Measuring and assuring the quality of home health care - Issues in Reforming Home Health Care

Health Care Financing Review, Fall, 1994 by Peter W. Shaughnessy, Kathryn S. Crisler, Robert E. Schlenker, Angela G. Arnold, Andrew M. Kramer, Martha C. Powell, David F. Hittle

PURPOSE

Certain terms, such as outcomes, case mix, indicators, and measures, have multiple meanings in the literature, and therefore are defined precisely in this article to frame the discussion on quality measurement and QA in home health care. Many of the concepts and issues discussed apply to health care in general, although they are anchored largely in their applicability to long-term care and especially home health care.

Primary emphasis is on patient outcomes and measuring outcomes for QA. Nonetheless, general issues related to quality of care, as well as the utility of other types of quality measures, are presented. For the most part, we concentrate on selected results from the conceptual, clinical, and empirical analyses that have constituted a research program designed to produce a system of outcome measures for use in assessing the effectiveness of home care.

The various studies that have comprised this program have afforded an opportunity to evaluate the appropriateness of most major secondary data sources and agency-obtained data for measuring outcomes, assess the feasibility of different approaches to primary data collection, obtain input from multidisciplinary clinical panels on the content and methodology of proposed methods for measuring the quality of home health care, and empirically test several different measurement approaches (Kramer et al., 1989a; Shaughnessy, Kramer, and Bauman, 1989; Kramer et al., 1989b; Crisler, Kramer, and Shaughnessy, 1990; Shaughnessy et al., 1991a; Shaughnessy et al., 1993).

CENTRALITY OF OUTCOMES

Our primary reason for providing health care is to benefit patients. In the context of analyzing issues about reimbursement, utilization, regulation, supply, integration, insurance coverage, health professions' education, cost, and even political topics, it is possible for us to overlook the basic fact that the raison d'etre of health care is to influence patient outcomes. At a time when health policy and health services issues are receiving considerable attention and form the basis for extensive policy debate, the effectiveness of the many components of our health care system, taken individually and holistically, is not being measured and analyzed adequately in view of what is at stake. Does hospital care accomplish what it should on behalf of patients? Do we have adequate evidence of the outcomes of systematic approaches to managed care based on data collected on individual patients or health maintenance organization (HMO) enrollees? Is home care more effective than institutional care? In terms of what happens to patients, is primary care as effective and as logical as its proponents argue? Have the regulatory programs put in place in nursing homes over the past 2 decades enhanced the well-being of nursing home residents?

We have made inroads into answering some of these questions, but are far from definitive evidence. One reason is that we often analyze utilization patterns, provision of services, distribution or supply of providers, organizational arrangements, and cost and reimbursement issues (to name a few) on the assumption that the care provided accomplishes what we expect. This assumption has not been challenged with sufficient objectivity and intensity, although there are several studies and analyses that have addressed and are continuing to address such issues (Grover et al., 1990; Hannan et al., 1989; Hughes et al., 1988; Shaughnessy, Schlenker and Kramer, 1990; Carlisle et al., 1992; Wennberg, 1990; Tarlov et al., 1989; Braun, Rose, and Finch, 1991; Park et al., 1990; Dubois and Brook, 1988; Shaughnessy et al., 1994; Helberg, 1993; Kemper et al., 1988; Kemper, 1992; Hedrick and Inui, 1986; Hughes, 1985; Zimmer, Groth-Juncker, and McCusker, 1985). In all, when examining the value or effectiveness of care, outcomes should be considered as more than one small piece of the entire setting; they should occupy center stage because they are the fundamental reason why we provide health care.

There are several reasons outcomes have not been comprehensively analyzed in addition to the rather obvious ones of limited resources and funding for such purposes. It is difficult to precisely specify outcome measures to properly adjust for the natural progression of disease or disability in analyzing outcomes, and to reliably and comprehensively collect the requisite data to properly analyze outcomes. Yet, analysis of what we are accomplishing on behalf of patients is likely to provide highly useful information to assist us in refining and possibly even substantially altering our approach to health care in the United States. Home health care is no exception. We know little about the effectiveness of home health care, although we are aware of the strong preference patients have for home care over most other alternatives, especially institutional care. Our challenge is to specify and measure outcomes in the home care field so that we might learn more about effectiveness, facilitate decision-making on what types of patients or clients benefit most from home care, and provide a foundation for continually improving the effectiveness or outcomes of home care.