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Outcomes in Home Care:
The Shaughnessy Study

By Alice Swan, MS, RN

In a competitive managed care environment both home care agencies and payors are interested in monitoring the cost and effectiveness of care. Monitoring the cost and effectiveness of care is facilitated when outcome data is standardized and easily retrieved.

Because Medicare funds a considerable amount of home care, the Health Care Financing Administration (HCFA) has supported research aimed at developing outcome-based measures of quality home care services. The final report of a major study funded by HCFA and the Robert Wood Johnson Foundation (RWJ) has been released recently. This study, entitled "Measuring Outcomes of Home Health Care," was conducted by Shaughnessy et al at the Center for Health Policy Research and Center for Health Services Research in Colorado. HCFA is planning demonstration projects which will further refine outcome measures from this report. As these outcome measures are refined, they will provide both an opportunity for collection of standardized data and a way for Medicare to benchmark agencies against each other and the industry as a whole. Eventually these outcome measures will be utilized in the Medicare certification process. Given these expected changes, it is important that agencies begin to examine existing resources which will help to provide the data needed in the future. One resource which exists is the CareFacts™ program, designed with the Omaha Classification System.

Shaughnessy's report delineates three types of outcomes: functional status, health status, and resource utilization. Functional status outcomes compare a client's level of functional disability between two time points. In the CareFacts program, as each client is admitted, the functional status for each Activity of Daily Living (ADL) and Instrumental Activity of Daily Living (IADL) category is assessed and rated as: Independent, Needs Supervision, Needs Assistance, or Dependent. On discharge, if appropriate, the client is again assigned a rating for each ADL and IADL category. Reports then can be generated which summarize whether there was improvement, stabilization or decline in functional status for a particular client or group of clients.

The second outcome category Shaughnessy recommends is health status. This outcome category is defined as a client's status on a broad range of physiological, mental and behavioral conditions. For example with acute cardiac and peripheral vascular conditions, an assessment of symptoms such as dyspnea, weight, and activity level would be expected. Within the CareFacts program, these symptoms would be assessed within the Omaha Problems (Diagnoses). According to the Omaha System, if signs and symptoms of a problem are present (such as edema under Circulation or cyanosis under Respiration) the nurse completes three ratings on a scale from 1 - 5: knowledge, behavior and status. At each visit and on discharge, these are rated again. Based on these ratings the CareFacts program allows an agency to generate reports at various times to monitor if clients have improved, stabilized, or declined since admission.

The third outcome designated by Shaughnessy is resource utilization. Resource utilization describes the services used by a client during a study interval and the reason for discharge from home care. For example, discharge status includes if a client is hospitalized, admitted to a nursing home, or needed to be seen in the clinic or physician's office. Again, the CareFacts program delineates various reasons for discharge from service. From time to time reports could be generated which would summarize frequency of various resources utilized by clients in home care.
In summary, as a result of Shaughnessy et al.'s study, HCFA will be incorporating standardized terminology to measure quality. Outcomes reporting based on these standards are expected to be included in the Medicare survey process of the future. The CareFacts program collects and analyses outcome data in part to assist providers in meeting these future Medicare reporting requirements.

Citation: Swan, A. (1994). Outcomes in Home Care: The Shaughnessy Study. The Quality Messenger, 1(3), 1, 4, 8.

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