Using OASIS Data to target Patient Satisfaction Quality Improvement

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    Using OASIS Data to target Patient
    Satisfaction Quality Improvement
    Initiatives in Home Health Care
    Kimberly McCaffrey, Manager of Research & Development, Press Ganey Associates, Inc. and
    Christine Lang, Product Manager, Outcome Concept Systems

    Changes in the health care landscape from the policy, consumer, and payor sides put greater priority on attaining high
    performance in patient outcomes, patient satisfaction, and efficient resource management. Most notably, a pay for
    performance (P4P) system will likely be implemented in the home health industry in the next one to three years. It is
    reasonable to expect that the initial P4P model will be built on OASIS outcome data, but that the next evolution will
    include data on patient satisfaction with care. Now is the time to understand how these critical indicators of agency
    performance are (or are not) related, and how we can use that information to improve in all areas of patient home care.

    Press Ganey partnered with Outcome Concept Systems (OCS) and a shared client to explore the relationship between
    patient satisfaction, OASIS data, and visit utilization data. The hope is that by fully understanding this relationship,
    Press Ganey clients will be able to use patient satisfaction data alongside OASIS data to better differentiate the needs
    of patients and target quality improvement initiatives accordingly.

    OCS is a health care information company with the nation’s largest and most comprehensive set of measures spanning
    clinical outcomes, financial performance, resource utilization, and operational indicators for home care, hospice, and
    private duty programs. Among other services, OCS manages Outcome and Assessment Information Set (OASIS) data and
    reporting to the Center for Medicare and Medicaid Services (CMS) for over 1,500 clients.

Satisfaction Monitor                                                                            September/October 2006
     We obtained permission from the              of heart failure,” hospital visits that   programs for falls and best practices
     Home Nursing Agency, a Visiting              occurred during care became               for the management of oral
     Nurse Association headquartered in           “presence or absence of                   medications. Further, they have
     Altoona, Pennsylvania, to link OCS           hospitalization,” and improvement in      identified key performance indicators
     and Press Ganey data to determine            pain throughout the course of care        to measure their staff, including
     differences in patient satisfaction          became “presence or absence of            management of medications,
     based on patient characteristics,            improvement in frequency of pain.”        improvement in pain interfering with
     what happened during the course              This allowed us to make direct            activity, keeping family informed,
     of care, and the ultimate clinical and       comparisons of satisfaction data          and contacting patients if running
     functional outcomes of care. This led        based on the presence or absence of       late. They have also started providing
     to the following three specific              each factor. Factors associated with      additional resources to patients
     research questions:                          higher patient satisfaction can be        including telehealth for cardiac
                                                  said to have a protective effect, while   patients, nutritionists for patients
       1.   What types of patients are            those associated with lower patient       struggling with obesity, psychiatric
            more/less satisfied than              satisfaction identify patients who are    nurses for patients who smoke, and
            others?                               at risk for low satisfaction.             wound specialists and access to
       2. How do events that take place                                                     wound clinics for patients with
                                                  Celeste Twardon, Vice President of        surgical wounds. Our analyses
          during care relate to patient           Quality and Customer Service at
          satisfaction?                                                                     verified that these best practices and
                                                  Home Nursing Agency, helped set           key performance indicators are on
       3. What is the relationship                the stage for quality improvement         target and that many of them are
          between clinical/functional             programs that were in progress            associated with higher patient
          outcomes and patient                    during our period of study                satisfaction.
          satisfaction?                           (September 2005–May 2006).
                                                  Using OCS perspectives on pay for         Question 1: What types of patients
     To answer these questions, we                performance and disease                   are more/less satisfied than others?
     summarized OASIS factors into flags          management, the agency identified         In examining the relationship
16   indicating the presence or absence           heart failure, diabetes, and              between patient characteristics and
     of a characteristic, event, or               respiratory patients as the focus         satisfaction, there is an apparent
     outcome. For example, the primary            of pay for performance initiatives.       interaction between type of patient
     diagnosis ICD-9 code would be                They are in the process of                and aspect of service being rated on
     summarized as “presence or absence           implementing risk assessment              the Press Ganey survey. Some of

     TABLE 1
            ICD-9 Category                                Description                               Percent of Population
                 V58              Other and unspecified aftercare                                            17.8%
                 V54              Other orthopedic aftercare                                                 15.3%
                 428              Heart failure                                                              4.9%
                 V57              Care involving use of rehabilitation procedures                            4.9%
                 250              Diabetes mellitus                                                          4.4%
                 486              Pneumonia, organism unspecified                                            2.3%
                                  Total                                                                      49.8%

     Satisfaction Monitor                                                                                September/October 2006
these interactions are obvious and        the aide’s concern for the patient’s       sensitivity to the personal difficulties
some are not, but they all point to       comfort, the technical skill of the        caused by the patient’s health
the individuals interacting with each     aide, and the aide’s attention to the      problems, and even the professional
type of patient and highlight             patient’s own ideas about care. Not        appearance of the therapist were
opportunities to train appropriate        surprisingly, they also rated their        rated significantly lower by diabetes
staff to be extra sensitive to patients   therapist higher across all measures       patients than by other patient
who are at particular risk for low        than patients with other primary           groups.
satisfaction.                             diagnoses.
                                                                                     This presents an opportunity for
The first patient characteristic we       Heart failure patients received an         significant improvement efforts.
examined was the patient’s primary        average of fourteen visits from a          Knowing the types of patients that
diagnosis, coded using ICD-9. Six         nurse and eight visits from a home         are less satisfied will help an agency
codes made up nearly fifty percent of     health aide. Accordingly, they gave        target quality improvement efforts.
this agency’s patient population,         significantly higher ratings to nurses     First, it is important to better
with diagnoses for the remaining          and aides than did other patients,         understand this subset of the
half consisting of very small             especially on technical skill and          patient population by working
numbers of patients. Therefore, the       concern for privacy. In addition, they     harder upfront to set their
analyses were constrained to the          rated the amount of attention the          expectations for care and
following six ICD-9 codes (see Table      nurses paid to the patient’s own           improvement.
1): other and unspecified aftercare;      ideas about care and the friendliness
other orthopedic aftercare; heart         of the aides significantly higher than     Finally, Pneumonia patients gave
                                                                                     only one significantly lower rating
failure; care involving use of            other patients.
                                                                                     than other patients—their likelihood
rehabilitation procedures; diabetes
                                          Diabetes patients showed an entirely       of recommending the agency’s home
mellitus; and pneumonia, organism
                                          different picture of care. They gave       health care services to others. This
                                          significantly lower ratings to items       presents an opportunity to find out
Patients with primary diagnoses of        having to do with arranging their          what it was about the care that
Other unspecified aftercare or care       care, the nurses and aides, therapy,       these patients received that made          17
involving use of rehabilitation           and family’s involvement in their          them less likely to recommend the
procedures showed no differences in       care. A significantly higher               service, especially considering that
satisfaction rates compared to other      proportion of these patients               their satisfaction was at parity with
patients.                                 improved in pain and received an           that of other patients across all other
                                          average of sixteen visits from nurses,     items.
Other orthopedic aftercare patients       but rated their ease of scheduling
received an average of eight visits       visits, the nurse’s concern for privacy,   The next patient characteristic we
from a physical therapist throughout      the technical skill of the nurses, and     examined was where the patient
their course of care. These patients      how well the nurses taught self care       had been discharged from in the
gave the agency significantly higher      significantly lower than did other         fourteen days prior to beginning
ratings overall and in likelihood of      patients. A minority of these patients     home care. Patients who were
recommending the agency for care.         also received therapy (physical,           discharged from hospital care gave
They reported an easier time              occupational, speech, or social work)      significantly higher ratings to how
arranging their home health care          and rated it significantly lower than      well their billing and cost questions
than other patients. Although they        did other patients. In particular, the     were handled, the nurse’s and aide’s
did not receive more visits from a        technical skill of the therapist, the      concern to contact the patient if he
home health aide than other               therapist’s attention to the patient’s     or she could not make it or would be
patients, they rated home health          own ideas about care, the therapist’s      late, and the technical skill of the
aides significantly higher in general     concern to contact the patient if he       aides. In addition, these patients
and specifically on items regarding       or she would be late, the therapist’s      rated the therapist’s sensitivity to

Satisfaction Monitor                                                                              September/October 2006
     the personal difficulties caused by         their privacy, and the therapist’s         aide’s concern for the patient’s
     the patient’s health problems, the          sensitivity to the personal difficulties   comfort and attention to the
     staff’s concern to keep the patient’s       caused by the patient’s health             patient’s own ideas about care.
     family informed about his or her            problems. Interestingly, patients with
                                                                                            Patients with no risk factors actually
     treatment, and how well calls were          a surgical wound gave significantly
                                                                                            had lower satisfaction than those
     handled after hours and on                  higher ratings than other patients
                                                                                            with risk factors on items related to
     weekends significantly more                 overall and across the entire
                                                                                            therapy. Since nutritionists and
     favorably than patients discharged          Press Ganey survey—specifically on
                                                                                            psychiatric nurses are available to
     from other facilities.                      items pertaining to arranging their
                                                                                            assist Home Nursing Agency
                                                 home care, dealing with the home
     Patients who were not discharged            care office, nurses, aides, therapists,
                                                                                            patients with obesity and smoking,
     from an inpatient setting (including        and general final ratings.
                                                                                            it is conceivable that the extra
     skilled nursing and rehabilitation                                                     attention is driving the increased
     facilities) rated similar aspects of        We also examined patient                   satisfaction in these patients.
     their home health care experience           satisfaction across personal factors
                                                                                            Question #2: How do events that
     significantly lower than those who          and demographics and found
                                                                                            take place during care relate to
     came from an inpatient setting.             additional protective effects and
                                                                                            patient satisfaction?
     Unlike those who came from a                characteristics that might put a
                                                                                            To answer this question, we turned
     hospital, these patients were less          patient at risk for low satisfaction.
                                                                                            to three different components of the
     satisfied with how their billing and        For example, patients who live alone
                                                                                            OASIS data set: the number and type
     cost questions were handled, the            rate the technical skill of the
                                                                                            of visits that the patient received,
     nurse’s sensitivity to the personal         therapist significantly lower than
                                                                                            the need for emergent care during
     difficulty and inconvenience caused         those who live with someone else.
                                                                                            treatment, and the need for
     by the patient’s health problems, and       Those who live with a spouse are
                                                                                            hospitalization during treatment.
     the staff’s concern to keep the             significantly more satisfied with the
     patient’s family informed about his         friendliness and technical skill of the    We have touched briefly on the
     or her treatment. These patients also       therapist, the therapist’s efforts to      number of visits for patients with
18   rated the aide’s concern for their          contact the patient if he or she could     specific primary diagnoses, but, in
     privacy, technical skill, and concern       not make it or would be late, and the      general, the relationship between
     to contact the patient if he or she         therapist’s sensitivity to the personal    satisfaction with care and number of
     could not make it or would be late          difficulties caused by the patient’s       visits did not prove to be a strong
     significantly lower than other              health problems. Those who live            one. In some cases, items within the
     patients.                                   with someone paid to help them are         Press Ganey survey were correlated
                                                 significantly more satisfied with the      significantly with the number of
     The third patient characteristic            nurse’s concern for the patient’s          visits received but trends were not
     examined was the presence of a              privacy, the technical skill of the        strong or particularly consistent.
     pressure ulcer, stasis ulcer, or surgical   nurse, and the amount of attention         Those that appeared did lend
     wound at the start of care. Patients        the nurse paid to the patient’s own        considerable credibility to our
     with a pressure ulcer, a small              ideas about care.                          methodology. For example, patients
     proportion of the overall population,
                                                                                            receiving more visits from a home
     gave a significantly lower rating to        Surprisingly, risk factors seemed to
                                                                                            health aide gave a more favorable
     the friendliness of the aides and the       have a protective effect on patient
                                                                                            rating to the friendliness of the aide
     overall quality of the agency’s home        satisfaction. Smokers rated the
                                                                                            and those receiving more visits from
     care services. Patients with a stasis       amount of attention that the
                                                                                            a physical therapist rated therapy
     ulcer, also a small proportion of           therapist paid to the patient’s ideas
                                                                                            more favorably overall. Perhaps the
     patients, gave significantly lower          about care significantly higher than
                                                                                            most interesting correlation was the
     ratings on the friendliness of the          non-smokers. Obese patients gave
                                                                                            negative relationship between the
     therapist, the therapist’s concern for      significantly higher ratings to the
                                                                                            number of visits by a speech

     Satisfaction Monitor                                                                                September/October 2006
therapist and the patient’s rating of      to the personal difficulty caused by       caused by falls or accidents at home
the therapist’s sensitivity to the         the patient’s health problems.             were related to significantly lower
personal difficulties caused by the        However, the presence of emergent          satisfaction with the ease of
patient’s health problems. In other        care was also associated with a            scheduling visits for the days and
words, patients who received more          significantly higher rating of the         times that the patient wanted and
speech therapy visits found the            degree of involvement that the             the helpfulness of the person who
therapists less sensitive than those       patient and his or her family had in       made the initial arrangements for
who received fewer visits.                 planning his or her home health            the patient’s services. Patients who
                                           care.                                      had been hospitalized for injuries
The need for any emergent care                                                        also gave lower ratings to their
during the course of home health           Interestingly, a hospitalization for       therapist on dimensions of
treatment was associated with              any reason during the course of            friendliness, contacting the patient
significantly lower ratings of the         home health care was associated            if running late or could not make it,
friendliness of the therapist, the         with significantly higher general          and sensitivity to the personal
therapist’s concern for the patient’s      final ratings. However,                    difficulties caused by the patient’s
privacy, and the therapist’s sensitivity   hospitalizations due to injuries           health problems. As this becomes

Table 2
  Variables                                Effect on Patient Satisfaction
                                           Factors Associated with Low Satisfaction   Factors Associated with High Satisfaction

                                           Heart failure
                                                                                      Other orthopedic aftercare
  ICD-9                                    Diabetes mellitus
                                                                                      Heart failure
  Discharged prior to start of care        Not discharged from hospital
                                                                                      Skilled nursing facility                    19
                                           Pressure ulcer
  Conditions                                                                          Surgical Wound
                                           Stasis ulcer
  Lives with                               Alone
                                                                                      Paid help
  Risk factors                             No risk factors
                                           Any emergent care
  Emergent care                            Emergent care for respiratory              No specific factors

  Hospitalization                          Hospitalization for injury                 No specific factors

                                                                                      Any improvement
                                                                                      Improvement in upper body dressing
                                                                                      Improvement in toileting
  Improvement                              No specific factors
                                                                                      Improvement in transferring
                                                                                      Improvement in management of oral
Note: Bold indicates very strong effect

Satisfaction Monitor                                                                                  September/October 2006
     more widespread, the agency’s risk       the most differences across the            While interesting from a research
     assessment program for falls, along      board. Patients who improved in            perspective, improvement in these
     with key performance indicators          management of their oral                   specifics may not be the best use of
     surrounding contacting patients          medications rated seventy percent of       quality improvement resources. To
     when running late, may help to           the Press Ganey items significantly        determine the drivers of that
     ameliorate this effect by reducing       higher than patients who did not           satisfaction, focus should be on
     the number of hospitalizations due       improve on this aspect of care. The        groups of patients that show the
     to injuries.                             Home Nursing Agency implemented            highest and lowest satisfaction. To
                                              best practices for management of           the extent possible, quality
     Question #3: What is the relationship                                               improvement initiatives should focus
                                              oral medications, including the
     between clinical/functional outcomes                                                on mirroring these drivers of high
                                              allocation of grant dollars from the
     and patient satisfaction?                                                           satisfaction and extinguishing the
                                              Home Nursing Agency’s Foundation
     Generally speaking, improvement in                                                  drivers of low satisfaction. Therefore,
                                              to supply medication planners to
     clinical and functional status was                                                  to complement our findings of low
                                              patients. These programs have paid
     found to have a protective effect on                                                satisfaction among diabetes patients
                                              off not only in improvement on this
     patient satisfaction. Patients who                                                  and high satisfaction among patients
                                              dimension of care but across the
     improved on any aspect of clinical or                                               who improved in management of
                                              spectrum of satisfaction. In addition,
     functional status rated aspects of                                                  oral medications, we used a
                                              dollars from the Home Nursing
     their nursing care, aides,                                                          statistical “decision tree” to ask and
                                              Agency’s Foundation have been used
     involvement, and their therapist                                                    answer one final research question:
                                              to provide weight scales for cardiac
     more favorably than patients who
                                              patients unable to afford their own
     did not improve. Those who                                                            What combination of factors is
                                              and to improve their self-
     improved in upper body dressing                                                       associated with the highest and
                                              management capabilities.
     were significantly more satisfied                                                     lowest overall patient satisfaction?
     overall with scheduling, nurses,         As displayed in Table 2, we found
                                                                                         As it turns out, patients with the
     therapists, and aides. Patients who      that patients with a primary
                                                                                         highest patient satisfaction were
     improved in toileting were also more     diagnosis for other orthopedic
20   satisfied overall, rated the home        aftercare, those with a surgical
                                                                                         individuals who improved in
                                                                                         management of oral medication and
     health office and nurses significantly   wound, those who improved in
                                                                                         required emergent care during the
     more favorably, and reported that        upper body dressing, and those who
                                                                                         course of home health care. While
     they were more likely to recommend       improved in management of oral
                                                                                         only six percent of the total sample,
     the agency to others. Improvements       medications rated satisfaction with
                                                                                         these patients averaged an overall
     in transferring was associated with      the majority of aspects of care
                                                                                         mean score nearly six points higher
     significantly higher Press Ganey         significantly higher than those that
                                                                                         than the least satisfied group of
     scores on the nurse’s sensitivity to     did not fit these criteria. Conversely,
                                                                                         patients—those who did not
     the personal difficulties and            those with a primary diagnosis of
                                                                                         improve in maintenance of oral
     inconvenience caused by the              diabetes mellitus rated satisfaction
                                                                                         medications. As such, the Home
     patient’s health problem, as well as     across a variety of aspects of care
                                                                                         Nursing Agency’s focus on best
     several therapy items. Similarly,        significantly lower than patients
                                                                                         practices for management of oral
     those who improved in ambulation         who did not have this primary
                                                                                         medications is well-served. By linking
     or locomotion rated nurses’              diagnosis at the start of care.
                                                                                         OCS outcome and visit utilization
     sensitivity to personal difficulties     Additional clinical, demographic, and
                                                                                         data with Press Ganey patient
     and the patients’ involvement in         functional factors also seem to have
                                                                                         satisfaction data, it is possible to
     making decisions about changes to        a protective effect on patient
                                                                                         verify that this agency’s ideas about
     care more favorably than those who       satisfaction or put patients at risk for
                                                                                         how to improve care were on target
     did not improve.                         low satisfaction ratings. However, as
                                                                                         and in the best interests of patients’
                                              we have shown, this is the case only
     The improvement in maintenance of                                                   most important needs.
                                              for certain aspects of satisfaction.
     oral medications was associated with

     Satisfaction Monitor                                                                             September/October 2006