two NH dimensions; these were poorly correlated across the three care settings. HSAs that ranked high on all dimensions had more general practitioners per capita, and fewer specialists per capita, than HSAs that ranked highly on only the hospital measures., Conclusion: Higher quality hospital, HHA, and NH care are not correlated at the regional level; regions where all dimensions of care are high differ systematically from regions which score well on only hospital measures and from those which score well on none., (© Health Research and Educational Trust.)

This study examined the intensity of home health services, as defined by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiaries with stroke. A cross-sectional secondary data analysis was conducted using 2009 home health claims data obtained from the Centers for Medicare and Medicaid Services' Research Data Assistance Center. There were no significant rural-urban differences in the number of home health visits. Rural beneficiaries were significantly less likely than urban beneficiaries to receive services from rehabilitation specialists. Current home health payment reform recommendations may have unintended consequences for rural home health beneficiaries who need therapy services.

Background: Home care services play an integral role in promoting independence, reducing hospital admission and readmission rates, and preventing or delaying nursing home admission among older adults. Despite important sex differences in functional status and use of services by recipients of home care, differences in home care performance measures by sex have not been examined., Objective: To assess sex differences in the quality of publicly funded home care services in Ontario, Canada., Methods: Validated, publicly reported home care quality indicators derived from the Resident Assessment Instrument for Home Care using the 2009 and 2010 Home Care Reporting System database were assessed for 119,795 Ontario home care clients aged 65 years and older. Unadjusted and risk-adjusted sex differences in performance were examined provincially and by health region., Results: In unadjusted analyses, there were sex differences in health outcomes on all indicators examined (decline or failure to improve in activities of daily living, cognitive decline, depressive symptoms, and pain control). After risk adjustment, differences were minimal. For example, in unadjusted analyses, 23.1% of women and 18.7% of men reported poorly controlled pain. After risk adjustment, 21.2% of women and 21.6% of men reported poorly controlled pain, with a difference of -0.4% (95% CI, -0.4% to -0.3%). Across health regions risk adjustment eliminated sex differences. There was 1.3-fold to 2.6-fold variation in performance on indicators across health regions., Conclusions: After risk adjustment, no important sex differences in home care quality indicators were identified. Sizable regional variations observed indicate potential to improve home care outcomes for both women and men. Sex differences in unadjusted analyses demonstrate the value of examining both unadjusted and adjusted outcomes and suggest sex-specific strategies will likely be needed to improve home care quality., (Copyright © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.

For-profit, or proprietary, home health agencies were banned from Medicare until 1980 but now account for a majority of the agencies that provide such services. Medicare home health costs have grown rapidly since the implementation of a risk-based prospective payment system in 2000. We analyzed recent national cost and case-mix-adjusted quality outcomes to assess the performance of for-profit and nonprofit home health agencies. For-profit agencies scored slightly but significantly worse on overall quality indicators compared to nonprofits (77.18 percent and 78.71 percent, respectively). Notably, for-profit agencies scored lower than nonprofits on the clinically important outcome "avoidance of hospitalization" (71.64 percent versus 73.53 percent). Scores on quality measures were lowest in the South, where for-profits predominate. Compared to nonprofits, proprietary agencies also had higher costs per patient ($4,827 versus $4,075), were more profitable, and had higher administrative costs. Our findings raise concerns about whether for-profit agencies should continue to be eligible for Medicare payments and about the efficiency of Medicare's market-oriented, risk-based home care payment system., (Project HOPE—The People-to-People Health Foundation, Inc.)

Semistructured interviews with nurses working for home health care agencies in five states raise serious questions about the deleterious effects of Medicare policies and procedures on depression care. The agencies have strong incentives to limit nursing time in a given payment episode and to increase volume, making it difficult to provide high-quality depression care for homebound patients. Some nurses felt forced to "abandon" many patients with depression. The authors call for incremental policy changes in several key areas.

Background: The key to ensuring quality care for older adults is a nursing workforce that collaborates across professions and provider levels (Wright M.C., Phillips-Bute, B.G., Petrusa, E.R., Griffin, K.L., Hobbs, G.W., & Taekman, J.M. (2008). Assessing teamwork in medical education and practice: Relating behavioural teamwork ratings and clinical performance. Med Teach, 29, 1-9)., Purpose: To improve communication and teamwork among interprofessional health care providers (HCPs) by using innovative teambuilding activities over three years., Participants: 97 multi-disciplinary HCPs from five long term or home care agencies in an underserved region of New England. PARTICIPANTS attended six interactive sessions focused on teambuilding skills through the use of role play, case studies, games, exercises and teambuilding strategies. The J. A. Hartford Foundation's (John A. Hartford Foundation. (2001). The John A. Hartford Foundation Geriatric Interdisciplinary Team Training (GITT) Program. Available at: http://www.nygec.org/index.cfm?section&#95;id=26&sub&#95;section&#95;id=18&page&#95;id=98) Geriatric Interdisciplinary Team Training (GITT) instrument and Interdisciplinary Teamwork IQ test were used to measure changes in knowledge and attitudes., Results: T tests performed on matched pre/post GITT instruments (n=26) revealed no significant change, although scores improved slightly from pre: (71%) to post test (73.3%) (p=.39). Teamwork IQ scores also improved slightly though not significantly. Qualitative data gathered suggest that teambuilding exercises were helpful in practice and allowed for better understanding of other provider roles., Conclusions: Rarely is a variety of health care disciplines invited to participate in educational opportunities together. The interprofessional small group methodology used is a replicable model with potential to overcome barriers in communication and teamwork skills., (© 2014.)

The Conditions of Participation for Discharge Planning are the case manager's guide as to how to correctly develop, implement and re-assess a hospital discharge planning program. Virtually any questions you may have as to how to conduct the discharge planning process can be found in the CoP. As case managers, we should never have to guess as to what the "right thing" is to do as it relates to discharge planning. Referring to the CoP any time a question comes up will always lead you in the right direction.

Background: A study was conducted to investigate health care agency central line-associated bloodstream infection (CLABSI) definitions and prevention policies and pare them to the Joint Commission National Patient Safety Goal (NPSG.07.04.01), the Centers for Disease Control and Prevention (CDC) CLABSI prevention recommendations, and a best-practice central line care bundle for inpatients., Methods: A telephone-based survey was conducted in 2011 of a convenience sample of home health care agencies associated with children's hematology/oncology centers., Results: Of the 97 eligible home health care agencies, 57 (59%) completed the survey. No agency reported using all five aspects of the National Healthcare and Safety Network/Association for Professionals in Infection Control and Epidemiology CLABSI definition and adjudication process, and of the 50 agencies that reported tracking CLABSI rates, 20 (40%) reported using none. Only 10 agencies (18%) had policies consistent with all elements of the inpatient-focused NPSG.07.04.01, 10 agencies (18%) were consistent with all elements of the home care targeted CDC CLABSI prevention recommendations, and no agencies were consistent with all elements of the central line care bundle. Only 14 agencies (25%) knew their overall CLABSI rate: mean 0.40 CLABSIs per 1,000 central line days (95% confidence interval [CI], 0.18 to 0.61). Six agencies (11%) knew their agency's pediatric CLABSI rate: mean 0.54 CLABSIs per 1,000 central line days (95% CI, 0.06 to 1.01)., Conclusions: The policies of a national sample of home health care agencies varied significantly from national inpatient and home health care agency targeted standards for CLABSI definitions and prevention. Future research should assess strategies for standardizing home health care practices consistent with evidence-based recommendations.

This research aims to increase transparency and simplify consumer decision-making regarding the selection of a home health care provider. Currently, quality information on home health care providers is fragmented and difficult to interpret. In this study, a quality-ranking model is developed by selecting multidimensional quality indicators across multiple sources and respective weights using expert judgment. Given the weights and providers' performance on each quality indicator, a composite score is calculated that summarizes a home health care provider's overall quality level. This quality information empowers consumers to narrow their search and select the best-performing, most efficient providers.

The way we deliver health care is changing fast and going in the direction of home care and hospice. This timely program addressed the threshold question of how your organization should play a part in a new arena that includes accountable care organizations, bundling of post-acute care, and integrated transitions in care. Should you be a partner with other health care sectors, assuming some of the financial risk for the success or failure of the endeavor? Should you choose instead to be an active participant or possibly a vendor to an integrated health delivery model? Join our panel as they discussed how to determine your role and gauge the community of health in which you function.

Objective: To examine whether home health agencies selectively discontinue services to areas with socio-economically disadvantaged people after the introduction of Home Health Compare (HHC), a public reporting program initiated by Medicare in 2003., Study Design /methods: We focused on agencies' initial responses to HHC and examined selective market-area exits by agencies between 2002 and 2004. We measured HHC effects by the percentage of quality indicators reported in public HHC data in 2003. Socio-economic status was measured by per capita income and percent college-educated at the market-area level., Data Sources: 2002 and 2004 Outcome and Assessment Information Set (OASIS); 2000 US Census file; 2004 Area Resource File; and 2002 Provider of Service File., Principal Findings: WE FOUND A SMALL AND WEAK EFFECT OF PUBLIC REPORTING ON SELECTIVE EXITS: a 10-percent increase in reporting (reporting one more indicator) increased the probability of leaving an area with less-educated people by 0.3 percentage points, compared with leaving an area with high education., Conclusion: The small level of market-area exits under public reporting is unlikely to be practically meaningful, suggesting that HHC did not lead to a disruption in access to home health care through selective exits during the initial year of the program.

Quality improvement is increasingly at the forefront of health care, creating a growing demand in clinical settings for health professionals adept at understanding and optimizing systems of health care delivery. Compared with clinicians, administrators, and health services researchers, health educators have to date played less of a role in quality improvement. However, as this article argues, the potential for health educators to contribute to such efforts is great because health education and quality improvement are more similar in their goals and approaches than is commonly recognized. Health educators bring important skills to quality improvement practice in areas such as needs assessment, participatory planning, and evaluation. To illustrate the mutual benefits that arise when these two practices intersect, the implementation of an electronic patient scheduling system led by quality improvement professionals in a large home care agency is described.

This report provides nationally representative data on documentation of advance directives (ADs) among home health (HH) and hospice patients. Advance directives were recorded for 29% of HH patients and 90% of hospice discharges. Among HH patients, increasing age and use of assistive devices were associated with greater odds of having an AD, while being Hispanic or black (relative to white) and enrolled in Medicaid decreased the odds of having ADs. Among hospice discharges, being enrolled in Medicare and having 4 or 5 activities of daily living (ADL) limitations were associated with higher odds of ADs while depression, use of emergency services, and being black (relative to White) were associated with lower odds. Even after adjustment for potentially confounding factors, racial differences persist in AD documentation in both care settings.

The "traditional" notion of social media in the workplace as employees logging on to Facebook for personal use from their desks is long gone. Social media, in some form or another, is now present in virtually every workplace, regardless of where employees perform their work.

This case study describes a local home health and hospice agency's effort to implement Lean principles and Kaizen methodology as a rapid improvement approach to quality improvement. The agency created a cross-functional team, followed Lean Kaizen methodology, and made significant improvements in scheduling time for home health nurses that resulted in reduced operational costs, improved working conditions, and multiple organizational efficiencies.

This article describes the efforts undertaken to reduce avoidable hospitalizations in a large, not-for-profit home healthcare agency over a period of 4 years by focusing on the improvement of transitional care-that is, moving patients from 1 level of care to another. Beginning as an effort to simply "teach" home care staff about best-practice tools, the challenges of implementing the changes required to improve the transition period were found to be complex and associated with a number of factors, ranging from the variation in discharge processes across hospitals to how clinicians perceived their roles and those of patients in the transition process. The author discusses the insights gleaned from the work that has been completed-and the work that still remains-while steadily decreasing the home healthcare agency's overall hospitalization rate.

Provisions within the recently passed health reform law provide support for new approaches to reducing the high cost of care for clinically complex patients. This article describes the characteristics of a recent transitional care pilot initiative that aims to reduce hospital readmissions among high-risk heart failure patients. The program was designed and implemented through a joint collaboration between a Certified Home Healthcare Agency and regional hospital. As a preliminary assessment of the impact of this program on patient outcomes, we compare the odds of rehospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Analyses indicated that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group. Although preliminary, our findings suggest that providing transitional care services to high-risk heart failure patients can be an effective deterrent against patterns of rehospitalization. The opportunities and challenges associated with implementing this pilot program are discussed., (© 2011 National Association for Healthcare Quality.)