- Email: [email protected]
Outcomes-based home health care improves results for patients with CHF
his article describes the results of a case study by Interim Healthcare to assess the effectiveness of its InterPath@ care management system. The study focused on home care patients with congestive heart failure (CHF) and demonstrated the effectiveness of using an integrated process of critical pathways, outcome measures, and concurrent outcomes monitoring to improve and lower care costs.
Age Mix
Gender
Mix
Female (53%) Male (47%)
results Market
Payer
Representation
Mix
Hartford, Corm. (39%)
InterPath@ is an integrated system for care management in home health care implemented throughout Interim’s network during the past 2 years. This care management system involves critical pathways, predefined outcome goals and measures, standard documentation, teaching materials, and a results-reporting database. The purpose of our study was to evaluate the impact of this system on the care of our home health care patients with CHF on the basis of outcomes, satisfaction, use, and costs.
PLE C~ARACTERi§TlCS The study sample included 146 discharged, intermittent care patients with a home care diagnosis of CHF (ICD9 Code 428) who were managed under the new cardiac medical plan of care from admission through discharge
JUNE 1997, VOL. 2 NO. 3
Hawaii (25%) Greenville, NC (14%) Cleveland, Ohlo (14%) El Paso, Texas (4%)
n n
Sacramento, Calif. (3%) San Francisco (1%)
between May 1995 and December 1996. Patients were drawn from Interim offices in eight geographic markets. Most patients in this sample received intermittent care for an acute exacerbation of their chronic condition rather than intermittent care over a long period. Such patients were slightly younger, included a higher proportion of men, and had a shorter length of stay than the more typical populations available to benchmark. We drew two samples, one quarter apart. Figure 1 illustrates age, gender, market, and payer specifics of the aggregate study sample.
ENCH
S
To gain insight and understanding, we compared results achieved with the new cardiac medical critical pathway with results achieved before its implementation. Field offices participating in the study reported on CHF discharges during 1994-95. We also compared results against three external benchmarks. l
A 1996 report on Medicare home health use by the U.S. General Accounting Office’ based on 199293 Medicare data served as our Medicare benchmark.
HOME
CARE PROVIDER
143
ASCA 1994 1995 claim data from Milliman & Robertson (M&R) served as our national market benchmark. M&R provided 11,624 claims for home health patients with CHF with use, age, gender, and payer data.
l
100 -
The 415 commercial claims from managed care and managed indemnity benefit plans within the M&R data set served as a commercial benchmark for our study.
99% 92%
80 -
z l
96% 97%
m
% espisode goals met
=
% visit outcomes
60 -
$40 it a 20 -
met
I
0
Normal
Transfer Inpatient
Death
We defined a set of data elements, including demographics, visits, skill mix, length of stay, disposition, and costs and cross-referenced these with _I-- ,,,A,.,,A ..-TIo+.
PATIENT
SURVEY
An independent research firm conducted brief telephone interviews of patients to solicit their feedback. As evidenced in standards of the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance and in common experience, patients’ satisfaction with their care, their understanding of their disease, their confidence in their ability to continue the self-care routines they had been taught, and their expectations about their ongoing health stability all correlate positively with actual health outcomes. A strong performance on these measures would give us an important indicator of the effectiveness of this outcomes-based care management system in achieving high levels of stability and independence among patients and would support documented levels of achievement of episode goals and visit outcomes.
OUTCOMES Patients who completed the full plan of care (60%) achieved 96% of their episode outcome goals and 97% of their visit outcome objectives. As expected, achievement of episode
144
HOME
CARE PROVIDER
0.06
-
0.03
-
0.02
-
0.01
-
5.9%
2.7%
0.00 Disease process
Medications
Activity
PsychoSocial
outcome goals by patients whose care was interrupted by transfer to an inpatient setting or death was much lower, as seen in Figure 2. On a visit-by-visit basis, however, all patients demonstrated high outcome achievement throughout the duration of their care. When patients failed to achieve outcomes, the explanations most frequently cited by the nurse case manager were related to the patient’s physical ability, understanding of disease process, and medication compliance. It is critical for case managers to track outcomes met, unmet, and why throughout the course of care to quickly recognize deviations and intervene early to make adjustments in the plan of care when outcomes fail to meet expectations. Figure 3 underscores unmet outcomes on the basis of critical path-
2.6%
Self monitoring
2.5%
2.4%
Safety
2.0%
Treatments Nut-Hyd Interelimination disciplinary
way component and highlights sons for medication failures.
rea-
Disposition at discharge was normal/ goals complete for 59.6% of patients. Another 9.6% died, 10.9% were transferred to an inpatient facility (hospital or skilled nursing facility) as might be expected with this diagnostic category, and 6.9% withdrew from care. The remaining 13% were coded “other” at discharge. Anecdotal information suggests this code often was used to indicate discharge based on conformance with a payer’s authorized plan of care. Unplanned hospitalization mid-episode was reported for 20 patients (13.7%). Although we know of no comparative norms for unplanned hospitalization of patients receiving home health care
JUNE 1997, VOL. 2 NO.3
ASCA
100r 80
-
E al 2
60
-
2
40
-
43.4 32.1 25.1
”
InterPath
IP Low LOS
IP Med. LOS
for CHF, the Center for Health Policy and Services Research3 reports that an average of 2 i .2% of all home care patients experience acute hospitalization between their start of care and 2 months or discharge, whichever comes first, The hospitalization rate for this chronically ill population appeared low, lending support for the effectiveness of the cardiac medical plan in maintaining stability of patients with CHF and avoiding acute episodes. This statistic is difficult to interpret, however, lacking information on hospital admissions of study group patients after discharge from home care.
IP High LOS
l
l
l
l
PRInterPath
8 1% believed er emergency a result
PIP LOW LOS
PIP Med. LOS
PIP Hiah LOS
they would have fewand hospital visits as
74% knew how to weigh themselves and when to report changes to their doctor 85% understood their medications, when to take them, and which side effects to look for understood their diet requirements and how to reduce salt and fat intake
96%
USE PATIENT SATISFACTION AND CONFIDENCE Study patients were highly satisfied with overall services, quality of care, and quality of health care staff. They also demonstrated high confidence, had a positive outlook about their health status, and were knowledgeable in areas essential to maintaining their health stability. In contrast to the depression, dependence, noncompliance, and resulting health deterioration
The impact of the new care management system on Interim’s use management practices during the past 2 years is evident in the comparison of total visits in Figure 4. Widespread change in behavior, assumptions, and expectations is occurring throughout home care. Two examples are: l
that have been reported among elderly patients with chronic diseases,’ study group patients reported the following: l l
85% were confident they could carry out the self-care routines taught them
JUNE 1997, VOL.
2
NO.
3
Nurse care managers and clinical supervisors at the front line are redefining “medical necessity” and “optimal care” in accordance with current standards of practice. Business managers are accepting greater accountability for use management and are systematically reducing visit volume proactively,
Nat’1 Market
Nat’1 Comm’l
Medlcare All
Medlcare Prop.
even while cost-based reimbursement incentives prevail. After a detailed segment analysis and examination of acuity payer, and age factors, we see the effects on optimal care when use rates are reduced systematically. Viewed against the national benchmarks, visit count for the total study population was significantly lower-53% below the national market average, 45% below the national commercial market, and 42% below the General Accounting Office proprietary HHAs. By our estimate, approximately 35% to 40% of this difference can be attributed to sampling differences, such as the strong influence of the older patient profile and the larger number of long-term care patients included in the HCFA and M&R data compared with the study group sample. Extensive data analysis leads us to believe approximately 30% of the difference in total visit count may be attributed to our new care management practices. Compared with the national benchmarks, study group patients received 72% more skilled nursing than the national market average and 28% more than the national commercial average. The skill mix in these two national benchmark populations more closely
HOME
CARE PROVIDER
145
ASCA
$8000 $7000 3047
$6000
$5531
$5000 $4038
$4000 $3000 $2000 $1000
-
!m InterPath
IP Low LOS
IP Med. LOS
PIP Law
IP High
PIP Med.
PIP High
InterPath
Nat’1 Market
Medicare All
Nat’1 Comm’l
Medicare Prop.
matched what we saw in our agencies before our introduction of new care management practices, consistent with sample characteristics in each case. 50
COSTS Average episode cost was significantly lower than all national benchmarks. At the time of this study, episode cost appeared to be only 39% of the national market average and 44% of the national commercial average, as seen in Figure 5. These results are strongly influenced by the sample characteristics in each case. Our analysis and projections indicate a 30% episode cost difference would be more accurate. These projections will be verified over time as the database matures,
PROPORTION OF FAT~ENTS IN EACH LENGTH OF STAY SUBGROUP Proportionately, distinct differences exist between the study group and our previous experience. Note the inverse relationship in Figure 6. Shifts over time also add to our understanding of use and cost changes, Contrary to expectations, the number of patients in the long length of stay (LOS) segment did not increase, whereas the medium LOS segment increased 14~6, and the short LOS segment decreased 9% over the quarter.
146
HOME
CARE PROVIDER
40 E
30
8 2
20 10 n” IP Low
LOS
IP Med. LOS
IP High LOS
AGE Age mix across these segments seems to support this observation, In this study we saw 47% more fragile elders older than age 80 in the low LOS segment of the study group than in our previous experience. Conversely, before the new care management system was introduced, the largest number of fragile elders was in the high LOS group (58%), with LOS significantly exceeding 60 days,
ACM As indicated by the percentage of patients who died or had to be transferred to a skilled nursing facility or hospital, the high acuity study patients
PIP
Low LOS
PIP Med.
LOS
PIP High LOS
appeared equally in the low and high LOS segments. This distribution differs markedly from previous experience, in which most high acuity patients had high LOS.
RELATlON§HlP TO OUTCOMES
OF SKILL MIX
The use of skilled nursing in end-stage disease was significantly higher for patients who died (76%) and for those transferred to an inpatient facility (65%) than for patients successfully completing the plan of care (48%). Importantly, we saw significantly higher use of aides (38%) and other professionals (I 3%) with patients who completed 100% of the outcome
JUNE 1997, VOL. 2 NO.3
ASCA
goals. Other professionals included physical, occupational, speech, and respiratory therapists; medical social workers; and nutritionists. This aspect deserves further study because many commercial payers limit coverage of aides, therapists, and medical social workers, although for elderly, chronically ill people with significant activities of daily living/instrumental activities of daily living deficits, supportive care is integral to maintaining optimum health and functional status.
rom a payer mix perspective, the percentage of commercial cases in the overall population is nearly the same “before” and “after” implementation of the critical pathway. Commercial payers were represented equally in all study group segments. Previously, however, we saw the strong influence of payer mix on use rates: 30% of the low LOS patients had commercial payers (five times more than the study group), and the high LOS segment was almost entirely on Medicare. SI Allowing for the acute care sample characteristics, the study demonstrates strong results and the effectiveness of home care managed in accordance with an outcomes-based critical pathway system of care. Given this elderly, chronically ill patient population, study patients demonstrated the following:
JUNE 1997, VOL. 2 NO. 3
l
High
outcomes
achievement
l
Fewer visits than all benchmarks
l
Lower
l
High
l
High confidence
costs than all benchmarks patient
avoid expensive hospital visits and keep patients stable and more independent for longer periods and at high levels of satisfaction, confidence, and positive outlook.
satisfaction I. GAO/HEHS-96-
and positive outlook
We have seen significant behavior change across our own network and acceptance of accountability for managing care and use of new standards. Experience demonstrates an outcomesbased care management system ensures provider accountability and stimulates innovation in disease management by: l
Managing
l
Focusing on the patient and outcomes
l
Documenting
l
Driving
16. Medicare:
continuous
care
improvement
The systematic use of detailed critical pathways that define care processes and limit unnecessary variation, explicit outcome goals and measures, and concurrent monitoring of outcome achievement improves results and lowers cost of care. These encouraging results offer promise of more costeffective CHF management. In our experience, outcomes-based home health care can help patients with CHF
health
Gail A. Currie, MS, is president of The Critical Edge, Inc., a consulting firm assisting health care organizations since I990 in health systems integration, competitive positioning, and
care
and measuring
home
utilization [report]. March 1996. 2. Milliman & Robertson, Actuaries & Consultants, I30 I Fifth Avenue, Suite 3800, Seattle,WA 98 IO I-2605. 3.The Center for Health Policy and Services Research. Measuring outcomes of home health care [hnal report]. September 1994; I :4-6. 4.Task Force for Compliance. Noncompliance with medications: an economic tragedy with important implications for health care reform [report]. April 1994.
strategic development. Lynn Brofman, RN, MSN, is vice president of clinical operations for Interim Healthcare, a national home health care company based in Ft. Lauderdale, Florida. Aditya N. Saharia, PhD, is an assistant professor of management information systems at the College of Business Administration and the director of the Center for Research in Information Management
at the
University
of Illinois
at Chicago. Reprint orders: Mosby-Year Book, Inc., I 1830 Westline industrial Drive, St. Louis, MO 63 l4633 18; phone (3 14) 453-4350; reprint no.
691 II8 I a29
HOME
CARE PROVIDER
147
Age Mix
Gender
Mix
Female (53%) Male (47%)
results Market
Payer
Representation
Mix
Hartford, Corm. (39%)
InterPath@ is an integrated system for care management in home health care implemented throughout Interim’s network during the past 2 years. This care management system involves critical pathways, predefined outcome goals and measures, standard documentation, teaching materials, and a results-reporting database. The purpose of our study was to evaluate the impact of this system on the care of our home health care patients with CHF on the basis of outcomes, satisfaction, use, and costs.
PLE C~ARACTERi§TlCS The study sample included 146 discharged, intermittent care patients with a home care diagnosis of CHF (ICD9 Code 428) who were managed under the new cardiac medical plan of care from admission through discharge
JUNE 1997, VOL. 2 NO. 3
Hawaii (25%) Greenville, NC (14%) Cleveland, Ohlo (14%) El Paso, Texas (4%)
n n
Sacramento, Calif. (3%) San Francisco (1%)
between May 1995 and December 1996. Patients were drawn from Interim offices in eight geographic markets. Most patients in this sample received intermittent care for an acute exacerbation of their chronic condition rather than intermittent care over a long period. Such patients were slightly younger, included a higher proportion of men, and had a shorter length of stay than the more typical populations available to benchmark. We drew two samples, one quarter apart. Figure 1 illustrates age, gender, market, and payer specifics of the aggregate study sample.
ENCH
S
To gain insight and understanding, we compared results achieved with the new cardiac medical critical pathway with results achieved before its implementation. Field offices participating in the study reported on CHF discharges during 1994-95. We also compared results against three external benchmarks. l
A 1996 report on Medicare home health use by the U.S. General Accounting Office’ based on 199293 Medicare data served as our Medicare benchmark.
HOME
CARE PROVIDER
143
ASCA 1994 1995 claim data from Milliman & Robertson (M&R) served as our national market benchmark. M&R provided 11,624 claims for home health patients with CHF with use, age, gender, and payer data.
l
100 -
The 415 commercial claims from managed care and managed indemnity benefit plans within the M&R data set served as a commercial benchmark for our study.
99% 92%
80 -
z l
96% 97%
m
% espisode goals met
=
% visit outcomes
60 -
$40 it a 20 -
met
I
0
Normal
Transfer Inpatient
Death
We defined a set of data elements, including demographics, visits, skill mix, length of stay, disposition, and costs and cross-referenced these with _I-- ,,,A,.,,A ..-TIo+.
PATIENT
SURVEY
An independent research firm conducted brief telephone interviews of patients to solicit their feedback. As evidenced in standards of the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance and in common experience, patients’ satisfaction with their care, their understanding of their disease, their confidence in their ability to continue the self-care routines they had been taught, and their expectations about their ongoing health stability all correlate positively with actual health outcomes. A strong performance on these measures would give us an important indicator of the effectiveness of this outcomes-based care management system in achieving high levels of stability and independence among patients and would support documented levels of achievement of episode goals and visit outcomes.
OUTCOMES Patients who completed the full plan of care (60%) achieved 96% of their episode outcome goals and 97% of their visit outcome objectives. As expected, achievement of episode
144
HOME
CARE PROVIDER
0.06
-
0.03
-
0.02
-
0.01
-
5.9%
2.7%
0.00 Disease process
Medications
Activity
PsychoSocial
outcome goals by patients whose care was interrupted by transfer to an inpatient setting or death was much lower, as seen in Figure 2. On a visit-by-visit basis, however, all patients demonstrated high outcome achievement throughout the duration of their care. When patients failed to achieve outcomes, the explanations most frequently cited by the nurse case manager were related to the patient’s physical ability, understanding of disease process, and medication compliance. It is critical for case managers to track outcomes met, unmet, and why throughout the course of care to quickly recognize deviations and intervene early to make adjustments in the plan of care when outcomes fail to meet expectations. Figure 3 underscores unmet outcomes on the basis of critical path-
2.6%
Self monitoring
2.5%
2.4%
Safety
2.0%
Treatments Nut-Hyd Interelimination disciplinary
way component and highlights sons for medication failures.
rea-
Disposition at discharge was normal/ goals complete for 59.6% of patients. Another 9.6% died, 10.9% were transferred to an inpatient facility (hospital or skilled nursing facility) as might be expected with this diagnostic category, and 6.9% withdrew from care. The remaining 13% were coded “other” at discharge. Anecdotal information suggests this code often was used to indicate discharge based on conformance with a payer’s authorized plan of care. Unplanned hospitalization mid-episode was reported for 20 patients (13.7%). Although we know of no comparative norms for unplanned hospitalization of patients receiving home health care
JUNE 1997, VOL. 2 NO.3
ASCA
100r 80
-
E al 2
60
-
2
40
-
43.4 32.1 25.1
”
InterPath
IP Low LOS
IP Med. LOS
for CHF, the Center for Health Policy and Services Research3 reports that an average of 2 i .2% of all home care patients experience acute hospitalization between their start of care and 2 months or discharge, whichever comes first, The hospitalization rate for this chronically ill population appeared low, lending support for the effectiveness of the cardiac medical plan in maintaining stability of patients with CHF and avoiding acute episodes. This statistic is difficult to interpret, however, lacking information on hospital admissions of study group patients after discharge from home care.
IP High LOS
l
l
l
l
PRInterPath
8 1% believed er emergency a result
PIP LOW LOS
PIP Med. LOS
PIP Hiah LOS
they would have fewand hospital visits as
74% knew how to weigh themselves and when to report changes to their doctor 85% understood their medications, when to take them, and which side effects to look for understood their diet requirements and how to reduce salt and fat intake
96%
USE PATIENT SATISFACTION AND CONFIDENCE Study patients were highly satisfied with overall services, quality of care, and quality of health care staff. They also demonstrated high confidence, had a positive outlook about their health status, and were knowledgeable in areas essential to maintaining their health stability. In contrast to the depression, dependence, noncompliance, and resulting health deterioration
The impact of the new care management system on Interim’s use management practices during the past 2 years is evident in the comparison of total visits in Figure 4. Widespread change in behavior, assumptions, and expectations is occurring throughout home care. Two examples are: l
that have been reported among elderly patients with chronic diseases,’ study group patients reported the following: l l
85% were confident they could carry out the self-care routines taught them
JUNE 1997, VOL.
2
NO.
3
Nurse care managers and clinical supervisors at the front line are redefining “medical necessity” and “optimal care” in accordance with current standards of practice. Business managers are accepting greater accountability for use management and are systematically reducing visit volume proactively,
Nat’1 Market
Nat’1 Comm’l
Medlcare All
Medlcare Prop.
even while cost-based reimbursement incentives prevail. After a detailed segment analysis and examination of acuity payer, and age factors, we see the effects on optimal care when use rates are reduced systematically. Viewed against the national benchmarks, visit count for the total study population was significantly lower-53% below the national market average, 45% below the national commercial market, and 42% below the General Accounting Office proprietary HHAs. By our estimate, approximately 35% to 40% of this difference can be attributed to sampling differences, such as the strong influence of the older patient profile and the larger number of long-term care patients included in the HCFA and M&R data compared with the study group sample. Extensive data analysis leads us to believe approximately 30% of the difference in total visit count may be attributed to our new care management practices. Compared with the national benchmarks, study group patients received 72% more skilled nursing than the national market average and 28% more than the national commercial average. The skill mix in these two national benchmark populations more closely
HOME
CARE PROVIDER
145
ASCA
$8000 $7000 3047
$6000
$5531
$5000 $4038
$4000 $3000 $2000 $1000
-
!m InterPath
IP Low LOS
IP Med. LOS
PIP Law
IP High
PIP Med.
PIP High
InterPath
Nat’1 Market
Medicare All
Nat’1 Comm’l
Medicare Prop.
matched what we saw in our agencies before our introduction of new care management practices, consistent with sample characteristics in each case. 50
COSTS Average episode cost was significantly lower than all national benchmarks. At the time of this study, episode cost appeared to be only 39% of the national market average and 44% of the national commercial average, as seen in Figure 5. These results are strongly influenced by the sample characteristics in each case. Our analysis and projections indicate a 30% episode cost difference would be more accurate. These projections will be verified over time as the database matures,
PROPORTION OF FAT~ENTS IN EACH LENGTH OF STAY SUBGROUP Proportionately, distinct differences exist between the study group and our previous experience. Note the inverse relationship in Figure 6. Shifts over time also add to our understanding of use and cost changes, Contrary to expectations, the number of patients in the long length of stay (LOS) segment did not increase, whereas the medium LOS segment increased 14~6, and the short LOS segment decreased 9% over the quarter.
146
HOME
CARE PROVIDER
40 E
30
8 2
20 10 n” IP Low
LOS
IP Med. LOS
IP High LOS
AGE Age mix across these segments seems to support this observation, In this study we saw 47% more fragile elders older than age 80 in the low LOS segment of the study group than in our previous experience. Conversely, before the new care management system was introduced, the largest number of fragile elders was in the high LOS group (58%), with LOS significantly exceeding 60 days,
ACM As indicated by the percentage of patients who died or had to be transferred to a skilled nursing facility or hospital, the high acuity study patients
PIP
Low LOS
PIP Med.
LOS
PIP High LOS
appeared equally in the low and high LOS segments. This distribution differs markedly from previous experience, in which most high acuity patients had high LOS.
RELATlON§HlP TO OUTCOMES
OF SKILL MIX
The use of skilled nursing in end-stage disease was significantly higher for patients who died (76%) and for those transferred to an inpatient facility (65%) than for patients successfully completing the plan of care (48%). Importantly, we saw significantly higher use of aides (38%) and other professionals (I 3%) with patients who completed 100% of the outcome
JUNE 1997, VOL. 2 NO.3
ASCA
goals. Other professionals included physical, occupational, speech, and respiratory therapists; medical social workers; and nutritionists. This aspect deserves further study because many commercial payers limit coverage of aides, therapists, and medical social workers, although for elderly, chronically ill people with significant activities of daily living/instrumental activities of daily living deficits, supportive care is integral to maintaining optimum health and functional status.
rom a payer mix perspective, the percentage of commercial cases in the overall population is nearly the same “before” and “after” implementation of the critical pathway. Commercial payers were represented equally in all study group segments. Previously, however, we saw the strong influence of payer mix on use rates: 30% of the low LOS patients had commercial payers (five times more than the study group), and the high LOS segment was almost entirely on Medicare. SI Allowing for the acute care sample characteristics, the study demonstrates strong results and the effectiveness of home care managed in accordance with an outcomes-based critical pathway system of care. Given this elderly, chronically ill patient population, study patients demonstrated the following:
JUNE 1997, VOL. 2 NO. 3
l
High
outcomes
achievement
l
Fewer visits than all benchmarks
l
Lower
l
High
l
High confidence
costs than all benchmarks patient
avoid expensive hospital visits and keep patients stable and more independent for longer periods and at high levels of satisfaction, confidence, and positive outlook.
satisfaction I. GAO/HEHS-96-
and positive outlook
We have seen significant behavior change across our own network and acceptance of accountability for managing care and use of new standards. Experience demonstrates an outcomesbased care management system ensures provider accountability and stimulates innovation in disease management by: l
Managing
l
Focusing on the patient and outcomes
l
Documenting
l
Driving
16. Medicare:
continuous
care
improvement
The systematic use of detailed critical pathways that define care processes and limit unnecessary variation, explicit outcome goals and measures, and concurrent monitoring of outcome achievement improves results and lowers cost of care. These encouraging results offer promise of more costeffective CHF management. In our experience, outcomes-based home health care can help patients with CHF
health
Gail A. Currie, MS, is president of The Critical Edge, Inc., a consulting firm assisting health care organizations since I990 in health systems integration, competitive positioning, and
care
and measuring
home
utilization [report]. March 1996. 2. Milliman & Robertson, Actuaries & Consultants, I30 I Fifth Avenue, Suite 3800, Seattle,WA 98 IO I-2605. 3.The Center for Health Policy and Services Research. Measuring outcomes of home health care [hnal report]. September 1994; I :4-6. 4.Task Force for Compliance. Noncompliance with medications: an economic tragedy with important implications for health care reform [report]. April 1994.
strategic development. Lynn Brofman, RN, MSN, is vice president of clinical operations for Interim Healthcare, a national home health care company based in Ft. Lauderdale, Florida. Aditya N. Saharia, PhD, is an assistant professor of management information systems at the College of Business Administration and the director of the Center for Research in Information Management
at the
University
of Illinois
at Chicago. Reprint orders: Mosby-Year Book, Inc., I 1830 Westline industrial Drive, St. Louis, MO 63 l4633 18; phone (3 14) 453-4350; reprint no.
691 II8 I a29
HOME
CARE PROVIDER
147