What makes a difference in the outcomes of QI participation

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What makes a difference in the outcomes of QI
participation?

• Shoshanna Sofaer, Dr.P.H.
• School of Public Affairs
• Baruch College

2
Overview

• Purpose of the research
• Methods
• Preliminary findings

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Purpose of the research

• Identify factors that may make a difference in
  the results of participation of home health
  agencies (HHAs) in quality improvement
• Specifically, look at variations across HHAs that
  participated in Wave 2 of the ReACH project

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Purpose of the research

• Identify the elements of the ReACH approach which
  appear to have made a difference in achieving
  changes in re-hospitalization rates at the local
  level

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Methods

• The ReACH project had extensive data on key
  outcome and process measures for all HHAs,
  including changes over time in the
• ACH rate for their entire population
• ACH rate for their target population
• Rates of performing risk assessments on patients
• Rates of front-loading visits for high risk
  patients

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Methods

• We ordered the agencies by performance on the two
  major outcomes for purposes of sampling
• Operating in the context of OMB constraints, our
  strategy was to purposively select nine agencies
  to interview
• Five high performers
• Four low performers

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Methods

• We varied agencies in each performance group by
  size, ownership and region
• We interviewed key staff at QIOs in the states
  where HHAs were located who participated at all
  in Wave 2 of ReACH prior to interviews with HHA
  staff

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Methods

• We conducted semi-structured, open ended
  interviews with the person in either the QIO or
  the HHA who was most directly involved in the
  project
• We have completed all QIO interviews and 7 of 9
  HHA interviews
• We present here a preliminary analysis of these
  interviews, focusing on some but not all issues
  of interest

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Preliminary Findings

• Who chose to participate and why?
• From the QIO perspective, a major driver was that
  the re-hospitalization rate was a metric they
  were required to move by CMS
• This led them to focus recruitment on agencies
  with high rates and to some extent larger
  agencies
• But many also wanted to influence as many HHAs as
  possible if they thought they could and would
  improve a few just asked everyone

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Preliminary Findings

• Who chose to participate and why?
• From the HHA perspective, decision-makers wanted
  to lower their rate, get access to high level
  expertise, tools individual support, education
  and opportunities to network with peers in their
  own state and beyond
• High performers often already had a strong
  orientation to improvement, at least within the
  leadership and/or those more directly involved
  with ReACH
• Some in both groups were already trying to lower
  rates

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Preliminary Findings

• Does size matter?
• By design, we chose a range of sizes in both
  groups
• But the issue of small size was more likely to be
  cited by both QIOs and HHAs as a reason for
  difficulties
• Being recruited
• Staying in the program
• Being able to change the outcome rates

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Preliminary Findings

• Does size matter?
• Larger HHAs much more likely to have staff
  assigned to and with experience in quality
  measurement and improvement
• Small agencies much more vulnerable to losing
  staff or dealing with staff turnover/shortages
• Small agencies also seem to have more difficulty
  raising issues of re-hospitalization with MDs

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Preliminary Findings

• Does ownership matter?
• The hospital-affiliated or hospital-owned
  agencies were clearly sensitive to the hospitals
  desire to admit patients and also discharge them
  as soon as they could
• But it does not appear that hospital ownership
  was an insuperable barrier to making progress in
  agencies with strong leadership commitment to the
  project

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Preliminary Findings

• Does patient mix matter?
• Apparently yes small agencies with a high
  proportion of long-term patients believe that
  readmissions are random and inevitable
• They dont believe a discharge based ACH rate
  is appropriate as a measure

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Preliminary findings

• Does process matter?
• Many agencies who didnt move their ACH rate did
  make enormous progress in instituting key
  processes
• This raises two issues
• Is one year enough time?
• Are we looking at the right processes (e.g. is
  the problem somewhere other than the HHA?)

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Preliminary findings

• Does leadership support matter?
• Almost all those we interviewed felt supported
  by leadership several QIOs noted that those
  without leadership support were more likely to
  drop out agencies with high level leadership
  involvement appeared to make this whole process a
  higher priority
• But followership may be just as important!

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Next steps

• Finish interviews
• Conduct a site visit
• Complete analysis
• Disseminate final findings