NAHC Report

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). Below is CMS’ proposal for collecting functional status assessment data beginning January 1, 2019.

CMS proposes to add several new assessment items to the Outcome and Assessment Information Set (OASIS) in order to satisfy the requirements of the IMPACT Act for both a cross setting functional measure and for standardized assessment items that capture function. The assessment items to be collected for these functional domains include standardized assessment items for  7 self-care activities and 17 mobility activities that are rated on a 6-level rating scale ranging from “6” “Independent” to “1” dependent. Three special codes (07, 09, 88) are included to report that a patient did not attempt an activity and to identify the rationale for why a patient did not attempt an activity. To review the standardized assessment items click here and scroll to page 7.

CMS proposes to calculate a functional quality measure using a subset of the items from the proposed standardized assessment items for self-care and mobility. The measure title is “Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function” (NQF #2631). The term “application” used in the measure title indicates that the measure has not received endorsement from the National Quality Forum (NQF) for home health agencies.

The proposed functional quality measure is a process measure that reports the percent of episodes with a Start of Care (SOC)/Resumption of Care (ROC) assessment and a discharge assessment that assesses functional status, along with a treatment goal for function. The treatment goal provides evidence that a care plan with a goal has been established for the patient. Click here to view the assessment items to be used for the measure calculation and data specifications. The discussion begins on page 2. Additional information can be found in Appendix 2 of the document.

The measure calculation requires the clinician to complete the assessment items as follows:

1. A valid numeric score indicating the patient’s functional status, or a valid code indicating the activity was not attempted or could not be assessed for each of the functional assessment items on the SOC/ROC assessment;
2. A valid numeric score, which is a discharge goal indicating the patient’s expected level of independence, for at least one self-care or mobility item on the SOC/ROC assessment; and
3. A valid numeric score indicating the patient’s functional status, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the discharge assessment.

In reviewing the proposed standardized functional assessment items the most notable aspect of the data set is the number of items the agency will be required to complete. As previously mentioned, there are a total of 24 assessment items.

Additionally, CMS is maintaining the following functional assessment items currently collected on the OASIS assessment tool.

M01810 Current Ability to Dress Upper Body

M01820 Current Ability to Dress lower Body

M01830 Bathing

M01840 Toilet Transferring

M01848 Toilet Hygiene

M01850 Transferring

M01870 Feeding and Eating

CMS claims there is not duplication between the proposed functional assessment items and the functional assessment items currently collected on the OASIS.

“The standardized items included …… do not duplicate existing items on the OASIS currently in use for data collection on functional assessment…………… there are several key differences between the two sets that may result in variation in the patient assessment results. Key differences include: (1) the data collection and associated data collection instructions; (2) the rating scales used to score a patient’s level of independence; and (3) the item definitions.”

The National Association for Home Care & Hospice (NAHC) disagrees with CMS’ assertion regarding duplication among the data sets. Although the assessment items might assess function in a slightly different manner, they still assess many of the same self-care and mobility activities, hence redundancy in data collection. CMS’ reluctance to remove the assessment items currently collected might be due more to the  applications these items  have for the payment system for home health agencies and the Home Health Value Based Purchasing program. Regardless of CMS’ rationale for maintaining two sets of data items that assess functional status, it creates additional burden for agencies without any added benefit.

Furthermore, the proposed standardized assessment items have an assessment period of 3 days. This time frame does not align with the 5 day window home health agencies have to complete the OASIS assessment.  Agencies will be required to complete some assessment items within 3 days while others will be completed within 5 days.

NAHC intends to construct its comments on the proposed standardized functional assessment items around the burden to implement the assessment items, overlap with the current OASIS assessment items, and the 3 day time period required to collect the items.

Comments on the proposed rule are due September 25, 2017.