Home Health CAHPS Responses to Public Comments 3-17-09--Comment Topics

CMS Responses to Public Comments from 60 day public comment period for the Home Health CAHPS Survey

Docket: CMS-2008-0149

CMS Home Health Care Survey (CMS – 10275)

Some commenters have expressed concern that the survey is too long which they felt would impact the response rate. A Technical Expert Panel included a recommendation to keep the survey as short as possible. During survey development, the number of questions included was minimized in order to focus on a core set of questions. The survey was field tested with 34 home health agencies across the country and there was no mention of concern about the length of the survey. The fielded survey was 54 questions in length and has been subsequently shortened as a result of the field test. The resulting length of the survey is now at 34 questions.

Some home health agencies have expressed concerns about the cost of administering the survey. The commenter stated that some providers investigated the cost of contracting for the completion of this survey and were told it would likely cost around $2500/year and expressed the fact that it was cost-prohibitive for most providers and is another unfunded mandate. The approximate cost per fielded survey is $6.00, however, home health agencies will need to negotiate the price with one of the approved survey vendors. The cost of the survey will vary across home health agencies and will differ according to the mode of administration, whether mail, phone or mixed (mail and phone follow-up).

One commenter wanted us to address the issue of her many clients who had a diagnosis of severe and persistent mental illness and the difficulty they would have in completing the survey. A Home Health CAHPS Technical Expert Panel (TEP) reported that proxy responses (i.e., responses provided by individuals other than the health care recipients) are inevitable because some home health care recipients are too impaired to participate. The survey has been designed to allow proxy respondents. In the field test, there was no statistically significant difference between responses by proxy status.

Several commenters wanted to address the fact that there were no timely initiation of services questions. A Home Health CAHPS Technical Expert Panel (TEP) discussed this topic. There was concern that it would be difficult to obtain correct responses from the patient since the patient may not know when the referral was made to the home health agency. If a delay occurs, it could be due to a problem with the discharging hospital rather than the home health agency. Also, the wait may have been because of physician orders or other appropriate reasons, such as patient wishes.

Some commenters were concerned that the survey lacks ability to actually rate service/care by discipline. In some cases, it can be difficult for patients to report which disciplines have provided care.

Several commenters wanted the survey to include questions relating to skill and knowledge of home care staff, encouragement and motivation of the staff, and whether the patient feels ready for discharge from the agency.

Depending upon services provided, it may be difficult for patients to assess the skill, knowledge and motivation of the home health staff. Patients may not be the best source of this information. Also, not all patients responding to this survey will be discharge patients. However, participating home health agencies and their survey vendors will have the option of adding their own questions to the HHCAHPS survey. If a home health agency/vendor plans to add their own questions, they must add them after the core HHCAHPS questions (Questions 1-25) and before or after the “About You” section. If a home health agency/vendor decides to add their own questions, attention should be paid to the length of the survey. The longer the survey, the greater the burden on respondents.

Some commenters felt that there were no questions specific to skill outcomes. Oasis clinical measures focus on outcomes. This survey compliments this information and evaluates care from the patient’s perspective which is not available in other home health quality measures now.

Several commenters stated that they saw no space for patients to provide narrative comments or feedback. Participating home health agencies and their survey vendors will have the option of adding their own questions to the HHCAHPS survey. If a home health agency/vendor plans to add their own questions, they must add them after the core HHCAHPS questions (Questions 1-25) and before or after the “About You” section. If a home health agency/vendor decides to add their own questions, attention should be paid to the length of the survey. The longer the survey, the greater the burden on respondents. There are also HHCAHPS Supplemental questions, not included in the core set of questions, which were developed through testing. The last question of the supplemental set is an open-ended question which allows respondents to add their own comments to the survey.

Some commenters felt that the survey questions were written at a too high level and that the survey was too technical. The survey was developed for approximately a 7^th grade educational level.

Some commenters were concerned that patients may not remember all information required to complete the survey accurately. The survey was field tested and this did not show up as a problem in the field test. We require monthly sampling so the home health care experience is close to survey receipt.

Some comments related to the fact that it was felt that patients can’t differentiate care in different settings (hospital, nursing home, home health care in multi-system campuses)

The respondents will know what home health agency the survey is referring to since the name of the agency (and the fact that it is a home health agency) is stated on the survey itself. In the beginning of the survey, patients are asked about types of people coming to their home to orient the respondent to the home health care provided.

Some commenters felt that some questions on the survey do not allow the respondent to rate satisfaction and may be inaccurate as some patients are not sure who is visiting them, for example, they think the PT is an RN, or the MSS is an RN). This set of questions is used to orient the patient to home health care and what the survey is referring to.

Several commenters wanted clarification of Question 9 regarding how often did home health providers seem informed and up-to-date about all the care or treatment the patient got at home. The commenter thought that this question was looking at coordination of care and teamwork. They thought the question should be clarified to read: “overall teamwork between home care staff…..”.

This question was designed to discover if the respondent thought the provider was cognizant of the care that the patient was receiving from the agency and was keeping up with the changes, if any.

Some commenters were concerned about the question asking about pain. The commenters suggested that the question should be worded to reflect the survey asking if the agency assessed their pain, and if pain was identified, did the agency control or reduce the pain, rather than just asking, as the survey does, if the health care provider just talked about pain. The TEP discussed this question. Due to the length of the survey, follow-up questions on pain were not included. Participating home health agencies and their survey vendors will have the option of adding their own questions to the HHCAHPS survey. If a home health agency/vendor plans to add their own questions, they must add them after the core HHCAHPS questions (Questions 1-25) and before and after the “About You” section. If a home health agency/vendor decides to add their own questions, attention should be paid to the length of the survey. The longer the survey, the greater the burden on respondents.

Several commenters felt that the first and second medicine questions were redundant (Questions 4 and 5). The first medicine question (Question 4) asks about discussion of the medicines being taken and the second medicine question (Question 5) deals with seeing and verifying those medicines.

Some commenters felt that it would be beneficial to add a response option dealing with medications “that are managed by someone else” for patients who do not have knowledge regarding their medications (for example, patients residing in Assisted Living or memory care units) – then skip to the next section of questions. Patients who do not have knowledge about their medications would have a proxy help complete the questionnaire for them. Our testing found that because some home health care respondents are too impaired to participate, it was found acceptable to use the family as the sampling unit and the family could supplement the patient’s opinions. Additionally, testing also revealed that the use of proxy and non-proxy respondents was not statistically significant.

Several commenters expressed the opinion that response options for Question 23, when you contacted this agency’s office, how long did it take for you to get the help or advice you needed, that the timeframes have too large a gap and should be shortened to 1) Same day 2) 1-2 days 3) 3-5 days, 4) More that 5 days 5) I did not contact this agency’s office.

The current survey has the breakdown as Same day, 1-5 days, 6-14 days, More than 14 days and I did not contact this agency during regular office hours. The commenter also wanted the words: “during regular office hours”. The field test showed that the timeframe breakdowns did not pose a problem for respondents. There is however, a typographical error on the last response. It should have read: “I did not contact this agency”. The phrase “during regular office hours” was removed.

Some commenters felt that some of the medication questions are already assessed on the OASIS data set and are unnecessary. They thought this might be an area for reduction of survey questions. This survey is trying to get data from the patient’s perspective.

Some commenters felt that the word “gently” is highly subjective. According to their patient satisfaction surveys, the agency has found that patients directly relate the level of safety they felt while receiving home care to their overall satisfaction level. The commenter recommended changing this question to relate to safety instead of gentleness.

We chose to keep the gentleness question in the survey because during the testing, it was felt that this question dealt with the patient’s interaction with the staff.

Some commenters asked about Question 24: did you have any problems with the care you got through this agency. They felt a follow-up question should be given with a place for listing the nature of the problem. Participating home health agencies and their survey vendors will have the option of adding their own questions to the HHCAHPS survey. If a home health agency/vendor plans to add their own questions, they must add them after the core HHCAHPS questions and before or after the “About You” section. If a home health agency/vendor decides to add their own questions, attention should be paid to the length of the survey. The longer the survey, the greater the burden on respondents.

Several commenters suggested using a scale of 1-5 rather than 1-10 regarding the global rating of respondent’s care from their agency’s home health provider. This response scale has been tested across multiple home health settings. The scale 0-10 works better when translated into different languages and produces more differentiation in responses.

Some commenters had comments in the About You Section, and the fact that it may lead patients to wonder why the agency is asking things they already know. Based on feedback through the National Quality Forum (NQF) process, we are taking the questions regarding age and gender out of the survey.

Several commenters felt that some of the survey questions were too subjective.

The survey was tested to get information from the patient’s perspective. A variety of stakeholders offered their input: consumers, home health agencies, advocate organizations, therapists, research institutions, government agencies, hospital and physician organizations, and home health national organizations.

Some commenters felt that the survey may confuse patients. The survey was developed for an approximately 7^th grade educational level. The survey was tested across multiple home health agencies and confusion did not pose problems.

Support for the Survey

A CEO of a provider offered support for the survey. His board believes the best opportunity to advance patient choice is complete and adequate disclosure. They feel a uniform or standard survey should be a beneficial tool for patients, families and reputable referral sources.