CMS Proposes a Falls Measure for Home Health Agencies
September 12, 2017 03:39 PM
The Centers for Medicare & Medicaid Services (CMS) published in the Federal Register on July 28, 2017 The Calendar Year (CY) 2018 Home Health Prospective Payment System Rate Update proposed rule.
A significant portion of the proposed rule is dedicated to proposals that update the Home Health Quality Reporting Program (HH QRP).The changes are many with the majority focused on cross setting quality measures and standardized assessment items that CMS is required to develop in accord with the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) (see NAHC Report article).
CMS is proposing a new Measure titled Application of Percent of Residents Experiencing One or More Falls with Major Injury. Major injury is defined as bone fractures, joint dislocation and closed head injuries with altered consciousness or subdural hematoma. The term “application” is used to indicated that the measure will be used in a setting other than the setting for which it was endorsed by the National Quality Forum (NQF). Therefor, the measure has not been endorsed by NQF for the home health setting. In order to collect the data require for the measure two new assessment items will need to be added to the Outcome and Assessment Information Set (OASIS).
In October 2016, the measure developers issued a call for public comments on the above falls with major injury measure for which the National Association for Home Care & Hospice (NAHC) submitted comments. NAHC plans to issue similar comments to CMS’ call for public comments on the proposed measure.
The main concern with the falls with major injury measure is that it is not risk adjusted. Although an unadjusted falls measure could provide valuable information regarding the overall rates of falls occurring within the agency, it has limited value when comparisons are made to other home health agencies.
Home health agencies provide intermittent care to patients with varying care needs, living environments and caregiver support. Agencies have limited control over a patient/caregiver’s ability or willingness to comply with fall prevention strategies. Additionally, home health patients are permitted to leave the home infrequently or for short duration, and are allowed unlimited absences for medical reasons. Therefore, a home health patient could encounter fall risks for which the agency could not be expected to mitigate.
Without risk adjustment, the measure could present a distorted correlation between the rate of major injuries related to falls and the quality of care provided by the agency, and as previously mentioned, has limitations when making comparisons among home health agencies. Concerns over the inclusion of the measure into CMS’ public reporting system, and potentially in a home health value based purchasing program, could result in agencies avoiding caring for patients perceived as high risk for falls.
The measure developed in their response to the October, 2016 public comments rejected the request for risk adjustment claiming that falls with major injury are considered a “ never event.” Although this position might make sense for institutionalized patients, it does not take into consideration the uniqueness of the home health setting. NAHC still believes a request for CMS to risk adjust this measure is warranted.
CMS could include an unadjusted rate for falls with major injury on the agency’s confidential feedback reports along with a risk adjusted rate for the measure. This will allow the agency to see their actual fall rates, while risk-adjusted rates could be used for pubic reporting, when required.
Of equal concern, is that the IMPACT Act requires the falls with major injury measure to be applied across other PAC settings; all of which are facility based with 24/7 supervision and the ability to affect fall prevention through direct interventions by the facility staff. The standard for fall risks and prevention that is applied to facility based care cannot be applied to community care settings.
Click here to view the data specifications for the Application of Percent of Residents Experiencing One or More Falls with Major Injurymeasure. Comments are due September 25, 2017.