What makes a difference in the outcomes of QI participation?

1. 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 AHRQ ANNUAL MEETING

3. 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 AHRQ ANNUAL MEETING

4. 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 AHRQ ANNUAL MEETING

5. 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 AHRQ ANNUAL MEETING

6. 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 AHRQ ANNUAL MEETING

7. 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 AHRQ ANNUAL MEETING

8. 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 AHRQ ANNUAL MEETING

9. 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 AHRQ ANNUAL MEETING

10. 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 AHRQ ANNUAL MEETING

11. 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 AHRQ ANNUAL MEETING

12. 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 AHRQ ANNUAL MEETING

13. Preliminary Findings • Does ownership matter? • The hospital-affiliated or hospital-owned agencies were clearly sensitive to the hospital’s 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 AHRQ ANNUAL MEETING

14. 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 don’t believe a “discharge based” ACH rate is appropriate as a measure AHRQ ANNUAL MEETING

15. Preliminary findings • Does process matter? • Many agencies who didn’t 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?) AHRQ ANNUAL MEETING

16. 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! AHRQ ANNUAL MEETING

17. Next steps • Finish interviews • Conduct a site visit • Complete analysis • Disseminate “final” findings AHRQ ANNUAL MEETING