In the current environment of decreasing resources and reimbursement cuts, home care organizations are under increasing pressure to demonstrate their value in the continuum of care by providing outcomes data. Whether the size of the organization is 10 employees or 1,000 employees, the need to demonstrate value is the same.
Outcomes are measurable results of the processes used and decisions made in providing care. Contrary to popular belief, outcomes are not just clinical. Health care outcomes encompass three areas: cost, clinical and patient satisfaction. When improving care, it is inevitable that by changing one outcome variable, another will be impacted.
During the past decade, health care outcomes and evidence-based medicine have had an impact on health care organization, financing and policy. They represent fundamental achievements that establish clinical medicine and assist policymakers with decisions regarding reimbursement.
In today's era of the Medicare Modernization Act (MMA), many policymakers have demanded relevant data instead of flowery anecdotes on the essential value of home care.
For both large and small providers, the following basic framework can assist in beginning to develop an outcomes management program.
Evaluating New Technology
Advances and innovations in health care technology are instrumental in reshaping the health care system, impacting the practice of medicine and improving patient satisfaction and operational efficiency. However, “new” does not always mean “better.”
The challenge is that DME/HME providers are forced to provide new devices. Yet, the new technology or device may cost more than what is currently provided but not improve patient satisfaction or reduce labor costs.
Home care organizations are faced with the following four questions related to adopting a new technology:
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Should the organization invest in this technology?
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What are the associated benefits and risks of the capital investment?
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What is the impact on patient outcomes as a result of adopting the technology?
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What is the return on investment to the organization? The focus absolutely needs to be on how the new technology improves patient care while not breaking the bank.
These issues represent challenging areas for the clinician, manager and policymaker. New techniques, with a business and outcomes research focus, allow for the development of quantitative and qualitative models to facilitate answering these questions.
By integrating business and clinical considerations, these models can impact policy at two levels: 1) By identifying optimal capital expenditure decisions for individual organizations, they can provide a significant competitive advantage for an organization; and 2) By identifying optimal health policies related to technology at a national health level, they can favorably impact health care systems and patient outcomes by facilitating the adoption of a “new” HCPCS code with appropriate reimbursement.
Evidence-based technology assessment begins with a clinical question: Does the new technology provide more of a benefit or more of an advantage than what is currently provided?
A search of databases for studies or clinical practice guidelines that include the use of the technology can help answer the question. Common databases include Medline and AHRQ (Agency for Healthcare Research & Quality).
Systematic reviews (which summarize large bodies of evidence from multiple published studies and help to explain differences among studies on the same question) are stronger than the primary observational studies and are best when they include a randomized clinical trial. The problem that exists in home care is that most new devices are approved by the FDA based on substantial equivalence, and little evidence exists. In this case an independent observational bench study, or critical appraisal, and patient-focused evaluation to compare the new device with existing products should be conducted.
The organization that conducts the independent studies must work directly with the manufacturer of the new device to agree on methodology and eliminate potential biases. The critical appraisal must answer the clinical question and needs to have consistent study design and bias under control. The results must be offered to interested physicians, and the information critically assessed and developed into evidence-based reports.
The Patient's Perspective
An outcome questionnaire that is patient-centered should encompass the aims, values and treatment effects that are prioritized by patients, and should enable each individual patient to provide his assessment of satisfaction over time. However, there is little evidence about how well outcome questionnaires perform in this regard.
Utilizing established questionnaires such as the SF-12 (recommended for small organizations with limited resources, www.sf-36.org/tools/sf12.shtml) or the SF-36 (appropriate for large organizations with resources to compile results from the question sets, www.sf-36.org) can eliminate response inconsistency. These issues relate to the co-existence of different perspectives and the impossibility of reducing health status to one “single truth.”
Qualitative evaluations of patient satisfaction have an important role to play in quantifying their perceptions of health outcomes and showing a correlation between satisfaction and economic savings as a result of the intervention. Incorporation of patient satisfaction is likely to lead to more modest and realistic appraisals of outcome questionnaire performance.
The need for outcomes in home care is becoming more commonplace. The availability of — or lack of — outcomes will likely determine what gets reimbursed and the amounts of reimbursement, now and in the near future. The current health care environment creates the absolute need for home care organizations to become more knowledgeable about the methods used to compile data that already exists, and to develop mechanisms to quantify data that demonstrate value when none exists.
Outcomes management provides a means for interdisciplinary collaboration in improving patient care, and provides financial outcomes that show the value of interventions provided by home care organizations. Interdisciplinary collaboration is a key component of an outcomes management program, and the need for an atmosphere of shared responsibility among disciplines to develop outcomes exists now more than ever before.
Optimal improvements in care will be forfeited, and we will continue to experience the pressure of demonstrating our essential value in the continuum of care unless we include outcomes management programs in home care.
With more than 10 years of experience developing and creating the framework for outcomes in health care, Vernon R. Pertelle is corporate director of respiratory/HME services for Apria Healthcare. Prior to joining Apria, he worked for Kaiser Permanente as California Division DME coordinator, and also served as senior project manager for pharmacy operations and senior consultant for the medical director, technology and assessment guidelines. He may be reached via e-mail at vernon_pertelle@apria.com or by phone at 949/639-4367.
