The CAHPS® Home Health Care Survey (HH-CAHPS) Current Status, Future

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					The CAHPS® Home Health Care Survey (HH-CAHPS):
Current Status, Future Implications
Stefoni A. Bavin, Knowledge Associate, Press Ganey Associates, Inc.
Bradley R. Fulton, PhD, Senior Research Associate, Press Ganey Associates, Inc.




Executive Summary
The home health care industry has become an integral part of health care in the
United States. Because Medicare and Medicaid bear a large portion of the costs
associated with home health care, the Centers for Medicare and Medicaid Services
(CMS) initiated the design of a home health care survey to evaluate the care that
patients receive from the home health care agencies that CMS pays. This tool,
developed by the Consumer Assessment of Healthcare Providers and Systems
(CAHPS®) Program, is known as the CAHPS® Home Health Care Survey, or HH-CAHPS. 1

While there has been no official statement on how the information captured by the
HH-CAHPS survey will be used, CMS recently mentioned that there is “the possibility
of including [the HH-CAHPS survey] as part of the pay for reporting requirements for
home health care agencies CY [Calendar Year] 2010” (p. 4),2 a potential process similar
to the one that ties CMS hospital payments to the CAHPS® Hospital Survey (HCAHPS).a
This means that home health care providers may not only need to learn the intricacies
of how CAHPS surveys are distributed, collected, coded, and how the results are sent to
CMS, but some monies home health care agencies receive from CMS may well be tied
to the HH-CAHPS survey.

Press Ganey has been, and continues to be, proactive in informing our clients of public-
reporting initiatives. Home health care providers can benefit from early education and
partnership with Press Ganey, whose experience with HCAHPS can help home health
care providers through the prospective HH-CAHPS survey process. Press Ganey’s tools,
consulting services, and resources can help clients establish and implement successful
quality improvement initiatives.

Background
The CAHPS® Home Health Care Survey (HH-CAHPS), currently in the development and
testing stage, will measure patient perceptions of care provided by Medicare/
Medicaid certified home health care agencies.1 Its development is led by the Consumer
Assessment of Healthcare Providers and Systems (CAHPS®) Program, a program of the
U.S. Agency for Healthcare Research and Quality (AHRQ).3

The CAHPS Program, founded in 1995, is a collaboration of private research entities,
public research organizations, and key government agencies, including several under
the auspices of the U.S. Department of Health & Human Services such as the Centers
for Medicare and Medicaid Services (CMS). The purpose of the CAHPS Program is to
create, support, and assess patient and consumer experiences with health care via


  aFor more information on how HCAHPS may impact home health care agencies, please see:

  Remington, L., and Mylod, D. 2008. HCAHPS: What Is It? And What Is The Potential Impact On
  Home Care? The Remington Report (supplement), Jan/Feb:14-15.

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            800.232.8032 • pressganey.com • April 2008
                                 CAHPS products and surveys that are designed to be public reporting tools. The CAHPS
                                 Program has released surveys for hospitals (the CAHPS Hospital Survey, or HCAHPS),
                                 physicians and medical groups (the CAHPS® Clinician & Group Survey,
                                 or CG-CAHPS), and is currently developing three instruments for nursing home
                                 residents and their families (CAHPS® Nursing Home Surveys, or NH-CAHPS).3
“Our research shows that
aspects of patient
centeredness that are not        The Inception of HH-CAHPS
included on HCAHPS, such         CMS plays a large role in home health care costs—it is estimated that 57% of home
as privacy, shared decision      health care expenses in the United States are paid for by Medicare/Medicaid.1,4 In
making, emotional support,       the fall of 2006, CMS initiated the process to develop an instrument to measure
service recovery, and            patient experiences in home health care agencies which it reimburses, and requested
coordination of care, are        that AHRQ develop a survey to capture these patient perceptions.1
key leading indicators of
HCAHPS outcomes.
Additionally, patient-           After a literature review and a Call for Measures in September 2006, AHRQ and CAHPS
centered measurement             Team members conducted interviews with home health care patients and their
that allows patients to          families. In February 2007, the CAHPS Team met with a Technical Expert Panel to
evaluate the extent to           review the issues gleaned from the patient interviews, discuss survey content and
which care met their needs,      priorities, and craft the first survey draft.1
rather than just how often
something happened,              HH-CAHPS Survey Structure and Methodology as of August 2007
provides more reliable
                                 The HH-CAHPS survey draft to be used in the pilot test contains fifty-four items
prediction of HCAHPS
outcomes. Our clients have
                                 divided into four sections.5 The response options for most items are either a simple
been focusing on these           yes, no, or a frequency rating (Never, Sometimes, Usually, Always). After the "Survey
critical drivers of patient      Instructions,” the first section is, “Your Home Health Care” (p. 1), which contains eight
centeredness. This makes         items pertaining to the start of patients’ care. The second section, “Your Care from
them more comfortable            Home Health Providers in the Last 2 Months” (p. 4), contains twenty-two items
and confident in the             pertaining to patients’ experiences with care in the past two months. The third
process of public reporting      section, “Your Home Health Agency” (p. 7), contains twelve items pertaining to patient
and allows them to know          interactions with the agency’s office, and general patient perceptions of the agency.
what to focus on to most         The final section, “About You” (p. 9), contains twelve demographic and background
effectively enhance              questions.5 AHRQ estimates the average time required to complete the survey is
performance.”                    twenty minutes.6
Dr. Deirdre E. Mylod,
Vice President, Public Policy,   In the pilot test, the survey will be mailed to eligible patients with a cover letter and
Press Ganey Associates, Inc.     postage-paid envelope. Follow-up telephone calls and two reminder mailings are
                                 planned in the event of non-response: a postcard reminder, a second letter with an
                                 enclosed survey, and then telephone calls after two weeks following the last
                                 mailing.6,7

                                 Press Ganey: A Strong Voice in HCAHPS
                                 HH-CAHPS appears to be building on the foundation established by HCAHPS. For
                                 HCAHPS, Press Ganey submitted survey items, comments, and supporting
                                 documentation in response to the Call for Measures issued by AHRQ in 2002, and the
                                 Call for Public Comments following the first draft of the HCAHPS survey in 2003. After
                                 the initial run of the first HCAHPS survey, Press Ganey again responded to the second
                                 Call for Public Comments at the end of 2003, and assisted a number of clients
                                 conducting pilot tests of the HCAHPS instrument in 2004.8



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                                           800.232.8032 • pressganey.com • April 2008
                                 Throughout 2005, Press Ganey assisted the growing number of clients testing the
                                 HCAHPS tool and reported psychometric findings, as well as client experiences using
                                 the tool, to AHRQ. During 2006 and 2007, Press Ganey prepared clients for the HCAHPS
                                 Dry Run by providing information on the survey, the survey process, and how to meet
                                 the mailing and reporting requirements.9
“When HCAHPS data were
first released to the public     Recent Press Ganey research has found that many Press Ganey Inpatient Satisfaction
in March of 2008, analysis
                                 Survey items are strong predictors of HCAHPS performance. Utilizing data from the
revealed that Press Ganey
                                 first quarter of 2007, Press Ganey identified the key drivers of HCAHPS global outcome
clients outperformed non-
clients. Specifically            measures from among the HCAHPS and Press Ganey survey items. It was discovered
Press Ganey clients score        that several Press Ganey Inpatient Satisfaction Survey items were highly correlated
higher on both of the two        with the HCAHPS measure, “Would you recommend this hospital to friends and
key outcome measures of          family.” In fact, the first fourteen most highly correlated items are from the
Overall Rating of the            Press Ganey Inpatient Satisfaction Survey.
Hospital and Likelihood of
Recommending the                 Predicting HCAHPS Performance
Hospital. Additionally, the
results show that
                                                             Items Driving Likelihood to Recommend
Press Ganey clients are
                                           Survey Item                      Correlation
significantly more likely to      Staff worked together to care for you                                                                             0.79
be in the top of the                 Response to concerns/complaints                                                                             0.75
                                                                                                                                                0.74
HCAHPS database than are                     Nurses kept you informed
                                      Staff include decisions re:trtmnt                                                                         0.74
non-Press Ganey clients.”          Attention to special/personal needs                                                                        0.73
                                      Nurses’ attitude toward requests                                                                        0.73
                                     Staff addressed emotional needs                                                                          0.72
Dr. Deirdre E. Mylod,                               Skill of the nurses                                                                      0.72
Vice President, Public Policy,       Explanations: happen during T&T                                                                         0.72
                                   Friendliness/courtesy of the nurses                                                                       0.72
Press Ganey Associates, Inc.              Staff attitude toward visitors                                                                     0.71
                                         Staff concern for your privacy                                                                     0.71
                                    How well your pain was controlled                                                                      0.70
                                                     Skill of physician                                                                   0.69
                                   Nurses expl in way you understand                                                                    0.68
                                    Nurses treat with courtesy/respect                                                                  0.67
                                          Promptness response to call                                                                  0.66
                                         Nurses listen carefully to you                                                               0.66
                                         Courtesy of person started IV                                                               0.65
                                             Instructions care at home                                                               0.65
                                                     Room cleanliness                                                                0.64
                                                                                                                                                 Source of
                                  Physician concern questions/worries                                                                0.64        Survey Item
                                    Friendliness/courtesy of physician                                                              0.64            Press Ganey
                                           Extent felt ready discharge                                                              0.64
                                                                                                                                                    HCAHPS
                                       Wait time for test or treatments                                                             0.64
                                                                       0.00         0.10     0.20      0.30      0.40     0.50      0.60      0.70     0.80       0.90

                                                                           Represents the experiences of 246,135 of patients treated
                                                                           at 1,293 facilities nationwide between January 1 and March 31, 2007.




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                               Press Ganey: An Experienced Voice in HH-CAHPS
                               As with HCAHPS, Press Ganey has also been actively involved in the HH-CAHPS
                               process. To date, Press Ganey has participated in two Calls for Comments related to the
                               HH-CAHPS instrument as listed in the Federal Register comment submission process
                               in January and September 2007, and is regularly reviewing supporting materials
“Press Ganey’s algorithm
identified where our
                               released by AHRQ.
systems did not work
together. Consequently, we     Press Ganey is also a CMS-approved survey vendor10 that is familiar with the
are implementing the           requirements of CAHPS survey protocols, such as sampling frames, multiple-wave
infrastructure we need to      mailings, collection and coding procedures, and reporting requirements. Based upon
meet the needs of our          experience partnering with clients for the HCAHPS survey, Press Ganey expects that
patients—we would not          the HH-CAHPS survey may also require vendors or self-administering organizations to:
have known where to start
if we did not have the          • Document the sampling frame from which eligible patients were drawn including:
Press Ganey Priority Index.”       - Total number of eligible patients,
Elizabeth Buff, Vice               - Total number of patients sampled, and
President of Quality               - Method of sampling used.
Services and Clinical
Excellence, VNSNY               • Conduct and document a random sample of eligible patients.
                                • Include and exclude specific patient populations.
                                • De-duplicate patients who have received a previous survey within a certain time
                                  frame (i.e., calendar month).
                                • Track the survey mailing process, including:
                                   - Documenting the returns of the first-wave,
                                   - Noting non-respondents, and
                                   - Initiating additional multiple waves to only non-respondents.
                                • Track the patient survey through the administration process, including linking the
                                  patient responses back to required administrative data for submission to CMS.
                                • Document the final disposition status of the survey.
                                • Compute the final status of the survey based upon aspects of eligibility
                                  determined after the survey is mailed, such as complete (if at least 50% completed
                                  questions), incomplete, ineligible due to patient death, or ineligible due to
                                  language barrier or physical or mental incapacity.

                               Press Ganey’s ability to meet CAHPS requirements as a vendor, first-hand knowledge
                               of HCAHPS protocols, and successful partnership with clients through the HCAHPS
                               process, speaks very clearly to the return on investment of partnering with
                               Press Ganey rather than attempting to administer CAHPS surveys independently.




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                             Visiting Nurse Service of New York and HH-CAHPS: Current and Future Insights
                             According to AHRQ, thirty-six home health care agencies will participate in a pilot test
                             to provide desired variation on the following four characteristics: (1) number of eligible
                             patients; (2) public, private for-profit, or private non-profit; (3) hospital-based or free-
                             standing; and (4) chain or independent.6
“Having worked with
Press Ganey, we already
have the methodology and     Visiting Nurse Service of New York (VNSNY) was one of the agencies selected to
the processes in place for   participate in the HH-CAHPS pilot test. With over 9,860 care providers, VNSNY is the
surveying patients and       largest not-for-profit home health care agency in the country. VNSNY provides skilled
receiving feedback. The      care for over 100,000 patients throughout New York City, visiting approximately
staff are comfortable with   30,000 patients daily.11
looking at the data and
working to improve
activities. The mindset is   Ms. Elizabeth Logan Buff, vice president of Quality Services and Clinical Excellence at
there, and that is to        VNSNY, said that as a condition of participation in this pilot VNSNY mailed out their
Press Ganey’s credit.”       patient lists in December, and that the HH-CAHPS pilot surveying likely began shortly
                             thereafter. Ms. Buff said, “We are fortunate to be involved in the [HH-CAHPS] pilot. We
Elizabeth Buff, Vice         are able to see the questionnaire and the approach that is being taken.”
President of Quality
Services and Clinical        Ms. Buff noted that the HH-CAHPS pilot reinforces the importance of performance
Excellence, VNSNY            improvement, and that VNSNY extensively utilizes their Press Ganey data in their
                             current improvement efforts. “The Press Ganey survey is a wonderful tool that helps us
                             to identify where systems do not work together. Rather than thinking that the survey
                             tool is wrong or that patients in New York City are different, we know that there are
                             areas where we need to improve and we know where to start—the Press Ganey
                             Priority Index.”

                             VNSNY incorporates their Press Ganey patient-centered data with their own outcome
                             data to assess various elements of their performance, from the team and program
                             levels up through the agency. Ms. Buff noted, “Press Ganey sends the data to us
                             electronically so we are able to do our own drill downs in addition to the information
                             on eCompassTM.” This data merge and examination enables VNSNY to assess their
                             performance from all angles and pinpoint areas on which to concentrate their
                             improvement efforts.

                             Regarding VNSNY’s experience partnering with Press Ganey, Ms. Buff stated,
                             “Press Ganey has been incredibly helpful with benchmarking, and the tools are user
                             friendly. The Online Forum, national client conferences, regional workshops, and
                             networking opportunities have been very helpful.”

                             After the pilot test, Press Ganey expects that CMS will pursue National Quality Forum
                             (NQF) endorsement of the HH-CAHPS survey in the summer of 2008. If the survey
                             achieves consensus through the NQF process, Press Ganey anticipates that CMS may
                             nationally implement the survey in late 2008 or early 2009, and that HH-CAHPS
                             results could be linked to home health care agency pay for reporting in 2010.2
                             Therefore, benchmarking an agency’s scores will become imperative in order to
                             ascertain not only how well an agency is performing, but how well it is performing in
                             comparison to other agencies.


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                                       800.232.8032 • pressganey.com • April 2008
Conclusion
Current Press Ganey home health care clients are well prepared. By implementing
Press Ganey’s survey and improvement tools, you know how satisfied your patients are
with the services provided by your agency, gaining insight as to which aspects of care
can and should be improved. By monitoring your patient satisfaction benchmarking
data, you know how you compare to other agencies. By observing your patient
satisfaction trending data, you and your staff are able to see if improvement efforts
have met your goals. By partnering with Press Ganey, you have access to the
consulting services, tools, networking opportunities, and multiple resources
Press Ganey provides to help you design and implement successful improvement
efforts.
Press Ganey has partnered with thousands of clients to successfully implement and
navigate HCAHPS. We expect that our partnership with our home health care clients
will lead to a successful implementation of any future HH-CAHPS processes, and that
this will be greatly informed by our experiences with HCAHPS.
Press Ganey has already participated in the creation of the HH-CAHPS survey and has
begun planning the implementation of HH-CAHPS with many of our clients. We are
excited about partnering with our home health care clients to fulfill any future
HH-CAHPS requirements, and look forward to continued partnership with clients to
improve the quality of care and services provided to patients


Disclaimer: The information presented in this white paper is for educational purposes
only; this information is not intended to be, and should not be construed as, legal
advice.

Glossary of Acronyms
AHRQ: Agency for Healthcare Research and Quality
CAHPS®: Consumer Assessment of Healthcare Providers and Systems
CG-CAHPS: CAHPS® Clinician & Group Survey (ambulatory care and medical settings)
CMS: Centers for Medicare and Medicaid Services
HCAHPS: CAHPS® Hospital Survey
HH-CAHPS: CAHPS® Home Health Care Survey
HHS: Health and Human Services, U.S. Department of
NH-CAHPS: CAHPS® Nursing Home Survey
NQF: National Quality Forum




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         800.232.8032 • pressganey.com • April 2008
Glossary of Websites
AHRQ: http://www.ahrq.gov/
AHRQ CAHPS Programs: https://www.cahps.ahrq.gov/default.asp
AHRQ HH-CAHPS Information:
http://www.cahps.ahrq.gov/content/products/HH/PROD_HH_Intro.asp
CMS/HHS: http://www.cms.hhs.gov/
NQF: http://www.qualityforum.org/
Press Ganey HH-CAHPS Resource Page:
http://www.pressganey.com/cs/news_and_notes/hhcahps
Press Ganey Home Health Care Resources:
http://www.pressganey.com/cs/research_and_analysis/patient_satisfaction/home_he
alth_resources
Press Ganey Information on HCAHPS:
http://www.pressganey.com/cs/news_and_notes/hcahps_information
Press Ganey Inpatient Hospital Pulse Report:
http://www.pressganey.com/galleries/default-file/2008_Hospital_Pulse_Report.pdf


References
1Agency of Healthcare Research Quality. 2007. CAHPS® Survey Products–CAHPS Home

Health Care Survey. U.S. Department of Health & Human Services. Available at:
https://www.cahps.ahrq.gov/content/products/HH/PROD_HH_Intro.asp?p=1021&s=217.
2Agency of Healthcare Research Quality. 2007. Supporting Statement Part A: Voluntary

Questionnaire and Data Collection to Pretest Proposed Home Health Care CAHPS®
Questions and Methodology. OMB No. 0935-0124. Version: Nov 26th.
3Agency of Healthcare Research Quality. 2007. CAHPS® Overview–The CAHPS Program.

U.S. Department of Health & Human Services. Available at:
https://www.cahps.ahrq.gov/content/cahpsOverview/Over_Program.asp?p=101&s=12.
4Centers for Medicare & Medicaid Services. 2008. National Health Expenditure Data.

Centers for Medicare & Medicaid Services. Available at:
http://www.cms.hhs.gov/NationalHealthExpendData.
5Agency of Healthcare Research Quality. 2007. Attachment B: CAHPS® Home Health

Care Survey Instrument.
6Agency of Healthcare Research Quality. 2007. Supporting Statement Part B: Voluntary

Questionnaire and Data Collection to Pretest Proposed Home Health Care CAHPS®
Questions and Methodology. OMB No. 0935-0124. Version August 2007.
7Agency of Healthcare Research Quality. 2007. Attachment C: CAHPS® Home Health

Care Cover Letter, Reminder Post Card and Reminder Letter. From Approved OMB No.
0935-0124. Draft Date: August 24, 2007.
8Press Ganey Associates, Inc. 2008. Frequently Asked Questions on HCAHPS.

Press Ganey Associates, Inc. Available at: http://www.pressganey.com/cs/faqs.




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9Press Ganey Associates, Inc. 2008. The Road to HCAHPS Implementation. Press Ganey

Associates, Inc. Available at: http://www.pressganey.com/cs/hcahps_updates/
hcahps_timeline.
10HCAHPS – Hospital Care Quality Information from the Consumer Perspective.

CAHPS® Hospital Survey. 2007. Approved Vendors: CAHPS® Hospital Survey (HCAHPS)
Approved Survey Vendors as of December 7, 2007. Available at:
http://www.hcahpsonline.com/app_vendor.aspx.
11Visiting Nurse Service of New York. 2007. About Us. Visiting Nurse Service of New

York. Available at: http://www.vnsny.org/mainsite/about/a_index.html.




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