Outliers in Home Care June 2001 ■ 81 The prospective payment system (PPS), imposed on home health care in October 2000, is reshaping the dynamics of agency management. The PPS recal- ibrates the economic incentives for reimbursing home health agencies (HHAs) for the costs incurred in delivering care to Medicare patients—the majori- ty of patients served. Home health administrators responsible for the fiscal stability of their agencies now face problems of patient mix: that is, projecting some degree of profitability based on expected resource-utilization profiles for the group of patients comprising an agency’s caseload at a given point. Agency leaders soon will demand better information from nurse researchers linking patient characteris- tics at intake with resource-utilization profiles for an episode of care. Such data will be essential to pro- tecting the long-term fiscal viability of HHAs. Home care administrators and staff have long been interested in issues of efficiency in service delivery. Some evidence has been generated exam- ining resource utilization in home health care. 1,2 In the future, however, resource utilization can be expected to occupy center stage in the daily think- ing of administrators and researchers. Home care resource utilization is defined as the amount of nursing services used by a single client or group of clients during one episode of care or time period. 3 Various measures have been used to describe home care client resource use, including patient classification systems, demographic and medical status indicators, nursing dependency tools, nursing diagnoses, and agency characteris- tics. 1 Ideally, such information helps providers establish norms of care delivery so as to predict and allocate agency efforts appropriately. Resource utilization profiles provide a basis for estimating care costs and managing an agency’s budget. By default, better comprehension of the norms of such utilization elicits information about clients whose episodes of home care fall outside custom- ary patterns. Thus, the underlying, unstated pur- pose of much of this work in home care resource utilization is to identify and characterize clients who are considered “outliers”—clients whose care consumes services substantially above the norm. 1 Identifying characteristics of such clients is critical for HHAs, particularly since the inception of the PPS. Outliers are those patients for whom an agency has assumed economic responsibility but whose care substantially exceeds the period allowed by their reimbursement status. Outliers drain an agency’s budgetary resources. Most of the current literature concerning the PPS in home care reflects an industry adapting to the radical change from fee-for-service to prospec- tive payment. Articles tend to address mechanistic facets of the new process, such as advice on imple- menting OASIS, legal and ethical dilemmas, and speculation about what the PPS will mean for the organizational climate and culture of home care. Missing, however, is evidence anticipating the prob- lems posed by outliers to agency reimbursement and sufficient evidence about resource utilization to develop profiles for predicting outliers. A recent search of standard computerized data- bases, including CINAHL, MEDLINE, and HEALTH- STAR, a health administrative database, revealed lit- tle research on outliers in home health care. In fact, using the descriptors home health care and outliers yielded 0 citations. This fact is particularly trou- bling as implementation of the PPS proceeds in the home care sector.We suspect this lack of research needs rapid remedy. What is known about outliers in home health care must be extrapolated from the abundant hospi- tal-focused literature on the topic, literature con- cerned with adverse outcomes (eg, hospital read- mission), 4,5 previous but limited resource utiliza- tion studies, and intuition of home care clinicians. With the inception of the PPS in 1983 in hospitals Mary Ann Anderson, PhD, RN, is an associate professor at the University of Illinois at Chicago College of Nursing on the Quad Cities Regional Campus in Moline, Ill. Lelia B. Helms, PhD, JD, is a professor in planning, policy, and leadership studies at the University of Iowa College of Education in Iowa City. Address for correspondence: Anita W. Finkelman, MSN, RN, Section Editor, 3350 Principio Ave., Cincinnati, OH 45208; resources 4excellence@fuse.net Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146- 3318; phone (314) 453- 4350; reprint no. 69/1/116264 doi:10.1067/mhc.2001.116264 Mary Ann Anderson, PhD, RN, and Lelia B. Helms, PhD, JD Leadership Forum