Home healthcare agencies have distributed the Home Health Care Consumer Assessment of Health Care Providers and Systems survey (HHCAHPS) for over 6 years. The survey is the home healthcare version of the tool originally developed by the Agency for Health Care Research and Quality to evaluate the quality of health plans from the enrollees' perspective. It is a well-researched, universal tool accepted as the current standard to understand the patient perspective of care.
For home healthcare, the survey is composed of three domains: professionalism, communication, and specific care issues defined as medication management, pain, and safety; and two global items; a rating of the overall quality of care and willingness to recommend the service to others. Survey results are available in multiple forms. Publicly, everyone can review patient responses by agency, state and nationally on the Medicare website (https://www.medicare.gov/homehealthcompare/search.html). On this site, results are displayed in two ways; as top box scores and as stars. These are two very different systems.
Top box scores are the percent of only the best responses to each question. All other responses are ignored. Essentially, a 90% score means that 90% of the people who answered the question gave the best possible rating. Star ratings use advanced statistics to incorporate all the responses and group similar agencies into 5-star levels. The stars are simple to comprehend and are easy to talk about. The goal is to earn 5 stars. However, the math to calculate the stars is not easy nor visible to users of the site. There is real confusion between top box scores and stars. At first glance, the website looks as though the stars are a symbol of the scores. But they are not. Users need to read further into the explanation of the website to understand these are different ways to summarize the same data. In addition to the public data, every agency uses a vendor to send and manage the survey data. The vendors provide a variety of reports to the agency, tracking and calculating the results in a variety of ways. The combination of these different ways to use the same data can be very complicated. It is very easy to get lost in trying to follow or align the various methods. This frustration increases the risk of ignoring all the results. This is a risk all clinicians need to avoid and stay focused on the patient.
These surveys are an important tool to understand how our patients experience our work. They are the only standard tool we can use across different patients, over time and across agencies. There are financial implications for the agency related to the scores. But clinicians: nurses, aides, therapists, social workers, everyone who enters the patient home, need to connect to these surveys personally. This is the voice of the people we care for. These data are about us. Am I professional? Am I communicating clearly? Am I helpful with pain, medications, or safety concerns?
Since 2012, national scores in all domains and the global questions have been steady (Table 1). For the last 6 years, only 84% of people receiving home healthcare rated the overall care as excellent (9 or 10 out of a 10-point scale). In other words, 16 of every 100 patients every year for 6 years say we could have done better. Why hasn't this improved? Leaving the agency motivations to improve scores aside, why are we as clinicians and professional caregivers not making improvements? What are the barriers delaying us from taking ownership of our practice? This is the voice of the people we serve. The questions are directly about the way we serve them.
There are numerous discussions about the value and meaning of the survey. There are many potential explanations for the stability of scores. Many are reasonable and accurate. Some people argue that the surveys are limited and don't provide a full understanding of the patient experience. They don't.The surveys are not everything we want to know about the patient experience. But the surveys are here. They are a valuable piece of information and offer a real chance to do better for the people relying on us. Six years of stability is too much.
Every clinician can look at the public website and examine their agency scores over time. Further, clinician can ask for the vendor reports in their agency. These reports are typically provided monthly with far more detail than on the website. Every clinician can challenge themselves to think about their own practice. "What can I learn?" "What can I change to better serve my patients?" (Box 1). These are difficult questions. They require each of us to be open to changing ourselves. But if we build on the 84% of patients who already think we are excellent, working to be excellent for all patients is a reasonable goal.
Self-awareness is challenging. When providing care, our focus is on the patient. Expanding our attention to include awareness of our body language, tone of voice, pace of speech, or eye contact is hard work. Adopting new ways to explain the same information about medications or safety issues takes planning and practice. But these are the types of adjustments we can make to improve the experience of the patient (Box 2).
HHCAHPS survey results are about us. There is a direct line between patient experience and the clinicians visiting their homes. Agencies can help to improve these results, but the real work is done by each individual clinician. We can support each other. We can provide encouragement, support, and reminders to help each other make change in ourselves once each of us commits to improve the experience of the patients we serve.