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Patient Satisfaction Doesn’t Equate to Quality at Home Health Agencies

Meeting a client’s needs and expectations is critical for any business, including healthcare. Yet, in an era of reform, it’s not enough to merely satisfy patients; providers must offer better clinical outcomes. To further that goal, CMS launched its healthcare comparison programs to rate hospitals, physicians, and other key players in the healthcare arena. Observers have noticed, though, that patient satisfaction and outcomes do not always correlate and even conflict in some cases. Based on Definitive Healthcare data and the latest updates to CMS’ Home Health Agency (HHA) Compare program, it’s clear that patient satisfaction has little basis on quality of care, at least by CMS standards.

Eligible HHAs can receive separate star ratings for clinical outcomes and patient satisfaction. Not every HHA has enough patients or submits enough data to receive a rating, and currently only about 5,700 and 9,200 HHAs have been assigned clinical and patient satisfaction scores, respectively. Clinical quality ratings are given in half-star increments and are based upon three process-of-care metrics involving procedures and nine measurements of clinical outcomes. The table below summarizes the clinical quality indicators as sorted by HHA patient experience ratings, with the exception of improvement in surgical wounds, which very few HHAs reported.

HHAs by Patient Experience Rating, Median Selected Measures, 2016

★ (151) ★★ (674) ★★★ (1,602) ★★★★ (2,365) ★★★★★ (952)
Average Quality Star Rating  3.09 3.17 3.34 3.38 3.41
Patients or Family Taught About Administered Drugs  96% 95% 96% 96% 97%
Flu Shot Administered  74% 71% 74% 75% 74%
Care Began in Timely Matter  93% 92% 92% 94% 95%
Admissions  15% 15% 16% 16% 16%
Hospital ER Use W/O Admission  12% 12% 12% 13% 13%
Breathing Improved  67% 66% 68% 67% 64%
Better Moving Around  60% 60% 62% 63% 64%
Less Pain Moving Around  68% 67% 67% 66% 65%
Better at Bathing  65% 66% 68% 68% 68%
Better at Taking Oral Medication  49% 51% 52% 52% 52%
Better at Getting In and Out of Bed  58% 56% 59% 59% 58%

Source: Definitive Healthcare

As shown in the table, many of the scores do not vary significantly between one- and five-star rated HHAs. There is a slight correlation in outcomes and patient experience in terms of quality star rating and improvements in moving around, but the rest of the values are fairly even or show no obvious relationship to satisfaction.

The findings beg the question of why patient experience rankings seem so unrelated to quality, especially when so many of CMS’s outcome-based scores describe real improvements in condition that patients would readily notice. One of the most likely explanations is that most of the HHCAHPS questions ask patients to assess caregiver interaction and communication, rather than care quality. As shown by the above data, surveyed HHAs had very little variation in process scores, such as how often home care personnel talked to patients or families about medications or if HHAs provided services in a timely matter. Only one of the survey questions, a rating of the HHA on the scale of 1 to 10, could possibly reflect a patient’s satisfaction with overall quality of care. Interestingly, CMS has also stated that when patients were asked if they’d recommend an HHA to family or friends, their response very often mirrored the findings of the standard HHCAHPS, even though the question would seem to include their opinion on clinical care quality.

Another possibility is that the patients may be less likely to assess HHAs in the same way as CMS. The agency bases its scores on condition improvement, rather than stabilization, and while it makes adjustments due to inherent risk factors and health, a patient in his late 80’s, for instance, probably won’t be able to self-determine if a lack of improvement in some areas is due to inadequate care or simple aging. The nature of home health care also requires caregivers to be more conscious of patient experience. Home health providers are aware of their presence in patients’ homes as guests, and the overall process demands a more personal relationship than would be necessary in a typical hospital or outpatient setting.

Even though most HHAs’ patient experience scores don’t correspond to clinical quality, it would be incorrect to conclude that the rating is insignificant. The high number of four- and five-star ratings attests to excellent patient service of HHAs as a whole, rather than a failure of the data to properly discriminate between them. The public reporting also provides a strong incentive for agencies to maintain high ratings, given that so many competitors are performing equally well. So long as patients understand what the rating measures and how it works, it will continue to be a useful indicator.

Definitive Healthcare has the most up-to-date, comprehensive and integrated data on over 7,700 hospitals, 1.4 million physicians, and numerous other healthcare providers. It includes an extensive database of information on skilled-nursing facilities, hospice, and home health agencies.

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