TIP OF THE WEEK
Risk Adjustment Models Provide a Roadmap
By: Elizabeth Madigan PhD, RN, FAAN, Associate Professor in the School of Nursing, Case Western Reserve University
The risk adjustment models available for seven of the 12 publicly reported quality measures are an additional resource for home health agencies (HHAs) to use to provide direction for the HHAs’ investigations into ways to improve their outcome measures.
RISK ADJUSTMENT REPORTS
The intent of risk adjustment is to provide a level playing field so that comparisons take into account important factors that can influence outcomes. For example in home healthcare, improvement and stabilization in functional activities may be affected by numerous factors including pre-existing conditions, age, the presence of a caregiver, cognitive functioning and others. Risk adjustment models, then, look at the outcome taking into account the factors (OASIS items in this case) that were expected to affect the outcome.
The risk adjustment models for seven of the current publicly reported OBQI outcome measures have been released by the Centers for Medicare & Medicaid Services (CMS). The reports include several features that will allow agencies to drill down into factors associated with the outcomes--the odds ratios.
ODDS RATIOS
Within each risk adjustment model, odds ratios are reported for each OASIS item. Odds ratios are values that indicate the likelihood of the outcome occurring given the OASIS predictor and taking into account all the other predictors for that outcome.
For example, for the outcome improvement in ambulation, one of the OASIS indicators is having a good rehabilitation prognosis with an odds ratio of 1.41. Thus, having a good functional status rehabilitation prognosis on admission means that a patient is 1.4 times as likely to improve in ambulation than someone with a fair or poor prognosis taking into account all the other OASIS predictors. Another way to say this is that a patient with a good rehabilitation prognosis is 41 percent more likely to improve in ambulation than a patient with a fair or poor rehabilitation prognosis.
Odds ratios of 1.0 are even odds--odds ratios close to 1.0 are close to even odds; thus an odds ratio of 1.03 means that a patient is 3 percent more likely to improve. For those odds ratios less than 1.0, the interpretation is based on 1 minus the odds ratio. Using the same outcome, improvement in ambulation, and examining the effect of having a stasis ulcer present with an odds ratio of .77 means that a patient with a stasis ulcer is 23 percent (1 minus .77) less likely to improve in ambulation than a patient without stasis ulcers, taking into account the other factors.
DRILLING DOWN
Using the odds ratios, agencies can identify which OASIS items are most associated with seven of the 12 publicly reported outcomes. One common question is where to set the thresholds--one approach is to use a 25 percent rule of thumb where odds ratios for OASIS indicators less than .75 and more than 1.25 are used to identify the most influential factors.
Using the same example for improvement in ambulation and the 25 percent threshold, the following items would be identified as influential in this outcome:
| Odds Ratios | |
| Inpatient patient discharge from hospital | 1.28 |
| Urinary catheter prior to past two weeks | .74 |
| Good functional status rehab. prognosis | 1.41 |
| Disability in transferring | .57 |
| Disability in ambulation | 5.96 |
| Disability in transportation | .73 |
| Prior disability in ambulation | .56 |
These items would give agencies some indication of the kinds of patients who are more likely to achieve this outcome--those who have been discharged from the hospital with a good functional status prognosis and who had a greater impairment in ambulation (they had more room to improve). The factors associated with less likelihood of improvement are those with a urinary catheter in the past two weeks, who have more problems in transferring and transportation and had more problems with ambulation prior to the current episode.
Over the next seven weeks, the Home Health Tip of the Week will identify for each of the additional seven current publicly reported quality measures the important factors in the risk adjustment models that can influence outcomes. In addition, case mix and system factors will be identified that can impact agency outcomes.
RESOURCE SPOTLIGHT
Patient Safety Cards
This set of cards can be used to train staff, caregivers, and patients on the basics of home safety. The cards describe common hazards around the patient's home and ways to make them safer. The message about safety is specific and clear. The cards have different color headings to differentiate focus: Blue -- throughout the house; Green -- out and about; orange -- staying fit.
IN THE NEWS
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OHIO KEPRO EVENTS
OBQI TRAINING
The Outcomes-Based Quality Improvement (OBQI) Process is a systematic, data-driven method of investigating patient health outcomes and developing improvement strategies that are tailored to suit your agency’s unique population.
Join us for a refresher course in your area. We are offering two courses:
- 9:00 to 12:00 -- OBQI Basics
- 1:00 to 4:00 -- Beyond the Basics
Date | Location |
| May 15 | Summa Home Health at St. Thomas Hospital, Akron |
| May 20 | Mount Carmel Home Health, Columbus |
| May 22 | St. Rita’s Hospital Home Care Aux. Conference Center, Lima |
| May 28 | Kettering Network Home Health, Miamisburg, Ohio |
| June 4 | Union Hospital Auditorium, Dover |
COMING ATTRACTIONS
Ohio Home Care Organization – Upcoming Education
- May 12 – Palmetto GBA Updates for Hospice and Home Care
- May 13-14 – Home Health Spring Conference
Ohio Council for Home Care – Upcoming Education
- May 13-15 – Breaking the Code – Competency in Diagnostic Coding
Health Policy Institute of Ohio: Regional Meetings on the Ohio Family Violence Prevention Project
The Tip of the Week Archive is available on the Ohio KePRO Web Site.
Clinically driven. Client focused. Value based.