A qualitative study of choosing home health care after hospitalization: the unintended consequences of 'patient choice' requirements

Abstract

Background: Although hospitals are increasingly held accountable for patients' post-discharge outcomes, giving them incentive to help patients choose high-performing home health agencies, little is known about how quality reports inform decision making.

Objective: We aimed to learn how quality reports are used when choosing home care in one northeast state (Rhode Island) .

Design: The study consisted of focus groups with home health consumers and structured interviews with hospital case managers.

Participants: Thirteen consumers and 28 case managers from five hospitals participated in the study.

Approach: We identified key themes and illustrative quotes by audiotaping each session, and then three independent reviewers conducted repeated examination and content analysis.

Key results: No participants were aware of existing state or Medicare home health agency public reports. Case managers provided agency lists to consumers, who routinely asked case managers to tell them which agencies to choose or which were best; but case managers felt unable to directly respond to consumers' requests for help in making the choice, because they did not have additional information to provide and because they feared violating federal laws requiring freedom of patient choice. Case managers also felt that there was little difference in agency quality, although they acknowledged they might not be aware of problems related to post-hospital care.

Conclusions: Home health consumers and hospital case managers were unaware of public reports about home health quality, which limited consumers' ability to make informed decisions and case managers' ability to assist them in that decision-making process. Case managers were otherwise prohibited from recommending specific providers to patients and viewed the 'patient choice' laws as restricting their ability to respond to patients' requests for help in choosing home health agencies. Public reports can be marketed as tools that case managers can use to help patients differentiate among providers, while supporting patient autonomy.