Understanding HHCAHPS Public Reporting

A guide to understanding HHCAHPS public reporting protocols and patient mix adjustment factors June 2012 www.deyta.com 888.893.1937 2012 Deyta LLC

A guide to understanding HHCAHPS public reporting protocols and patient mix adjustment factors June 2012 Table of Contents About HHCAHPS Survey Public Reporting.3 When HHCAHPS Survey Results are Posted.4 Patient Mix Adjustment Factors..4 How Patient Mix Adjustment Factors are Calculated 5 Example of How Patient Mix Adjustment Factors are Calculated 5 Ongoing HHCAHPS Public Reporting.7 Additional Resources 7

About HHCAHPS Survey Public Reporting The Consumer Assessment of Healthcare Providers and Systems (CAHPS ) Home Health Care Survey, also called the Home Health Care CAHPS Survey (HHCAHPS), is the first national, standardized, publically reported survey of patients' perspectives of home health care. While many Home Health Agencies (HHA) have collected information on patient satisfaction for their own internal use, until HHCAHPS there were no common metrics and no national standards for collecting and publically reporting information about patient experience of care. On April 19, 2012, the Centers for Medicare & Medicaid Services (CMS) began publically reporting results from the HHCAHPS Survey allowing valid comparisons to be made across HHAs locally, regionally and nationally. The HHCAHPS Survey is designed to measure the experiences of people receiving home health care from Medicare-certified home health care agencies. The standardized survey questions and the implementation protocol produce data that allow objective and meaningful comparisons of HHAs on topics that are important to consumers. Per CMS regulations, publically reporting data on the patient s perspective of care received serves three main purposes. First, it allows consumers to make objective and meaningful comparisons between home health agencies on domains that are important. Second, reporting these metrics creates new incentives for HHAs to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of home health care provided in return for the public investment. With these goals in mind, the Centers for Medicare & Medicaid Services (CMS) and the HHCAHPS Survey Coordination Team have taken substantial steps to assure that the survey results are credible, useful, and practical. Five HHCAHPS measures (three composite measures and two global items) are publically reported on the Home Health Compare Website under the Patient Survey Results tab (http://www.medicare.gov/homehealthcompare/search.aspx) for each participating HHA. Each of the three composites is constructed from multiple survey questions. Combining related questions into composites allows consumers to quickly review patient experience of care data and increases the statistical reliability of these measures. The three composite measures include: 1. Percent of patients who reported that their home health team gave care in a professional way. a. Short title: Care of Patients b. Includes survey questions: Q9, Q16, Q19, Q24 2. Percent of patients who reported that their home health team communicated well with them. a. Short title: Communications Between Providers and Patients b. Includes survey questions: Q2, Q15, Q17, Q18, Q22, Q23 3. Percent of patients who reported that their home health team discussed medicines, pain, and home safety with them. a. Short title: Specific Care Issues b. Includes survey questions: Q3, Q4, Q5, Q10, Q12, Q13, Q14 2012 Deyta LLC 3

The two global item measures include: 1. Percent of patients who gave their home health agency a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). a. Short title: Overall Rating b. This score is drawn only from survey question Q20 2. Percent of patients who reported YES, they would definitely recommend the home health agency to friends and family. a. Short title: Willingness to Recommend b. This score is drawn only from survey question Q25 c. Includes only those patients who responded definitely yes to Q25 When HHCAHPS Survey Results are Posted HHCAHPS Survey results are publically reported when a Home Health Agency (HHA) has reported 12 months of HHCAHPS Survey data. The publically reported results are based on the data from a sample of patients, collected according to the CMS data collection protocol for the HHCAHPS Survey. The results are not publically reported until six months following the patients care. For example, the first set of results was released on April 19, 2012 for data from patients who received skilled home care from October 2010 through September 2011. This time lag is necessary to allow for data analysis and posting by CMS. Dry run data is not included in the calculation of the publically reported scores. The results are refreshed quarterly, with data from the oldest quarter being replaced by data from the most recent quarter of the HHCAHPS Survey. HHCAHPS results are reported at the level of the HHA s CMS Certification Number (CCN). HHAs participating in the HHCAHPS Survey are able to preview their survey results each reporting period on the HHCAHPS Survey website about two weeks before the results are publically reported. Patient Mix Adjustment Factors To ensure that publically reported HHCAHPS scores allow fair and accurate comparisons across HHAs, it is necessary to adjust for factors that are not directly related to home health care performance but which affect how patients answer HHCAHPS Survey items. CMS applies risk or factor adjustments (a statistical methodology) to the HHCAHPS scores that are intended to eliminate any advantage or disadvantage in scores that might result from the characteristics of patients that are beyond an agency s control. Before the HHCAHPS results are publically reported, they are adjusted for patient mix differences. The HHCAHPS Survey scores are adjusted for differences between an HHA s patient composition according to the HHA s patient mix characteristics and the overall national composition of home health patients on these same characteristics. A 2010 study conducted by CMS concluded that certain patient characteristics (i.e. age, education, etc.) were shown to have an effect on the way patients respond to survey questions. Therefore, CMS makes adjustments or changes to the data before the results are publically reported. The changes allow one to look at the results across different agencies and know that they represent true differences in care perception and cannot be interpreted as a factor of differences of the patient population. 2012 Deyta LLC 4

Patient Mix Adjustment Factors continued Patient-Mix Adjustment Factors Patient age Educational attainment level Self-reported overall health status Self-reported mental health status Presence of diagnosis of schizophrenia or dementia Whether the patient lives alone Whether the survey was conducted by a proxy respondent Whether the interview was conducted in a language other than English How the Patient Mix Adjustment Factors are Calculated Patient mix factor adjustment must be applied individually to each measure and for each participating HHA. CMS recalculates patient mix adjustment factors quarterly. In order to calculate the patient mix factor adjustment, several things must be known: 1. How certain demographics or characteristics affect the likelihood of a person to give a top box rating 2. The overall national composition of patient mix for HHAs (mean score) 3. The individual HHA s composition of patient mix (mean score) 4. The individual HHA s unadjusted measure score The adjustment is made by subtracting the national mean for a given patient characteristic (#2) from the HHA s mean on this same patient characteristic (#3) and multiplying this difference to a predetermined number calculated by CMS (#1). That number is then applied to the individual HHAs unadjusted score (#4). Example of Patient Mix Adjustment Factor Calculations When an HHA s measure score is adjusted, it either goes up or down depending on how the HHA s patient mix composition compares to the national patient mix composition. Let s look at an example. For this example, we are only going to risk adjust age and mental/emotional status, but from this, one can see how it works and can be applied to any other patient mix characteristic. According to the table below, more than half of BestCare HHA s patients are less than 65 years old (60%) and most have poor mental status (60%). By looking at the adjustment factor provided in the table, we know that people less than 65 years old and people with fair/poor mental status tend to give lower ratings to the Overall Rating Measure (Q20 on the HHCAHPS). Therefore, because adjustments help make the scores fair by reducing the effect of the patient mix, we would expect that the patient mix factor adjustment would raise our mean for this measure. 2012 Deyta LLC 5

Example of Patient Mix Factor Adjustment Calculations continued A B C D Row Patient Mix Characteristic Adjustment Factor National Mean for Level (totals 100%) Age R1 18-49.071.04.30 R2 50-64.024.115.30 R3 65-74 (referent) --.237.20 R4 75-84.003.327.10 R5 Over 85.013.281.10 R6 Mental/Emotional Status R7 Excellent/Very good -.043.405.20 R8 Good (referent) --.318.20 R9 Fair/Poor.018.277.60 BestCare HHA Mean for Characteristic Level Let s also assume that our unadjusted agency mean for this measure was 84%. To do the calculation, we would first need the National Mean for each patient characteristic level (Col C) and BestCare HHA Mean for each patient characteristic level (Col D). We also need the adjustment factor (Col. B). CMS must provide both the adjustment factor and the national mean for agencies. Calculation: Step 1: Adjusted score = unadjusted agency mean +[for R1(col B)(col D col C)]+[for R2(col B)(col D col C)]+R3+R4. Adjusted score =.84+(.071)(.30-.04)+(.024)(.30-.115)+(.003)(.10-.327)+(.013)(.10-.281)+(-.043)(.20-.405)+(.018)(.60-.277) Step 2: Adjusted score =.84+(.018)+(.004)+(-.001)+(-.002)+(.01)+(.006) Step 3: Adjusted score =.84+.035 =.875 or 87.5% From this you can see that our biggest advantages (what helped raise our score the most) is the large number of patients we treated in the 18-49 category (they tend to rate lower) and the lower number of patients in the excellent mental health (they also tend to rate lower). Our score is raised by 3.5% 2012 Deyta LLC 6

Ongoing HHCAHPS Public Reporting HHCAHPS Survey results will be reported on a quarterly basis hereafter, with the results calculated from the most recently available 12 months of data. That is, data from the most recent quarter will replace data from the oldest quarter. Patient mix adjustment factors to account for HHA differences in patient mix are recalculated quarterly and applied to HHA scores for the respective quarter. The last four quarters of adjusted scores are then averaged to produce the current quarter s published scores. An HHA will only be able to approximate the effect of patient mix adjustment on its HHCAHPS Survey results. Exact replication of published HHCAHPS results is not possible because of the effects of data cleaning and small differences between the effects of quarterly patient mix adjustments and the four quarter averages provided by CMS. Additional Resources To view the publically reported scores, please visit Home Health Compare: http://www.medicare.gov/homehealthcompare/search.aspx To learn more about the HHCAHPS, please visit CMS dedicated website: https://homehealthcahps.org/ Questions may also be sent to the HHCAHPS Survey Coordination Team via e-mail at hhcahps@rti.org or call toll-free at 866.354.0985. About Deyta Deyta partners with thousands of hospice, home health, human services and other organizations, to measurably improve the quality of patient care and services, the experience of customers and employees, and the effectiveness of their operations. With 20 years of experience in survey administration and healthcare quality improvement, Deyta offers proven solutions with powerful reporting and extraordinary customer service. Our clients are providers, industry associations, regulatory agencies, vendors, and consultants who are committed to improving healthcare. 2012 Deyta LLC 7