Wound Management and Home Health Value-Based Purchasing Strategies for Success
Author: Leigh Massey, RN, JD, WOCN, CHC, CHPC Posted: June 7, 2022
The original HHVBP Model was implemented in nine states on January 1, 2016, and resulted in an average of 4.6 percent improvement in HHAs' total performance scores (TPS) and an average annual savings of $141 million to Medicare without evidence of adverse risks. The evaluation of the original model also found reductions in unplanned acute care hospitalizations and skilled nursing facility (SNF) stays, resulting in reductions in inpatient and SNF spending. The U.S. Secretary of Health and Human Services determined that expansion of the original HHVBP Model would further reduce Medicare spending and improve the quality of care.
The expanded HHVBP Model began on January 1, 2022, and includes Medicare-certified HHAs in all fifty states, District of Columbia, and the U.S. territories. During CY 2022, CMS will provide HHAs with resources and training. This will allow HHAs time to prepare and learn about the expectations and requirements of the expanded HHVBP Model without risk to payments. The first full performance year for the expanded HHVBP Model is CY 2023, beginning January 1, 2023. Calendar Year 2025 will be the first payment year, with payment adjustment amounts determined on CY 2023 performance.
The computation of the total performance scores (TPS) are based on quality measures data in the expanded HHVBP Model that come from three sources: the Outcome and Assessment Information Set (OASIS) assessment instrument, Medicare claims, and the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey. Under the expanded Model, there are twelve applicable quality measures in the measure set, including five OASIS-based measures, two Medicare claims-based measures, and five measures from the HHCAHPS survey. All these areas may be impacted by properly managing patients with wounds.
OASIS Measures
While OASIS based measures are not directly taken from the integumentary status section, consideration of a comprehensive wound program should be considered to assist in improving the total performance score (TPS). Patients with wounds will experience pain and functional limitations that affect care needs, outcomes, and reimbursement.
The OASIS-based measures included in the TPS that are impacted by the presence of a wound are: M1800 grooming, M1810 upper body dressing, M1820 lower body dressing M1830, bathing M1850 bed transferring, M1860 ambulation/locomotion. The intent of these items is to identify the patient’s ability, not necessarily actual performance. “Willingness” and “adherence” are not the focus of these items. These items address the patient’s ability to safely perform, given the current physical and mental/emotional/cognitive status, activities permitted, and environment. The patient must be viewed from a holistic perspective in assessing ability to perform ADLs. Ability can be temporarily or permanently limited by physical impairments (for example, limited range of motion, impaired balance due to the presence of a wound); emotional/cognitive/behavioral impairments (for example impaired judgment, fear); sensory impairments (for example, pain) all of which are likely to be impacted when someone has a wound.
The OASIS measures also include composite measures. The Home Health Value-Based Purchasing (HHVBP) composite measures, Total Normalized Composite (TNC), Change in Self-Care and TNC Change in Mobility, capture the magnitude of change (not just improvement) in multiple OASIS items. Therefore, they reward efforts to improve patients who are less independent at start or resumption of care, as these patients have a greater opportunity for higher TNC measure scores. Normalization accounts for the variation in the number of response options on the applicable OASIS items for each TNC Measure.
Accurate assessment of these items at start of care as they are impacted by the presence of wounds, as well as an individualized care plan that focuses on improvement in those areas can impact the TNC changes at the end of the episode.
Strategies for success include:
- Building OASIS proficiency with clinicians at OASIS collection points to accurately reflect improvements with home health interventions.
- Collaborative care planning with therapy disciplines as needed to incorporate wound considerations in outcomes management.
Medicare Claims-based Measures
The Medicare claims-based measures used in the TPS calculation are straightforward.
- Acute Care Hospitalization During the First 60 Days of Home Health (ACH)
- Emergency Department Use Without Hospitalization During the First 60 Days of Home Health (ED Use)
Improvement with this measure is clearly impacted by the appropriate management of wounds. Implementing strategies for decreasing ED use and hospitalizations related to wounds is key. Tailored care plans for teaching and early interventions related to wound infections, when to report changes in condition and prescribed visit schedule can help decrease hospitalizations for wound complications. Addressing the risk for rehospitalization at during the comprehensive assessment and including mitigating factors in the plan of care can assist in decreasing these events.
Strategies for success include:
- Provide patients and caregivers written instructions about wound protocols, early signs, and symptoms of infection, dressing changes, when to notify the agency
- Establish individual goals with the patient/caregiver for wound success
- Utilize wound specialists where available to evaluate the effectiveness of wound protocols
Measures from the HHCAHPS Survey
Measures from the HHCAHPS survey that may also be impacted by patients with wounds include Care of Patients Composite summarized as, “patients who reported that their home health team gave care in a professional way”. Another measure includes Communications between providers and patients composite defined as, “patients who reported that their home health team communicated well with them”.
These measures are directly related to the way patients perceived the care they received from the home health agency and can be linked to wound management. Specific items included in the composites are listed as:
- Seemed informed and up to date about all the care or treatment received at home
- Treated as gently as possible
- Treated with courtesy and respect
- Explained things in a way that was easy to understand
- Listen carefully to you
- Get you the help or advice you needed
Strategies for success:
- Standardize protocols for wound patients
- QAPI program management of wound patients
- Prioritize wound outcomes as part quality improvement efforts
Calendar Year (CY) 2022 is the pre-implementation year before performance is assessed and will be eligible for a CY 2025 payment adjustment. Now is the time to strategize and plan success. Please reach out to [email protected] to obtain more information and schedule a call to discuss how MHA can assist.
Sources
https://innovation.cms.gov/media/document/hhvbp-exp-qm-processes
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/hhvbp%20computing%20the%20hhvbp%20composite%20measures.pdf
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/OASIS-D-Guidanc-Manual-final.pdf
https://innovation.cms.gov/innovation-models/expanded-home-health-value-based-purchasing-model