January 4, 2005 Kenneth W. Kizer, M.D., M.P.H. President and CEO National Quality Forum 601 Thirteenth St, NW Suite 500 North Washington, DC 20005 Dear Dr. Kizer: On behalf of the American Health Quality Association (AHQA), a National Quality Forum (NQF) member representing the national network of Quality Improvement Organizations, thank you for this opportunity to vote on the NQF National Voluntary Consensus Standards for Home Health Care. QIOs have worked closely with home health agencies under the national Centers for Medicare & Medicaid Services (CMS) Home Health Quality Initiative. We are beginning to see data demonstrating the benefits of this partnership to improve the quality of care on the Outcomes-Based Quality Improvement measures and provide consumers with home care quality data. AHQA is voting in favor of the following OASIS/OBQI home care measures, which have been recommended by NQF staff. Measure #1: Improvement in ambulation/locomotion Measure #2: Improvement in bathing Measure #3: Improvement in transferring Measure #4: Improvement in management of oral meds Measure #6: Improvement in pain interfering with activity Measure #7: Improvement in status of surgical wounds Measure #8: Improvement in dyspnea Measure #9: Improvement in urinary incontinence Measure #18: Acute care hospitalization Measure #20: Discharged to community Measure #21: Any emergent care In the QIO 8th Scope of Work, QIOs will work with home health agencies to improve their performance on these indicators and we are pleased that they have been included in the proposed measure set. We also appreciate that NQF plans to highlight our concerns related to some of the shortcomings inherent in OBQI measures, such as the impact on performance of elements that are outside of the home care agency’s control. However, we must reiterate our concern about the recommendation to publicly report Measure #7 (surgical wounds) considering that this measure is not risk adjusted and does not account for severity of illness. We also are disturbed that the NQF steering committee opted not to include OBQI stabilization measures upon reconsideration. We maintain that stabilization measures are appropriate information for consumers to use in making health care decisions and for providers to use in improving care, particularly considering that stabilization represents high quality care for many home care patients. AHQA is voting against the following OBQM measures: Measure #5: Substantial decline in management of oral medications. Measure #10: Increase in number of pressure ulcers. Measure #14: Emergent care for wound infections Measure #15: Emergent care for improper medication administration Measure #16: Emergent care for hypo/hyperglycemia Measure #17: Discharge to the community needing wound care or medication assistance Measure #19: Unexpected nursing home admission. As we commented previously, the OBQMs are useful for agencies to improve quality by identifying and preventing potential adverse events; however, this information is inappropriate for public reporting. These measures are not risk adjusted and occur relatively infrequently, meaning that agencies treating a higher volume of patients and generally sicker patients would predictably appear worse off in public displays and face a comparative disadvantage. AHQA is voting against the following ACOVE measures. Measure #22: Comprehensive geriatric assessment Measure #23: Evaluation of pressure ulcers Measure #24: Risk assessment for pressure ulcers Measure #25: Evaluation of reversible causes of malnutrition Measure #26: Evaluation of falls Measure #27: Caregiver support and patient safety for dementia patients Measure #28: Documentation of advance directive, surrogate of preferences As confirmed by the measure developer, the ACOVE measures have undergone only limited testing among home care patients. Furthermore, the steering committee’s review confirmed that the assessment and data collection through required medical record abstraction would create “feasibility issues” for home care providers (NQF Voting Member Draft, page 14). Finally, AHQA agrees that the Family Evaluation of Hospice Care Measures (Measure #’s, 11, 12, 13) should be deferred for consideration under NQF’s project on Hospice/Palliative Care Quality. Thank you for providing this opportunity to vote on the proposed home health quality measures. Please contact Dave Adler or me at (202) 261-7572 with any questions regarding this letter. Sincerely, David G. Schulke Executive Vice President