Misalignment Between Medicare Policies and Depression Care in Home Health Care: Home Health Provider Perspectives Yuhua Bao, Ph.D. Ashley A. Eggman, M.S. Joshua E. Richardson, Ph.D., M.S. Martha L. Bruce, Ph.D., M.P.H.
Objective: Depression affects one in four older adults receiving home health care. Medicare policies are influential in shaping home health practice. This study aimed to identify Medicare policy areas that are aligned or misaligned with improving the quality of depression care in home health care. Methods: This qualitative study was based on semistructured interviews with nurses and administrators from five home health care agencies in five states (N=20). Digitally recorded interviews were transcribed and analyzed by using the grounded theory method. A multidisciplinary team iteratively developed a codebook from interview data to identify themes. Results: Several important Medicare policies are largely misaligned with depression care quality improvement in home health care. Medicare eligibility requirements for patients to remain homebound and to demonstrate a need for skilled care restrict nurses’ ability to follow up with depressed patients for a sufficient time. Lack of explicit recognition of nursing time and quality of care in the home health prospective payment system provides misaligned incentives for depression care. Incorporation of a two-item depression screening tool in Medicare-mandated comprehensive patient assessment has raised clinician awareness of depression; however, inclusion of the tool at the start of care only but not at other follow-up points limits its potential in helping nurses manage depression care. Underdevelopment of clinical decision support for depression care in vendor-developed electronic health records constitutes an important barrier to improvement of depression care. Conclusions: Several influential Medicare policies and regulations for home health practice may be misaligned with evidence-based depression care for home health patients. (Psychiatric Services 65:905–910, 2014; doi: 10.1176/appi.ps.201300158)
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lder patients are typically admitted to home health care after hospitalization or other medical events that result in substantial decline in health and functioning. They have a high burden of medical illness and disability (1), and the prevalence of comorbid mental health
conditions is disproportionately high in this population. Depression that meets clinical diagnostic criteria affects almost one in four older patients in home health care (2). However, depression is seriously underrecognized and poorly managed in this setting (2– 4). In this population, depression is
Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bruce is with the Department of Psychiatry, all at Weill Cornell Medical College, New York City (e-mail: [email protected]).
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associated not only with an enormous amount of suffering but also with an increased risk of falls (5,6), hospitalization (7), and excess service use (4,8). Features of home health care and the home setting offer opportunities for improving the quality of depression care. In 2011, home health nurses made, on average, 17.2 visits to every user of Medicare-covered home health care (9). They are well positioned to assess depression, to help initiate treatment, and to follow up. These nurses visit patients in their homes and witness psychosocial issues (for example, family, financial, and environmental) that may contribute to depression or complicate patient self-care and recovery. Finally, home health nurses commonly manage multiple chronic conditions (10) and are trained and expected to take a holistic approach to patient care. They also strongly identify with the notion that mind and body are inseparable. On the basis of these premises, researchers have recently developed a nurse-delivered depression care management intervention for the home health setting called Depression CAREPATH (Care for Patients at Home) (11,12). It builds on and adapts the primary care–based collaborative care model (13,14). The clinical components of the Depression CAREPATH model, including ongoing symptom assessment, care coordination with the primary care physician and other specialists, medication management, assistance with selfcare and goal setting, and education, are comparable to those of the primary care 905
model but also consistent with typical home health practice and designed to fit naturally in a routine home visit. The role of home health care providers in caring for depression among older patients may be substantially influenced by Medicare policies. Medicare is the dominant payer for home health care for patients age 65 and older, covering care received by 75% of this population (15). Because many Medicare policies and regulations serve as preconditions for reimbursement, they may provide important incentives and play a critical role in shaping the practice of depression care in home health care. In this study, we asked, How well aligned are current Medicare policies with depression care quality improvement in home health care? We sought to answer the question by assessing home health administrators’ and nurses’ perspectives in an interview study.
Overview of Medicare policies for home health care Several Medicare policies and regulations were identified in our study as relevant to depression care in home health care and are summarized below. Homebound and “skilled need” requirements The homebound condition requires that patients “have a condition due to an illness or injury that restricts their ability to leave their place of residence” except with some kind of aid or assistance (16). Medicare also requires that patients have a need for skilled care (by nursing or therapy professionals) on an intermittent basis and that is “reasonable and necessary.” When elaborating on the “reasonable and necessary” principles, the Medicare Benefit Policy Manual emphasizes the need to prevent future complications or acute episodes and to ensure medical safety. Home health PPS Medicare’s prospective payment system (PPS), first implemented in 2000, specifies a 60-day episode rate with applicable adjustments. Case-mix adjustment is based on home health diagnoses, functional severity, and home health service utilization (17). Only home visits received for physical, 906
speech-language, and occupational therapies are factored into the service utilization adjustment. The PPS provides strong incentives to home health agencies (HHAs) to contain costs within the per-episode payment and, in particular, to limit the number and duration of nursing visits in a given episode. A related condition of Medicare participation requires that HHAs conduct the initial assessment in a timely manner (within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician-ordered start-ofcare [SOC] date) (17). This requirement, coupled with the fact that only new admissions (but not ongoing care) generate additional revenue to HHAs under the PPS, leads HHAs to assign higher priorities to SOC visits than to follow-up visits. OASIS and implications for electronic clinical systems The Centers for Medicare and Medicaid Services (CMS) requires every HHA to conduct standardized assessments of patients using the Outcome and Assessment Information Set (OASIS). The OASIS is more comprehensive at the SOC and less so at discharge (to home), transfer (to an inpatient setting), or resumption of care (after a hospital admission). The current OASIS (OASIS-C) at SOC contains 79 items (18), making the first home visit a long and involved session. The SOC OASIS must be completed within five days of SOC and, after agency review for errors and updates, submitted to the state within 30 days (17). HHAs are regularly monitored for submission timeliness. The OASIS-C encourages the systematic assessment of depressive symptoms at SOC with a two-item depression screen known as the Patient Health Questionnaire–2 (PHQ-2) (19–21). In addition, the discharge OASIS queries whether an intervention was conducted for patients who screened positive at SOC and whose physicians ordered interventions. HHAs are subject to many other reporting and documentation regulations by CMS, partly as a result of mounting concerns regarding inefficient or inappropriate use of Medicare resources and rapidly growing PSYCHIATRIC SERVICES
expenditures (9). Software vendors have responded by supplying HHAs with electronic clinical and billing systems. HHAs are typically small, independent, and resource poor. They rely heavily on vendor products and rarely have home-grown systems. Clinicians routinely use laptops or tablets in the field that are synchronized or linked to a central system (22). Home health managers rely on the system to supervise frontline clinicians and manage cases.
Methods Research team Our multidisciplinary research team comprised complementary expertise in mental health policy (YB), evidencebased depression care intervention in home health care (MLB), qualitative research methods (JER), and health care organizational behavior (AAE). Participant recruiting We sought administrators and nurses from five HHAs located in five states in the Northeast, South, and Midwest regions of the United States. These agencies recently participated in a randomized trial led by one of the coauthors to test the Depression CAREPATH intervention (11,12). Based on our experience with the trial, we selected three types of key informants to provide complementary perspectives: home health nurses who worked on a CAREPATH intervention team and home health nurses who worked on a usual care team, nurse supervisors of CAREPATH intervention teams, and medical or clinical directors involved in their agency’s initial decision to participate in CAREPATH or who played a leadership role in facilitating participation. A liaison at each agency identified potential informants, who were then contacted by the study team by e-mail or phone to recruit them and schedule interviews. After the study was described to informants, written informed consent was obtained. The study received approval from the Institutional Review Board at Weill Cornell Medical College. Interview guides We designed a semistructured interview guide to assess perceptions of depression and perceived roles in and
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responsibilities for depression care, current practice of caring for depression either by themselves (nurses) or at their agency (administrators), and perspectives regarding facilitators of and barriers to depression care quality improvement at four levels: system (including policy), organization (HHA), provider (home health and non–home health), and patient. Open-ended questions allowed informants to elaborate on issues they found most salient. Three interview guides covered the same domains of inquiry but were worded differently to account for informants’ roles. The guides were pilot-tested with a home health clinical director, a nursing team supervisor, and a nurse outside the CAREPATH agencies and iteratively revised throughout the interviews. [The final interview guides are included in an online data supplement to this article.] Interviews The first author conducted telephone interviews with informants between February 2012 and November 2012. Notes taken during and immediately after the interview were incorporated into data analysis (23). Data management and analysis Audio-recorded interviews were transcribed into Microsoft Word documents by a third-party service and analyzed with grounded theory methodology (24), an established qualitative analytic approach by which researchers generate overall themes from transcripts by iteratively reading and reviewing them, attributing labels (codes) to salient text, and documenting recurring topics that emerge. Following accepted qualitative analytic methods (25–28), two investigators (YB and AAE) independently coded each transcript and met to discuss the definitions of codes and negotiate consensus. For further analytical rigor, a third investigator (JER) independently coded selected transcripts and participated in coding meetings to provide an outside voice and help negotiate consensus. The process was documented throughout and led to the development of a codebook and themes (the final codebook is available from the authors on request). Data were organized and managed with the qualitative analysis software, PSYCHIATRIC SERVICES
Nvivo, version 9. The software facilitated text and code consolidation into larger themes intended to reflect how current Medicare policies are aligned (or misaligned) with depression care quality improvement in home health care.
Results We conducted interviews with 20 individuals—six directors, five supervisors, and nine nurses—from the five CAREPATH agencies. All but one were women. Average years of experience in home health care were 16 for administrators, nine for supervisors, and ten for nurses. The average interview lasted 45 minutes (range 33 to 56 minutes). Below, we detail four primary themes that emerged. Eligibility requirements are at odds with depression care Informants expressed concerns that Medicare eligibility requirements for patients to remain homebound and to demonstrate a “skilled need” were at odds with evidence-based depression care. Informants expressed frustration that they were not able to follow up with patients to track progress once patients were no longer homebound or their “skilled needs” were considered met and therefore ought to be discharged. This was a prominent theme voluntarily endorsed by more than half of informants in all three roles. One supervisor stated, “You [home health nurse] know that you’ve called the doctor, you’ve expressed to the doctor how you felt, but at this point—it’s not a skilled need to keep the patient open. . . . I’ve felt a lot of times that I’ve abandoned the patient, in a way. There’s no skilled need.” Informants believed that the eligibility requirements were especially restrictive for antidepressant management because it takes four to eight weeks before a psychotropic medication can be determined effective. This concern intensified and became more difficult to reconcile among supervisors and nurses in the CAREPATH intervention, because they received training on antidepressant management as part of the CAREPATH protocol and practiced it in routine care.
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Nevertheless, several administrators and nurses recognized the fiscal reality of Medicare and believed that Medicare could not afford to have patients stay longer in home health care because “the problem [need for depression and other chronic condition management] is so pervasive.” These informants reflected on the short-term, transitional nature of home health care and believed that their role was to get patients “on track” and to leave them to community-based providers for longterm management: “It would just feel better if there was good mental health support to turn [patients] over to . . . after we leave,” one informant said. PPS incentives are misaligned with depression care The lack of explicit recognition of nursing time and quality of care in the home health PPS provides misaligned incentives for chronic condition management in general and depression care in particular. Several agency directors described myriad challenges providing high-quality, evidence-based mental health services in ways that are financially sustainable. As one said, “The payment system is the same whether you focus on completing tasks . . . or if you spend this additional time [on depression care management]. . . . Nursing salary is very high, so yeah, we’re doing great care . . . but it’s destroying our budget.” Two subthemes emerged regarding how the PPS incentives “trickled down” to affect how home health nurses manage their caseloads and compromise their ability to care for depressed patients. First, the productivity expectation (in the range of six or seven home visits per day) pressures nurses to limit time in patients’ homes. Informants acknowledged that they would like to do much more care coordination and patient and caregiver education, but they did not have time. Although one agency allowed nurses to schedule extended visits for patients with complex conditions, interviews with nurses revealed that extending visits was not always feasible. One noted, “You don’t always have the luxury of doing those extended visits.” Second, incentives embedded in PPS coupled with the regulation regarding timely assessment at SOC led 907
HHAs to assign higher priority to new admissions. A common solution to a scheduling conflict between a SOC and a follow-up visit was to have other nurses “pick up” the follow-up visit. However, several informants expressed concern that doing so might disrupt the clinician-patient relationship and continuity of care. One nurse noted that patients with depression or other mental health needs may be adversely affected by the inconsistency in care providers: “I try to make sure that I’m the person that sees [patients with mood issues] . . . because they don’t like a lot of change.” Current OASIS provides limited support for depression care Several administrators applauded the inclusion of the two-item depression screen in the current OASIS, believing that it raised awareness of depression among home health providers. However, informants cited two ways in which the screening tool as currently incorporated limits its potential to assist nurses with depression care management. First, the SOC visit may not be the best time to screen for depression; it should not be the sole screening attempt, and the results should not solely determine a patient’s need for depression care. Informants noted that the SOC OASIS assessment typically takes two hours and is too involved to allow adequate assessment of depression. In addition, patients are not always willing to discuss mental health issues at the first visit. Several informants mentioned that they usually readminister the screen in a week or two to confirm or update the initial assessment, which is consistent with evidence-based practice and the CAREPATH protocol. However, because the OASIS assessment becomes “locked” to the nurse after five days (in compliance with the timely completion requirement), nurses who readministered the screen did not usually revise the SOC assessment— even though nurse supervisors or other administrators are able to “unlock” it to correct errors or make updates. Thus the adequacy and accuracy of screening results recorded in SOC OASIS are of concern. Second, the lack of follow-up assessment for depression in OASIS 908
represents missed opportunities for continued evaluation and ongoing management. Currently, depression assessment is not included in the OASIS at resumption of care (after hospitalization), recertification (for another 60-day episode), transfer (to an inpatient setting), or discharge. An agency director put it this way, “I think it [OASIS] needs to go a whole lot further because, as you know, it just asks, ‘Was an assessment done?’ But it doesn’t ask, ‘What was the result? What was the follow-up?’ ” Challenges with vendordeveloped home health EHRs Underdevelopment of clinical decision support for depression care management in vendor-supplied electronic health records (EHRs) for home health care and the high cost of customization constitute an important barrier to quality improvement. Several informants affirmed that having structured prompts or protocols built into the system would help with nurses’ adoption of evidence-based depression care. They pointed out that before the CAREPATH study customized their EHRs to support the intervention, functionalities for documenting depression care were weaker than for those documenting other major medical conditions, such as congestive heart failure and diabetes. In particular, informants noticed that once nurses documented depression, the system they worked with offered little guidance (such as through prompts or dropdown menus) on what to do next.
Discussion Our study suggests that several Medicare policy areas are largely misaligned with the need to improve the quality of depression care in home health care. Specifically, Medicare’s homebound and “skilled need” eligibility requirements, inclusion of depression assessment only in the SOC OASIS but not at other time points, and lack of minimum standards for vendordeveloped home health EHRs to support depression care are at odds with evidence-based depression care and the chronic nature of depression. Strong PPS incentives for HHAs to limit nursing time in a given payment episode and to increase volume (new admissions) PSYCHIATRIC SERVICES
are misaligned with the need for more nursing time and continuity of care for depressed patients. Below we discuss potential policy solutions and how current health care reform initiatives could be leveraged to address some issues. Our findings provide clear directions for incremental policy changes in the following areas. Future revision of the OASIS should consider incorporating PHQ-2 at resumption of care (after hospitalization) and recertification because these two time points provide prime opportunities to reassess depression and incorporate depression care into the plan of care if needed. In addition, depression assessment in the discharge OASIS would promote inclusion of information on depression as part of care transition. To further support ongoing management, OASIS designers may consider incorporating PHQ-9 (29,30), a nineitem assessment tool, for patients whose PHQ-2 scores indicate significant depressive symptoms. Currently adopted by a small number of HHAs on a voluntary basis, PHQ-9 is widely used in primary care. Ongoing assessment with PHQ-9 is part of the CAREPATH intervention. Inclusion of PHQ-9 in the Medicare-mandated OASIS for patients at heightened risk would improve the quality of clinical information available for treatment decisions and management. A complementary policy would be to require vendor-developed home health EHRs to incorporate a PHQ-9 assessment tool and clinical decision support for evidence-based depression care as a certification criterion for these systems. Feasibility of such a mandate is supported by the experience of the CAREPATH study, which worked with EHR vendors to integrate the intervention protocol into the clinical system of each HHA. Requirements for clinical decision support for depression are highly consistent with the Stage 2 federal “meaningful use” objectives (31) and recent recommendations on health information technology to support integrated behavioral health and general medical care (32). Policy barriers associated with home health eligibility criteria and PPS reflect a fundamental mismatch between depression care specifically and chronic
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care generally and the postacute nature of home health care. It may not be fiscally feasible to lift the homebound and “skilled need” requirements, which are essential in defining patient eligibility and for Medicare to rein in rapidly increasing home health care spending. Changing the key structures of the home health PPS (such as by incorporating nursing visits in case-mix adjustment) may be politically difficult and may have unintended consequences, such as providing incentives for overusing nursing service. These policy issues call for systemwide approaches, rather than remedies specific to the home health setting. Emerging health care delivery and payment reform models under the Affordable Care Act, such as accountable care organizations (ACOs), may be leveraged to address the need to align incentives systemwide (33). To the extent that ACOs recognize the importance for their patient population of depression care for overall quality and costs of care, the shared savings provision in an ACO contract should provide incentives for depression care coordination between home health clinicians and community providers. Even though our study focused on depression care, several findings (for example, those related to home health eligibility and PPS) have implications for management of chronic conditions in home health care. Although systemlevel reform efforts discussed above will help address the general issue of misaligned incentives, it is imperative that specific policy tools—in particular, accreditation, payment, and performance evaluation policies—be deployed to ensure attention to depression and other behavioral health conditions (33). For example, as a structure measure, ACOs may be required to implement PHQ-9 as an assessment tool across all care settings; significant improvement in depression (based on PHQ-9 scores) within six months of treatment initiation (regardless of setting) may be considered a patient outcome target. Our study has a few potential limitations. By design, the qualitative data reflected the perspectives of home health nurses and administrators in our study and not the perspectives of other stakeholders, such as patients, PSYCHIATRIC SERVICES
non–home health care providers, and policy makers. Our study HHAs may have perceived a greater need than the average HHA to improve the quality of depression care, as indicated by their voluntary participation in a depression intervention study. Finally, this research, like qualitative research in general, is not intended to be generalizable. However, readers may consider the findings “transferrable” to other circumstantial or organizational contexts (34).
Conclusions We found that several Medicare policy areas that affect home health practice may be misaligned with evidence-based depression care for patients receiving home health care. In regard to the design of OASIS and of home health EHRs, incremental policy changes may provide immediate remedies and are not likely to encounter substantial political hurdles. Although major changes to patient eligibility requirements and home health PPS are at odds with the postacute nature of home health care and therefore unlikely policy solutions, current initiatives spurred by health care reform that either strengthen care coordination across settings or provide targeted incentives for quality improvement may, to some extent, address the misalignment. Acknowledgments and disclosures This research was funded by grants K01MH090087 and R01 MH082425 from the National Institute of Mental Health. The authors thank Catherine Reilly, M.P.H., for assistance with recruitment of informants. The authors report no competing interests.
References 1. Caffrey C, Sengupta M, Moss A, et al: Home Health Care and Discharged Hospice Care Patients: United States, 2000 and 2007. National Health Statistics Report, no 38. Hyattsville, Md, National Center for Health Statistics, 2011 2. Bruce ML, McAvay GJ, Raue PJ, et al: Major depression in elderly home health care patients. American Journal of Psychiatry 159:1367–1374, 2002 3. Brown EL, Bruce ML, McAvay GJ, et al: Recognition of late-life depression in home care: accuracy of the outcome and assessment information set. Journal of the American Geriatrics Society 52:995–999, 2004 4. Shao H, Peng TR, Bruce ML, et al: Diagnosed depression among Medicare home health patients: national prevalence esti-
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verity measure. Journal of General Internal Medicine 16:606–613, 2001 31. Stage 2: Eligible Professional Meaningful Use Core Measures. Baltimore, Centers for Medicare and Medicaid Services, 2012. Available at www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/ downloads/Stage2_EPCore_6_ClinicalDecisionSupport.pdf. Accessed Sept 20, 2013 32. Behavioral Health Roundtable: Using Information Technology to Integrate Behavioral Health and Primary Care: Summary Report of Findings. Washington, DC, US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, 2012. Available at http://www.healthit.gov/policyresearchers-implementers/behavioral-healthinitiative-overview. Accessed Sept 20, 2013 33. Bao Y, Casalino LP, Pincus HA: Behavioral health and health care reform models: patient-centered medical home, health home, and accountable care organization. Journal of Behavioral Health Services and Research 40:121–132, 2013 34. Patton MQ: Qualitative Research and Evaluation Methods, 3rd ed. Thousand Oaks, Calif, Sage, 2001
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Objective: Depression affects one in four older adults receiving home health care. Medicare policies are influential in shaping home health practice. This study aimed to identify Medicare policy areas that are aligned or misaligned with improving the quality of depression care in home health care. Methods: This qualitative study was based on semistructured interviews with nurses and administrators from five home health care agencies in five states (N=20). Digitally recorded interviews were transcribed and analyzed by using the grounded theory method. A multidisciplinary team iteratively developed a codebook from interview data to identify themes. Results: Several important Medicare policies are largely misaligned with depression care quality improvement in home health care. Medicare eligibility requirements for patients to remain homebound and to demonstrate a need for skilled care restrict nurses’ ability to follow up with depressed patients for a sufficient time. Lack of explicit recognition of nursing time and quality of care in the home health prospective payment system provides misaligned incentives for depression care. Incorporation of a two-item depression screening tool in Medicare-mandated comprehensive patient assessment has raised clinician awareness of depression; however, inclusion of the tool at the start of care only but not at other follow-up points limits its potential in helping nurses manage depression care. Underdevelopment of clinical decision support for depression care in vendor-developed electronic health records constitutes an important barrier to improvement of depression care. Conclusions: Several influential Medicare policies and regulations for home health practice may be misaligned with evidence-based depression care for home health patients. (Psychiatric Services 65:905–910, 2014; doi: 10.1176/appi.ps.201300158)
O
lder patients are typically admitted to home health care after hospitalization or other medical events that result in substantial decline in health and functioning. They have a high burden of medical illness and disability (1), and the prevalence of comorbid mental health
conditions is disproportionately high in this population. Depression that meets clinical diagnostic criteria affects almost one in four older patients in home health care (2). However, depression is seriously underrecognized and poorly managed in this setting (2– 4). In this population, depression is
Dr. Bao, Ms. Eggman, and Dr. Richardson are with the Department of Healthcare Policy and Research, and Dr. Bruce is with the Department of Psychiatry, all at Weill Cornell Medical College, New York City (e-mail: [email protected]).
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associated not only with an enormous amount of suffering but also with an increased risk of falls (5,6), hospitalization (7), and excess service use (4,8). Features of home health care and the home setting offer opportunities for improving the quality of depression care. In 2011, home health nurses made, on average, 17.2 visits to every user of Medicare-covered home health care (9). They are well positioned to assess depression, to help initiate treatment, and to follow up. These nurses visit patients in their homes and witness psychosocial issues (for example, family, financial, and environmental) that may contribute to depression or complicate patient self-care and recovery. Finally, home health nurses commonly manage multiple chronic conditions (10) and are trained and expected to take a holistic approach to patient care. They also strongly identify with the notion that mind and body are inseparable. On the basis of these premises, researchers have recently developed a nurse-delivered depression care management intervention for the home health setting called Depression CAREPATH (Care for Patients at Home) (11,12). It builds on and adapts the primary care–based collaborative care model (13,14). The clinical components of the Depression CAREPATH model, including ongoing symptom assessment, care coordination with the primary care physician and other specialists, medication management, assistance with selfcare and goal setting, and education, are comparable to those of the primary care 905
model but also consistent with typical home health practice and designed to fit naturally in a routine home visit. The role of home health care providers in caring for depression among older patients may be substantially influenced by Medicare policies. Medicare is the dominant payer for home health care for patients age 65 and older, covering care received by 75% of this population (15). Because many Medicare policies and regulations serve as preconditions for reimbursement, they may provide important incentives and play a critical role in shaping the practice of depression care in home health care. In this study, we asked, How well aligned are current Medicare policies with depression care quality improvement in home health care? We sought to answer the question by assessing home health administrators’ and nurses’ perspectives in an interview study.
Overview of Medicare policies for home health care Several Medicare policies and regulations were identified in our study as relevant to depression care in home health care and are summarized below. Homebound and “skilled need” requirements The homebound condition requires that patients “have a condition due to an illness or injury that restricts their ability to leave their place of residence” except with some kind of aid or assistance (16). Medicare also requires that patients have a need for skilled care (by nursing or therapy professionals) on an intermittent basis and that is “reasonable and necessary.” When elaborating on the “reasonable and necessary” principles, the Medicare Benefit Policy Manual emphasizes the need to prevent future complications or acute episodes and to ensure medical safety. Home health PPS Medicare’s prospective payment system (PPS), first implemented in 2000, specifies a 60-day episode rate with applicable adjustments. Case-mix adjustment is based on home health diagnoses, functional severity, and home health service utilization (17). Only home visits received for physical, 906
speech-language, and occupational therapies are factored into the service utilization adjustment. The PPS provides strong incentives to home health agencies (HHAs) to contain costs within the per-episode payment and, in particular, to limit the number and duration of nursing visits in a given episode. A related condition of Medicare participation requires that HHAs conduct the initial assessment in a timely manner (within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician-ordered start-ofcare [SOC] date) (17). This requirement, coupled with the fact that only new admissions (but not ongoing care) generate additional revenue to HHAs under the PPS, leads HHAs to assign higher priorities to SOC visits than to follow-up visits. OASIS and implications for electronic clinical systems The Centers for Medicare and Medicaid Services (CMS) requires every HHA to conduct standardized assessments of patients using the Outcome and Assessment Information Set (OASIS). The OASIS is more comprehensive at the SOC and less so at discharge (to home), transfer (to an inpatient setting), or resumption of care (after a hospital admission). The current OASIS (OASIS-C) at SOC contains 79 items (18), making the first home visit a long and involved session. The SOC OASIS must be completed within five days of SOC and, after agency review for errors and updates, submitted to the state within 30 days (17). HHAs are regularly monitored for submission timeliness. The OASIS-C encourages the systematic assessment of depressive symptoms at SOC with a two-item depression screen known as the Patient Health Questionnaire–2 (PHQ-2) (19–21). In addition, the discharge OASIS queries whether an intervention was conducted for patients who screened positive at SOC and whose physicians ordered interventions. HHAs are subject to many other reporting and documentation regulations by CMS, partly as a result of mounting concerns regarding inefficient or inappropriate use of Medicare resources and rapidly growing PSYCHIATRIC SERVICES
expenditures (9). Software vendors have responded by supplying HHAs with electronic clinical and billing systems. HHAs are typically small, independent, and resource poor. They rely heavily on vendor products and rarely have home-grown systems. Clinicians routinely use laptops or tablets in the field that are synchronized or linked to a central system (22). Home health managers rely on the system to supervise frontline clinicians and manage cases.
Methods Research team Our multidisciplinary research team comprised complementary expertise in mental health policy (YB), evidencebased depression care intervention in home health care (MLB), qualitative research methods (JER), and health care organizational behavior (AAE). Participant recruiting We sought administrators and nurses from five HHAs located in five states in the Northeast, South, and Midwest regions of the United States. These agencies recently participated in a randomized trial led by one of the coauthors to test the Depression CAREPATH intervention (11,12). Based on our experience with the trial, we selected three types of key informants to provide complementary perspectives: home health nurses who worked on a CAREPATH intervention team and home health nurses who worked on a usual care team, nurse supervisors of CAREPATH intervention teams, and medical or clinical directors involved in their agency’s initial decision to participate in CAREPATH or who played a leadership role in facilitating participation. A liaison at each agency identified potential informants, who were then contacted by the study team by e-mail or phone to recruit them and schedule interviews. After the study was described to informants, written informed consent was obtained. The study received approval from the Institutional Review Board at Weill Cornell Medical College. Interview guides We designed a semistructured interview guide to assess perceptions of depression and perceived roles in and
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responsibilities for depression care, current practice of caring for depression either by themselves (nurses) or at their agency (administrators), and perspectives regarding facilitators of and barriers to depression care quality improvement at four levels: system (including policy), organization (HHA), provider (home health and non–home health), and patient. Open-ended questions allowed informants to elaborate on issues they found most salient. Three interview guides covered the same domains of inquiry but were worded differently to account for informants’ roles. The guides were pilot-tested with a home health clinical director, a nursing team supervisor, and a nurse outside the CAREPATH agencies and iteratively revised throughout the interviews. [The final interview guides are included in an online data supplement to this article.] Interviews The first author conducted telephone interviews with informants between February 2012 and November 2012. Notes taken during and immediately after the interview were incorporated into data analysis (23). Data management and analysis Audio-recorded interviews were transcribed into Microsoft Word documents by a third-party service and analyzed with grounded theory methodology (24), an established qualitative analytic approach by which researchers generate overall themes from transcripts by iteratively reading and reviewing them, attributing labels (codes) to salient text, and documenting recurring topics that emerge. Following accepted qualitative analytic methods (25–28), two investigators (YB and AAE) independently coded each transcript and met to discuss the definitions of codes and negotiate consensus. For further analytical rigor, a third investigator (JER) independently coded selected transcripts and participated in coding meetings to provide an outside voice and help negotiate consensus. The process was documented throughout and led to the development of a codebook and themes (the final codebook is available from the authors on request). Data were organized and managed with the qualitative analysis software, PSYCHIATRIC SERVICES
Nvivo, version 9. The software facilitated text and code consolidation into larger themes intended to reflect how current Medicare policies are aligned (or misaligned) with depression care quality improvement in home health care.
Results We conducted interviews with 20 individuals—six directors, five supervisors, and nine nurses—from the five CAREPATH agencies. All but one were women. Average years of experience in home health care were 16 for administrators, nine for supervisors, and ten for nurses. The average interview lasted 45 minutes (range 33 to 56 minutes). Below, we detail four primary themes that emerged. Eligibility requirements are at odds with depression care Informants expressed concerns that Medicare eligibility requirements for patients to remain homebound and to demonstrate a “skilled need” were at odds with evidence-based depression care. Informants expressed frustration that they were not able to follow up with patients to track progress once patients were no longer homebound or their “skilled needs” were considered met and therefore ought to be discharged. This was a prominent theme voluntarily endorsed by more than half of informants in all three roles. One supervisor stated, “You [home health nurse] know that you’ve called the doctor, you’ve expressed to the doctor how you felt, but at this point—it’s not a skilled need to keep the patient open. . . . I’ve felt a lot of times that I’ve abandoned the patient, in a way. There’s no skilled need.” Informants believed that the eligibility requirements were especially restrictive for antidepressant management because it takes four to eight weeks before a psychotropic medication can be determined effective. This concern intensified and became more difficult to reconcile among supervisors and nurses in the CAREPATH intervention, because they received training on antidepressant management as part of the CAREPATH protocol and practiced it in routine care.
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Nevertheless, several administrators and nurses recognized the fiscal reality of Medicare and believed that Medicare could not afford to have patients stay longer in home health care because “the problem [need for depression and other chronic condition management] is so pervasive.” These informants reflected on the short-term, transitional nature of home health care and believed that their role was to get patients “on track” and to leave them to community-based providers for longterm management: “It would just feel better if there was good mental health support to turn [patients] over to . . . after we leave,” one informant said. PPS incentives are misaligned with depression care The lack of explicit recognition of nursing time and quality of care in the home health PPS provides misaligned incentives for chronic condition management in general and depression care in particular. Several agency directors described myriad challenges providing high-quality, evidence-based mental health services in ways that are financially sustainable. As one said, “The payment system is the same whether you focus on completing tasks . . . or if you spend this additional time [on depression care management]. . . . Nursing salary is very high, so yeah, we’re doing great care . . . but it’s destroying our budget.” Two subthemes emerged regarding how the PPS incentives “trickled down” to affect how home health nurses manage their caseloads and compromise their ability to care for depressed patients. First, the productivity expectation (in the range of six or seven home visits per day) pressures nurses to limit time in patients’ homes. Informants acknowledged that they would like to do much more care coordination and patient and caregiver education, but they did not have time. Although one agency allowed nurses to schedule extended visits for patients with complex conditions, interviews with nurses revealed that extending visits was not always feasible. One noted, “You don’t always have the luxury of doing those extended visits.” Second, incentives embedded in PPS coupled with the regulation regarding timely assessment at SOC led 907
HHAs to assign higher priority to new admissions. A common solution to a scheduling conflict between a SOC and a follow-up visit was to have other nurses “pick up” the follow-up visit. However, several informants expressed concern that doing so might disrupt the clinician-patient relationship and continuity of care. One nurse noted that patients with depression or other mental health needs may be adversely affected by the inconsistency in care providers: “I try to make sure that I’m the person that sees [patients with mood issues] . . . because they don’t like a lot of change.” Current OASIS provides limited support for depression care Several administrators applauded the inclusion of the two-item depression screen in the current OASIS, believing that it raised awareness of depression among home health providers. However, informants cited two ways in which the screening tool as currently incorporated limits its potential to assist nurses with depression care management. First, the SOC visit may not be the best time to screen for depression; it should not be the sole screening attempt, and the results should not solely determine a patient’s need for depression care. Informants noted that the SOC OASIS assessment typically takes two hours and is too involved to allow adequate assessment of depression. In addition, patients are not always willing to discuss mental health issues at the first visit. Several informants mentioned that they usually readminister the screen in a week or two to confirm or update the initial assessment, which is consistent with evidence-based practice and the CAREPATH protocol. However, because the OASIS assessment becomes “locked” to the nurse after five days (in compliance with the timely completion requirement), nurses who readministered the screen did not usually revise the SOC assessment— even though nurse supervisors or other administrators are able to “unlock” it to correct errors or make updates. Thus the adequacy and accuracy of screening results recorded in SOC OASIS are of concern. Second, the lack of follow-up assessment for depression in OASIS 908
represents missed opportunities for continued evaluation and ongoing management. Currently, depression assessment is not included in the OASIS at resumption of care (after hospitalization), recertification (for another 60-day episode), transfer (to an inpatient setting), or discharge. An agency director put it this way, “I think it [OASIS] needs to go a whole lot further because, as you know, it just asks, ‘Was an assessment done?’ But it doesn’t ask, ‘What was the result? What was the follow-up?’ ” Challenges with vendordeveloped home health EHRs Underdevelopment of clinical decision support for depression care management in vendor-supplied electronic health records (EHRs) for home health care and the high cost of customization constitute an important barrier to quality improvement. Several informants affirmed that having structured prompts or protocols built into the system would help with nurses’ adoption of evidence-based depression care. They pointed out that before the CAREPATH study customized their EHRs to support the intervention, functionalities for documenting depression care were weaker than for those documenting other major medical conditions, such as congestive heart failure and diabetes. In particular, informants noticed that once nurses documented depression, the system they worked with offered little guidance (such as through prompts or dropdown menus) on what to do next.
Discussion Our study suggests that several Medicare policy areas are largely misaligned with the need to improve the quality of depression care in home health care. Specifically, Medicare’s homebound and “skilled need” eligibility requirements, inclusion of depression assessment only in the SOC OASIS but not at other time points, and lack of minimum standards for vendordeveloped home health EHRs to support depression care are at odds with evidence-based depression care and the chronic nature of depression. Strong PPS incentives for HHAs to limit nursing time in a given payment episode and to increase volume (new admissions) PSYCHIATRIC SERVICES
are misaligned with the need for more nursing time and continuity of care for depressed patients. Below we discuss potential policy solutions and how current health care reform initiatives could be leveraged to address some issues. Our findings provide clear directions for incremental policy changes in the following areas. Future revision of the OASIS should consider incorporating PHQ-2 at resumption of care (after hospitalization) and recertification because these two time points provide prime opportunities to reassess depression and incorporate depression care into the plan of care if needed. In addition, depression assessment in the discharge OASIS would promote inclusion of information on depression as part of care transition. To further support ongoing management, OASIS designers may consider incorporating PHQ-9 (29,30), a nineitem assessment tool, for patients whose PHQ-2 scores indicate significant depressive symptoms. Currently adopted by a small number of HHAs on a voluntary basis, PHQ-9 is widely used in primary care. Ongoing assessment with PHQ-9 is part of the CAREPATH intervention. Inclusion of PHQ-9 in the Medicare-mandated OASIS for patients at heightened risk would improve the quality of clinical information available for treatment decisions and management. A complementary policy would be to require vendor-developed home health EHRs to incorporate a PHQ-9 assessment tool and clinical decision support for evidence-based depression care as a certification criterion for these systems. Feasibility of such a mandate is supported by the experience of the CAREPATH study, which worked with EHR vendors to integrate the intervention protocol into the clinical system of each HHA. Requirements for clinical decision support for depression are highly consistent with the Stage 2 federal “meaningful use” objectives (31) and recent recommendations on health information technology to support integrated behavioral health and general medical care (32). Policy barriers associated with home health eligibility criteria and PPS reflect a fundamental mismatch between depression care specifically and chronic
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care generally and the postacute nature of home health care. It may not be fiscally feasible to lift the homebound and “skilled need” requirements, which are essential in defining patient eligibility and for Medicare to rein in rapidly increasing home health care spending. Changing the key structures of the home health PPS (such as by incorporating nursing visits in case-mix adjustment) may be politically difficult and may have unintended consequences, such as providing incentives for overusing nursing service. These policy issues call for systemwide approaches, rather than remedies specific to the home health setting. Emerging health care delivery and payment reform models under the Affordable Care Act, such as accountable care organizations (ACOs), may be leveraged to address the need to align incentives systemwide (33). To the extent that ACOs recognize the importance for their patient population of depression care for overall quality and costs of care, the shared savings provision in an ACO contract should provide incentives for depression care coordination between home health clinicians and community providers. Even though our study focused on depression care, several findings (for example, those related to home health eligibility and PPS) have implications for management of chronic conditions in home health care. Although systemlevel reform efforts discussed above will help address the general issue of misaligned incentives, it is imperative that specific policy tools—in particular, accreditation, payment, and performance evaluation policies—be deployed to ensure attention to depression and other behavioral health conditions (33). For example, as a structure measure, ACOs may be required to implement PHQ-9 as an assessment tool across all care settings; significant improvement in depression (based on PHQ-9 scores) within six months of treatment initiation (regardless of setting) may be considered a patient outcome target. Our study has a few potential limitations. By design, the qualitative data reflected the perspectives of home health nurses and administrators in our study and not the perspectives of other stakeholders, such as patients, PSYCHIATRIC SERVICES
non–home health care providers, and policy makers. Our study HHAs may have perceived a greater need than the average HHA to improve the quality of depression care, as indicated by their voluntary participation in a depression intervention study. Finally, this research, like qualitative research in general, is not intended to be generalizable. However, readers may consider the findings “transferrable” to other circumstantial or organizational contexts (34).
Conclusions We found that several Medicare policy areas that affect home health practice may be misaligned with evidence-based depression care for patients receiving home health care. In regard to the design of OASIS and of home health EHRs, incremental policy changes may provide immediate remedies and are not likely to encounter substantial political hurdles. Although major changes to patient eligibility requirements and home health PPS are at odds with the postacute nature of home health care and therefore unlikely policy solutions, current initiatives spurred by health care reform that either strengthen care coordination across settings or provide targeted incentives for quality improvement may, to some extent, address the misalignment. Acknowledgments and disclosures This research was funded by grants K01MH090087 and R01 MH082425 from the National Institute of Mental Health. The authors thank Catherine Reilly, M.P.H., for assistance with recruitment of informants. The authors report no competing interests.
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