Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement.

OBJECTIVES: To evaluate effects on patient outcomes of Outcome-Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC). DESIGN: A quasi-experimental design with prospective pre/post and study/control components within two multiyear demonstration trials (occurring from 1995 to 2000) in which 73 home health agencies implemented OBQI, receiving several annual cycles of outcome reports to evaluate and enhance patient outcomes. SETTING: New York and 27 other states. PARTICIPANTS: The study involved 157,548 predominantly older adult patients admitted over 3 years to 54 OBQI agencies from 27 states in the National Demonstration Trial, 105,917 patients admitted over 4 years to 19 OBQI agencies in the New York State Trial, and 248,621 patients admitted over 3 years to non-OBQI control agencies in the 27 demonstration states. INTERVENTION: As a clinical management and administrative intervention, OBQI involves collecting, encoding, and transmitting patient-level health status data to a central source that provides each OBQI agency with a risk-adjusted outcome report comparing the agency's patient outcomes with those from a reference population and with its own outcomes from the prior period. Target outcomes are selected and focused plans of action implemented to change care behaviors. Outcome changes are evaluated through the next report cycle. MEASUREMENTS: Outcome measures include hospitalization rates and improvement and stabilization outcome rates in functional, physiological, emotional/behavioral, and cognitive health. RESULTS: For the National and New York State Demonstration Trials, the risk-adjusted relative rates of decline in hospitalization of 22% and 26%, respectively, for OBQI patients over the 3-year and 4-year demonstration periods were significant (P <.001) and unparalleled by considerably smaller rates of decline for the non-OBQI patients in the 27 states. The risk-adjusted rates of improvement in OBQI target outcome measures of health status averaged 5% to 7% per year in both demonstration trials and were significantly greater (P <.05) than analogous improvement rates for nontarget comparison outcomes, which averaged about 1% per year. CONCLUSION: It is feasible to integrate the programmatic, data collection, data transmission, and outcome enhancement components of OBQI into the day-to-day operations of home health agencies. The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients. OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare settings.