Form CMS-10688 Home Health Agency Qualitative Interview Guide

Home Health Agency Qualitative
Interview Guide
Organization Name:
Respondent Name:
Respondent Position:
Interviewer Name:
Interview Date:

INTRODUCTION AND PURPOSE OF THE INTERVIEW
Thank you for agreeing to participate. I’d like to briefly review the purpose
of this interview and the confidentiality provisions that were described in the
email we sent you.
→ We are conducting interviews with home health agencies on behalf
of the Centers for Medicare & Medicaid Services (CMS).
→ CMS implements a variety of performance measures in the home
health setting to assess the quality and efficiency of care provided to
Medicare beneficiaries. CMS reports home health agency
performance scores on its Home Health Compare website (i.e., Star
Ratings).
→ The purpose of today’s interview is to learn about your agency’s
experiences in reporting and working to improve performance on
the CMS measures and your efforts to improve the quality and
efficiency of care at your home health agency.
→ As I ask you questions today, I would like you to be thinking
specifically about the CMS performance measures and actions
your agency has taken in response to those measures.
→ Before getting started, I just want to confirm that you are familiar
with the CMS measures. [YES/NO] We sent you a list of current
measures, which we will refer to later in the interview, did you
receive those? [YES/NO; If NO: Please forward measures to R
before starting interview]
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this collection of information is 0938-[PLACEHOLDER FOR
NEW NUMBER]. The time required to complete this information collection is estimated
to average 60 minutes per response, including the time to review instructions, search

existing data resources, gather the data needed, and conduct the interview. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CONSENT/CONFIDENTIALITY PROVISIONS
[INTERVIEWER: You must read the consent language and obtain
verbal consent both for participation and for audio recording]
→ All of your responses are confidential to the extent permitted by law.
→ No one outside of the project will have direct access to the information
you provide. The evaluation team will only produce summary information
from the set of interviews. You will not be identified by name or home
health agency affiliation.
→ You do not have to participate in the interview. You can stop at any
time for any reason. Your decision regarding whether to participate
will not affect your agency’s Medicare reimbursement or quality
scores.
→ You can decline to discuss any topic that we raise.
Do you have any questions? (YES/NO)
Do you agree to participate in the interview? (YES/NO)
As we mentioned in our email, we would like to audio-record the interview if
that is all right with you. This is to help with note-taking after the interview is
done, and we will not share the recording with CMS. Do you agree to have
this interview be audio-recorded? (YES/NO)
[If yes:] Great. Let’s get started. I’ll start the recording, there might be a
momentary pause while it gets going.
[For the interviewer: Press *2 to start recording, note it may take a few
moments.] [If no:] That’s fine. We will take notes and not tape the
discussion. Let’s get started.
[Note to interviewer: [POTENTIAL ITEM TO SKIP] indicates a question that may
be skipped if the interviewer estimates that there will not be sufficient time to
complete all questions.]
I’d like to start by asking you to very briefly describe your position and
background, as well as answer a few background questions about your agency.

Respondent Background
1. We understand that you are the [position] at [home health agency]. Is
that correct?
(YES/NO)
2. Briefly, what is your professional background? [how long in clinical role?
How long in current role?]
3. Have you or any member of your home health agency staff quality team
received formal training/certification on quality improvement strategies
(LEAN, Six Sigma, etc.)?
[If Yes: indicate strategy and
certification:______________________________]

Home Health Agency Characteristics and Organizational
Structure
I would now like to discuss your organization’s structure.
4. Is your home health agency freestanding or is it affiliated with (or owned
by) a larger entity? (YES/NO) Examples of larger entities might include a
chain of agencies, a hospital, or an integrated delivery system. 1
a. [If necessary:] Is your agency owned by or affiliated with this [larger
entity]?”
5. Does your home health agency have a quality improvement
department or specific quality improvement personnel?
(YES/NO/DON’T KNOW)
b. [If yes:] To whom does the Director of Quality (or similar position)
report?
6. [If part of a larger entity or corporation (answered “No” to being a
freestanding agency on Question 4)]: You indicated earlier that your
home health agency is affiliated with a larger entity or corporation.
An IDS is an integrated network of healthcare providers and organizations such as nursing homes,
primary and specialty care, hospitals, rehabilitation centers, home health care agencies, and hospice
services that provides or arranges to provide a coordinated continuum of services to a defined
population.

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Does the larger corporation have a quality improvement department
or specific quality improvement personnel? (YES/NO/DON’T KNOW)
7. Does your agency have an electronic health record (EHR) 2? (YES/NO)
[If yes:] Can you tell me whether your EHR has any of the following features or
functions?
EHR Features/Functions

Does EHR Have?
(Yes/No/Don’t Know)

Ability to electronically exchange information with
providers in community (e.g., receiving orders and
feedback from hospitals or sending care
summaries to ambulatory physicians)
Clinical decision support functions
(If yes: for what clinical areas or functions?)
Ability to automatically report OASIS data for CMS
quality measures
Documenting or monitoring patient status, even if
not related to quality measures (prompts: changes in
patient functioning, summary results)
[If “don’t know” for the above:] Is there someone we can speak with in
your organization who might be able to answer some of these
questions about your EHR?
[if no:] Does your agency use a point-of-care electronic documentation
system to collect data for OASIS, such as using software based on
mobile devices to document and upload data to third party vendors or
CMS?
How has implementation of EHRs helped/hindered your agency with
regard to quality measurement and quality improvement (QI) activities?
(Prompts: better care coordination with other providers, reduced staff
burden, better data collection and analysis, identification of QI
activities, decreased /increased costs, etc.)

Quality Improvement (QI) Changes to Improve Care Delivery and
An electronic health record (EHR) is an electronic version of a patient's medical history that is
maintained by the provider over time, and may include all of the key clinical data relevant to that person's
care under a particular provider, including demographics, progress notes, problems, medications, vital
signs, past medical history, immunizations, laboratory data and radiology reports.
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Patient Outcomes
[OPTIONAL, CAN SKIP INTRO IF R HAS GOOD FAMILIARITY] As we
discussed at the outset, CMS measures the performance of home health
agencies, using measures of quality and resource use. These measures are
publicly reported on Home Health Compare and are used in the Home Health
Quality Reporting Program; they are also tied to financial incentives and
payments as part of the Home Health Value-Based Purchasing Model. The next
few questions will be specifically about the CMS measures.
8. In your experience, have the CMS quality measures led your
agency to change how it delivers care? (YES/NO)
a. [If yes:] Please describe the changes your home health agency has
made in response to CMS quality measures.
i. [If needed (mention no improvement strategies or only mention
improving documentation), prompts include using standardized
checklists, clinician training, telehealth strategies, data
exchange or coordination with hospitals and other providers,
financial incentives to clinical staff, education on how to teach
patient self-management strategies, collaboration with quality
improvement organizations]
b. [If no:] Why do you believe that CMS quality measurement of
your Home Health Agency’s performance have not led to
changes in care delivery at your agency? [If needed, prompts
include improvement not needed, lack of resources, quality
initiative fatigue].
9. Do you think any of the changes your home health agency has
made have affected your agency’s performance specifically on the
CMS performance measures? (YES/NO)
a. [If yes:] Please describe which of the changes have had the
largest impact on your performance.
10. Can you describe any changes your frontline clinical staff have
initiated themselves at the point of care, versus agency-wide
changes, that have affected your performance on the CMS
measures?
11. Does your home health agency provide nurses, physical
therapists, and other clinical staff with information about your

agency’s performance on the CMS measures? (YES/NO/DON’T
KNOW)
a. [If yes:] How often do nurses and clinicians receive feedback on
their performance on the measures?
12. Have the changes your home health agency has made in response to
the CMS measures led to improvements in quality of care outside of the
clinical areas that the CMS measures cover (i.e., spillover effects)?
[Example, if needed: For example, adopting an EHR system including
reminders for flu vaccines that you were also able to use for an area not
subject to measurement (reminders regarding IV catheter care).]
(YES/NO) [If yes: Please describe.]
a. [If yes:] What measures has your home health agency used to
track improvements in other areas?
13. [POTENTIAL ITEM TO SKIP:] Has your home health agency used any
of the following care redesign methods to improve performance? 3
(YES/NO) Examples include Deming/Lean processes (constantly
improve the system of production and service to improve quality and
decrease cost), Six Sigma (measurement-based strategy/data-driven
approach for eliminating defects; focuses on process improvement and
variation reduction), Plan, Do, Study, Act (PDSA) improvement cycles
14. Have you received assistance in improving care delivery, either
directly from CMS or from a Quality Improvement Organization
(QIO)?
a. [If yes:} Was assistance from CMS or QIOs helpful in improving
performance?
[If no to 5a:] Why was it not helpful?
15. [If better documentation not mentioned as cause of better
performance in previous answers:] In addition to improving care,
have you tried to improve documentation of care or other patient
information to improve performance scores on the CMS quality
measures?

Some organizations use specific methodologies or frameworks to guide and ensure consistency in
improvement activities throughout the organization. Examples include the Model for Improvement or
Plan, Do, Study, Act (PDSA); Cycle or Deming Cycle; Lean Improvement adapted from the Toyota
Production System; Six Sigma DMAIC (which stands for define, measure, analyze, improve, control); and
the Seven-Step Method Problem-Solving Model. Other organizations have not adopted a specific
improvement methodology.
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a. [If yes:] About how much of your agency’s improvement would
you attribute to improved documentation as opposed to
improved patient care?

Factors Associated with Change in Quality Performance
For the next couple of questions, I am going to ask you to focus on specific
measures. Can you please look at the list of measures we sent you?
[Note to interviewer: If respondent does not have the list, please direct him/her
to the reminder email. If respondent is not able to find it, please forward it.]
16. For the CMS performance measures where your home health agency
is performing well [interviewer to have home health agency performance
list ready, can provide examples if needed], what factors do you think
help your agency perform highly? [If needed, examples include overall
resources, data systems, the organization’s culture, internal incentives,
leadership engagement, frontline staff engagement, investments in care
redesign.]
17. For those measures where your home health agency’s performance is
lagging [interviewer to have home health agency performance list
ready, can provide examples if needed], what factors do you believe
inhibit higher performance?
a. [If needed, examples include overall resources, data systems, lack
of timely data from CMS, lack of data from other providers, the
organization’s culture, insufficient internal incentives, lack of
leadership or frontline staff engagement, few investments in care
redesign.]
b. [If respondent describes areas in which performance has been
lagging:] Has your home health agency experienced difficulties
getting nurses, and other clinical staff to change their behavior
related to any of the CMS measured areas of performance?
(YES/NO)
i. [If yes,]Please describe which areas. [Possible probes: Why
do you think it was difficult to achieve changes in behavior?
Did your home health agency work to address these
barriers, and if so, how?]

c. [If respondent describes areas in which performance has been
lagging:] How much of your agency’s lagging performance would
you attribute to inadequate documentation by staff? [Examples, if
necessary: inconsistent documentation of improvement, undercoding of comorbidities]
18. From your perspective, is it harder to improve scores on some CMS
measures than others? [YES/NO] [Follow-up, if not answered as part
of the response: Which measures, and why?]
19. Thinking about the full list of CMS measures we are discussing, do
you think these CMS measures are clinically important? (YES/NO)
Why or why not?
20. Do you think home health agencies have sufficient control over care to
be held responsible for performance on these measures? (YES/NO)
[If no:]
a. Whom do you think should be responsible?
21. CMS is interested in understanding how it could streamline the set of
measures used in quality measurement programs to reduce provider
burden. Based on your experience to date using CMS home health
agency measures:
a. Which measures are of lower value to collect – i.e., lower clinical
utility given the effort to collect the data?
i. [Interviewer: If any are noted to be low-value, ask respondents
as to why they think that. Potential prompts if needed: Topped
out; minimal patient benefit]
b. Should any clinical areas that are not subject to measurement be
addressed in future quality measures?
i. [Interviewer: If any areas mentioned, ask respondents as to why
they think these clinical areas would benefit from additional
measures]
Many external factors may influence your home health agency to invest in
improving performance on the CMS measures. Examples of external factors
include: public reporting of quality scores (including the Star Rating), financial
incentives or penalties (including those expected/incurred due to the Home
Health VBP model), receipt of feedback reports with quality results, regulatory
compliance and survey visits, and pressure from external organizations that
make referrals.

22. What do you see as the most important factors guiding your home
health agency’s investments for improving performance on the CMS
quality measures at your agency? [Interviewer: repeat above list as a
prompt if needed.] What are the most important external factors that are
influencing investments by your home health agency to improve on the
CMS quality measures?
a. Have you noticed hospitals or other providers in your area changing
their home health agency referral patterns in response to CMS quality
measures? [Example: if needed: for example, the readmissions
measure makes hospitals financially responsible for patients who are
readmitted within 30 days of discharge. It may be that hospitals
change their referral patterns to home health agencies with better
readmission scores to avoid financial penalties for excess
readmissions.]
23. Have other factors besides CMS measurement and reporting programs
led your home health agency to make changes in care delivery?
(YES/NO) [Follow-up if needed: Please describe the initiatives and the
changes you have made in response. Examples: regulations from state
government or commercial insurance]

Challenges to Reporting CMS Measures
I’d like to talk about what you see as challenges to reporting the
data/measures to CMS.
24. Have you experienced difficulties in reporting the CMS measures?
(YES/NO/DON’T KNOW) [If needed, prompts include challenges with
CMS reporting tools, difficulty capturing or extracting the data,
difficulty uploading OASIS data, insufficient resources, confusing
measure specifications, or measure specifications changing each
year.]
a. [If yes:] Please describe the difficulties and whether and how you
addressed them.

Effects of Performance Measurement Programs
Some providers and other stakeholders have expressed concern that CMS
measurement programs might lead to negative, or undesirable, unintended
consequences. CMS is interested in learning about possible unintended
consequences related to measurement, so that measurement and reporting
programs can be modified to minimize these effects.

[Note to interviewer: Be sure to state the following:] All of the responses you
provide are confidential. Your candid feedback will be especially
important in helping CMS improve these programs so that they work well
for providers and patients.
25. Are you aware of any unintended consequences in your home health
agency that stem from the CMS measures and the use of the
measures in public reporting and payment/value-based purchasing
efforts? (YES/NO/DON’T KNOW)
a. [If yes:] Please describe these undesired effects.
ii. Why do you think these unintended consequences have
occurred?
iii. What do you think could be done to mitigate those unintended
consequences?
[If no, if respondent is vague on specific undesired effects, or if the
unintended consequences are different from those described below]
Possible Unintended Consequence
Inappropriate changes in treatment
(example if needed: For example,
“Improvement in Pain
Interfering with Activity” measure
might lead to overuse of scheduled
narcotics to ensure metric is met)
Significant effort on data coding
to increase reimbursement
(example if needed: documenting
more comorbidities, under-coding
baseline function or over-coding
post-treatment function)
Avoid sicker or more difficult patients
to achieve higher scores on measures
Ignore or pay less attention to areas
of care that are not measured

Yes/No

Specific Measure
Examples?

Perspectives of Different Stakeholders and Leaders
We’re interested in how different leaders and groups within your home health
agency have viewed and approached CMS quality measures and related public
reporting and payment programs.
26. [POTENTIAL ITEM TO SKIP] On a scale of 0 to 10, with 0 being
extremely unsupportive and 10 being extremely supportive, how would
you characterize the following groups’ support of the CMS measurement
programs:
[Interviewer to fill in table with ranking:]

Stakeholder Group
Executive management team (CEO, “C-suite”
leaders) at agency
Nursing/clinical leadership
Board of directors (if agency has one)
Clinical staff [SKIP if already noted as impediment]

Ranking from 0 to 10
-

27. [POTENTIAL ITEM TO SKIP] [If home health agency has a board of
directors:] Is performance on the CMS quality measures on the board
agenda at each board meeting? (YES/NO)

Additional Home Health Agency Market Characteristics
I’d like to take a few moments to ask a few additional questions about your
home health agency’s organizational structure.
28. [POTENTIAL ITEM TO SKIP] How many competitor home health
agencies exist within your agency’s service area? [Interviewer: This is
an estimate. If needed: Are there 0, 1, 2, 3, or more home health
agencies that are considered competitive?]
29. Do you face a shortage of nurses, physical therapists, or other
clinicians in your area that makes it difficult to staff your agency?
(YES/NO)
c. [If YES to “face a nursing shortage”:] Is the nursing shortage for a
particular type of nurse, for example, Registered Nurses, Licensed
Vocational Nurses, or Certified Nursing Assistants?
d. [If YES to “face a shortage of other clinicians”:] Are there shortages
of physical therapists, occupational therapists, dietitians, social
workers?

30. What source of insurance coverage do your patients hold, for
example, Medicare, Medicaid, commercial insurance, self-pay?
Can you provide approximate percentages? [Note: should total
~100%]
31. [POTENTIAL ITEM TO SKIP:] Does your home health agency
participate in any alternative payment models, for example,
accountable care organizations (ACOs) 4 or bundled payments?
(YES/NO/
DON’T KNOW)
[If yes:]
Alternative
payment
model type

Does agency Does agency have a risksharing arrangement?
participate?
(Yes/No/Don’t Know)
(Yes/No/
If yes: what is it
Don’t Know)
(upside only –
gainsharing, or
gainsharing and
downside financial risk)?

Do agency’s
referral
sources
participate?

Medicare
ACO
(SSP,
Pioneer,
Advanced
Payment
Model)
Medicaid ACO
Private
commercial
insurer ACO
(if yes, how
many different
ACOs?)
Bundled
payments
Global
payments
Accountable care organizations are networks of health care providers and organizations (usually
hospitals and physician groups, and possibly including nursing homes, home health, and hospice
organizations) that agree to take some financial responsibility for reducing the costs and improving the
quality of care of enrollees.

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32. Does your home health agency care for patients referred by nurse
practitioners?
[If yes:] Have you faced delays in adjusting medication or other
treatment plans due to current CMS requirements that nurse
practitioners obtain physician approval for any treatment changes for
home health patients?

Closing
Thank you very much for your time.