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Home Health Quality Initiatives


There are over 9000 Medicare certified home health agencies throughout the United States. In 2006, over 3 million beneficiaries were served, and 103,931,188 visits made. As baby boomers age, the need for patient centered, cost effective care will be a priority to CMS. 78 million baby boomers are about to begin turning 65.

Home health is covered under the Part A Medicare benefit. It consists of part-time, medically necessary skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) that is ordered by a physician. If patients are eligible for skilled services, they can also receive part-time assistance with personal care needs by a home health aide. Patients are required to be "homebound" as a condition of eligibility for these services. Home health care services are delivered at home to patients who are recovering from care in hospitals or nursing homes; patients who are disabled; the frail elderly; and chronically or terminally ill persons in need of medical, nursing, or therapeutic treatment as well as assistance with the essential activities of daily living. As in all areas of health care, the quality of care provided is of concern to consumers, purchasers, providers and others.

In 2000, as part of a broad quality improvement initiative, the federal government began requiring that every Medicare-certified home health agency complete and submit health assessment information for their clients. The instrument/data collection tool used to collect and report performance data by home health agencies is called the Outcome and Assessment Information Set (OASIS). Since fall 2003, CMS has posted on www.medicare.gov a subset of OASIS-based quality performance information showing how well home health agencies assist their patients in regaining or maintaining their ability to function. Measures of how well people can get along in their homes performing activities of daily living (ADLs) form a core of the measures, but these are supplemented with questions about physical status and use-of-service measures (hospitalization and emergent care).

In 2004-05, a private non-profit organization, the National Quality Forum (NQF), convened technical experts representing varying perspectives to review quality measures for home health care. Following a long review and consensus development process, the group endorsed measures for use in public reporting. The initial ten measures CMS included in Home Health Compare (as of September 2005) reflect those recommendations.

The 2005 measures (all collected via the OASIS data set) are:

  • Improvement in Ambulation/Locomotion
  • Improvement in Bathing
  • Improvement in Transferring
  • Improvement in Management of Oral Medication
  • Improvement in Pain Interring with Activity
  • Acute Care Hospitalization
  • Emergent Care
  • Discharge to Community
  • Improvement in Dyspnea (Shortness of Breath)
  • Improvement in Urinary Incontinence

NQF had previously endorsed additional measures and two of those related to wounds were added to Home Health Compare in December of 2007. Several more previously endorsed measures may be added in 2009.

Another part of the HHS/CMS quality initiative includes Quality Improvement Organizations (QIOs). QIOs exist in each state and are private organizations that contract with CMS to help improve the quality of care provided to Medicare patients. In addition to assisting beneficiaries with complaints about the quality of care they receive, physicians and other health care experts work with home health agencies to encourage the adoption, use, and monitoring of best practices and quality measures. These best practice measures will assist agencies in adapting to process measures in testing for future OASIS revisions.

While the current home health assessment and reporting tool, OASIS, will remain in use in the foreseeable future, several new priorities have emerged and are expected to be part of planning for the future: 

  • Pay for Performance - tying a portion of reimbursement to delivery of care that has been proven to be effective - this is currently in demo and based on HH Compare measures.
  • Integration of measures of process and systems

OASIS C - A balanced set of measures

  • Home Health Agencies have adapted well to outcomes, which is important. There are 3 types of measures most commonly used in quality work.
  • Structure - Physical equipment and facilities such as using EHR.
  • Process - How the system works - performing what is known to be clinically relevant and evidence based.
  • Outcome - The final product, results - stabilization, decline or improvement.
  • Electronic Health Record (EHR) - ASPE will begin to work with AHIMA and Reigenstreif to LOINC enable the OASIS C version as a step toward interoperability standards.
  • Standardizing assessment/quality measurement across (post-acute) health care settings. The PAC demo has begun in 2008 and will result in a report to Congress in 2011 on the potential to use a single instrument to measure patient care and costs longitudinally. In the interim, OASIS, MDS and CARE will determine like elements that can be described and measured the same way.
  • Global Harmonization of Measures across settings will be a National Quality Forum priority beginning with flu and Pneumonia Immunizations.

It is too early to know exactly how these changing priorities may impact the entire health care system. Planning/discussions are in a preliminary phase. Pay for performance logically will link to Value and Efficiency and actual activities and efforts of providers - using evidence-based practices and systems (in the form of process measures that will be collected at the agency level) - to promote use of such practices. Providers, consumers, and interested parties, such as the many organizations that represent and work with patients in post-acute, home, community, and long-term care settings will be part of these efforts as they evolve As we look to become stewards of the Medicare trusts funds and meet the domains of the Institute of Medicine for Safe, Effective, Patient Centered, Efficient. Timely, and Equitable care; those that are quality and mission driven while maintaining some efficiencies will become increasingly important in transforming the healthcare system.

Overview [PDF 120 KB]

Role of QIOs & SSAs [PDF 95 KB]
Related Links Inside CMS


Home Health Compare
Related Links Outside CMS
External Linking Policy
OBQI Training

Medicare Quality Improvement Community

Agency for Healthcare Research & Quality

American Association of Home Care

National Association for Home Care and Hospice

National Association State Units on Aging

National Quality Guidelines

National Pressure Ulcer Advisory Panel

Visiting Nurse Association of America

Wound Ostomy Continence Nurses Society


Page Last Modified: 05/01/2008 2:00:00 PM
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