OASIS in Home Health

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The following course content

​Introduction (5, 6) 

In today’s world, older adults want to live at home as long as possible, even when circumstances limit their autonomy, such as chronic illnesses or life-changing injuries. Home care has been and continues to rise in terms of clients residing in a familiar setting rather than receiving care for chronic health conditions or aging needs in an institutionalized setting.  

Home health care is a significant source of home-based skilled care and is often reimbursed by Medicare. Health care agencies help to treat and provide education on chronic conditions such as heart disease, diabetes, depression, and functional and cognitive impairments, which include activities of daily living (ADL) limitation, as well as Alzheimer’s and other dementia-related diseases. Home health care agencies help to facilitate early identification of clinical status change, promote functional improvement, reduce the risk of hospitalization and emergency department (ED) visits, and prolong independent stay at home. Compared to previous years, those living at home needing skilled care are, on average, older than 85, meaning most receive Medicare benefits; therefore, home care agencies need to be knowledgeable in OASIS to receive reimbursement, monitor performance, and modify their practices.  

Outcome and Assessment Information Set (OASIS) (1, 2, 3, 4) 

The Outcome and Assessment Information Set (OASIS) is a standardized client-specific instrument/data collection tool, also known as a comprehensive assessment tool, utilized in home care since 1999. Home health agencies (HHA) OASIS assessments to collect and report data on their clients. This standardized assessment tool was implemented to contain all essential items needed to measure a client’s service needs and quantify that need into a reimbursement level. A single tool also allows for monitoring performance and modifying practices as required. It utilizes around 100 items related to the client’s demographic information, clinical status, functional status, and services needed. OASIS collects and transmits data for all adult clients whose care is reimbursed by Medicare and Medicaid with the following exceptions: those under 18 receiving maternity services, personal care, homemaker, or chore services. OASIS data calculates quality reports, which help guide home health agencies’ quality and performance improvement efforts.  

It was implemented by the Centers for Medicare & Medicaid Services (CMS) and is required by Medicare-certified HHA to receive payment from CMS while measuring the quality of care. OASIS plays a crucial role in ensuring home health agencies: 

• Provide safer care by reducing the harm caused while care is delivered  
• Involve clients and families in care  
• Promote effective communication and coordination of care 
• Promote effective prevention and treatment of acute and chronic illnesses  
• Ensure communities are helping people live healthier 
• Making care affordable 

OASIS serves multiple purposes, including: 

• Assessing Client Needs: 
  • Captures critical client data related to functional abilities, clinical conditions, and social determinants of health. 
• Improving Quality of Care:  
  • Data collection contributes to home health agency performance metrics, influencing Medicare’s Home Health Star Ratings and Value-Based Purchasing (VBP) programs. 
• Determining Reimbursement:  
  • Impacts payment under the Patient-Driven Groupings Model (PDGM) by categorizing clients based on their clinical complexity and service needs. 
• Enhancing Care Coordination:  
  • Standardized assessment data tool allows interdisciplinary teams to develop personalized care plans and ensure continuity of care. 

OASIS is completed admission, discharge or death, resumption of care, recertification, transfer, follow-up, or during any change in health status for all Medicare and Medicaid, non-maternity, non-pediatric beneficiaries. Any home health care clinician can complete OASIS data collection, whether as a nurse (RN) or therapist (PT, OT, SLP/ST), via direct observation and interview of the client and/or caregiver. OASIS data affects both clinical outcomes and financial reimbursement. Therefore, home health clinicians need to complete assessments accurately and consistently. Errors or inconsistencies in documentation can lead to compliance issues, reduced reimbursement, and compromised client care. 

OASIS Structure and Data Elements/Sections (3, 4) 

OASIS was developed using outcome quality measures for home health agencies (HHA) and Medicare to improve the effectiveness of home health care continuously. Research developed a core group of data elements to measure uniformly and risk-adjusted outcome quality measures. Selected OASIS items were later identified for payment determination in the Prospective Payment System (PPS). In addition to OASIS’ primary purpose, it is commonly used for research, capturing a range of information, including sociodemographic status, social environment support (home environment and support systems), clinical status, and health service utilization. OASIS includes items in several different categories. These categories include: 

Administrative Information-Client Tracking  

This category includes key data elements to identify the client, track their episodes of care, and manage agency-level administrative details. These elements help to ensure proper documentation, compliance, and accurate billing. This information only needs to be revised if a client’s information changes during an episode of care. This category ensures home health agencies can track client care across episodes, maintain compliance with CMS regulations, and facilitate seamless transitions between care settings. Key components of this category include: 

• Client Identifiers  
• Referral and Start of Care (SOC) Information  
• Episode Tracking Information  
• Agency and Provider Information 
• Discharge and Transfer Details (if applicable) 

Hearing, Speech, and Vision  

The items in this category assess how literate the client is in healthcare, meaning the questions in this section are used to gather information on the client’s ability to obtain, process, and understand basic health information needed to make appropriate healthcare decisions. This category includes assessment items that evaluate a client’s ability to speak, hear, and see, which are crucial for communication, safety, and daily functioning. These elements help to determine a client’s care needs, risk factors, and necessary interventions for home health clients. Key components of this category include: 

• Hearing  
• Vision  
• Health Literacy  
  • Identifies the client’s self-reported health literacy 
  • Low health literacy interferes with communication between provider and client 
  • It can also affect the ability of clients to understand and follow treatment plans, including medication management 
  • Poor health literacy is linked to lower levels of knowledge of health, worse outcomes, the receipt of fewer preventive services, higher medical costs, and rates of emergency department use  

Cognitive Patterns  

This category assesses a client’s cognitive abilities, including memory, decision-making, and level of awareness. This section helps home health providers determine clients’ ability to follow instructions, manage daily activities, and identify potential safety risks. It is also used to determine a client’s attention, orientation, memory, hearing, possible language barriers, mental status changes, and ability to register and recall information. This section contains guidance for nine items that assess cognitive function, including the Brief Interview for Mental Status (BIMS) and Signs and Symptoms of Delirium from CAM©. It includes general guidance for basic BIMS interview instruction, cue cards for administering the BIMS in written format, and specific advice on the individual items. Key components of this category include: 

• Cognitive Functioning 
  • When confused 
  • When Anxious  

Mood  

This category contains items that address mood distress. It assesses a client’s psychological and physical distress, ability to participate in therapy and activities, and function status. It also looks at a client’s emotional and psychological well-being, focusing on signs of depression and behavioral symptoms that may affect their ability to participate in home health care and function independently. This category helps clinicians identify clients needing mental health interventions, counseling, or additional support. Mood disorders are common in home care and are often underdiagnosed and undertreated. Key components of this category include: 

• Client Mood Interview (PHQ-2 to 9) 
  • PHQ-2 to 9 Total Severity Score  
  • Used to track changes in severity over time 
  • 0-4: minimal depression 
  • 5-9: mild depression 
  • 10-14: moderate depression  
  • 15-19: moderately severe depression  
  • 20-27: severe depression  
• Social Isolation  

Behavior 

The items in this section help identify and describe the presence and frequency of behaviors associated with various disorders. This category assesses behaviors impacting their ability to receive and participate in home health care. This section helps providers identify clients needing additional supervision, caregiver support, or behavioral interventions to ensure safe and effective care. Key components of this category include: 

• Cognitive, Behavioral, and Psychiatric Symptoms  
  • Identifies specific behaviors associated with significant neurological, developmental, behavioral, or psychiatric disorders.  
  • Evaluates the presence and severity of behavioral symptoms that may interfere with daily activities or care delivery. 
• Frequency of Disruptive Behaviors Symptoms  

Preferences for Customary Routine Activities  

This section identifies the client’s living situation, including types, sources, and amounts of assistance needed for routine activities. This category assesses clients’ daily routines, activities, and social engagement preferences. This section helps home health providers develop a care plan that respects the client’s lifestyle, cultural values, and individual choices. It includes questions about preferences for routine activities. Key components of this category include: 

• Client Living Situation  
  • Types and sources of assistance  

Functional Status  

The items in this section address the client’s ability to perform personal care activities safely. The items identify the client’s ABILITY, not necessarily actual performance. “Willingness” and “adherence” are not the focus of these items. The client must be viewed holistically in assessing the ability to perform ADLs. Ability can be temporarily or permanently limited by: 

• Physical impairment  
• Emotional/cognitive/behavioral impairment  
• Sensory impairment  
• Key components of this category include: 
• Grooming  
• Current Ability to Dress Upper Body 
• Current Ability to Dress Lower Body 
• Bathing  
• Toilet Transferring 
• Toileting Hygiene 
• Transferring 
• Ambulation and Locomotion 

Functional Abilities and Goals  

This category assesses a client’s current ability to perform essential daily activities and sets measurable goals for improvement during their home health care episode. This section helps clinicians identify areas where the client requires assistance, determine safety risks, and develop personalized care plans to support functional recovery. Key components of this category include: 

• Prior Functioning: Everyday Activities  
• Prior Device Use  
  • Manual or motorized wheelchair  
  • Mechanical lift 
  • Walker 
  • Orthotics/prosthetics 
• Self-Care and Mobility  
  • Evaluate current ability and goal for improvement in: 
    • Oral hygiene 
    • Dressing the upper and lower body 
    • Toileting hygiene 
    • Washing the entire body 
    • Eating and swallowing safety 
  • Assesses current mobility status and sets goals for improvement in: 
    • Rolling in bed, sitting to lying, lying to sitting, transferring to/from bed or chair, walking 50+ feet, climbing steps 

Bladder and Bowel  

This category assesses a client’s ability to manage bowel and bladder function, including incontinence, urinary retention, and needing assistance or devices. This section helps home health providers determine the level of aid required, identify potential complications, and develop appropriate interventions for continence management. The items in this section assess bowel and bladder function to identify situations that could impact the client’s health status or care plan. Key components of this category include: 

• Has this client been treated for an Urinary Tract Infection in the past 14 days?   
• Urinary Incontinence or Urinary Catheter Presence 
• Bowel Incontinence Frequency 
• Ostomy for Bowel Elimination 

Active Diagnosis  

This section includes three items that identify active diagnoses and co-morbidities. This category helps to identify the client’s current medical conditions that impact their health, functional status, and home health care needs. This category helps healthcare providers develop a comprehensive care plan, determine the focus of interventions, and support accurate reimbursement under the Patient-Driven Groupings Model (PDGM). Key components of this category include: 

• Primary Diagnosis/Other Diagnosis  
  • Coded using ICD-10-CM diagnosis codes. 
  • Impacts PDGM payment classification and care planning. 
• Active Diagnoses-Comorbidities and Co-existing Conditions  

Health Conditions  

This section includes seven items to assess the risk for hospitalization, pain interfering with activities, frequency of falls, and shortness of breath. This category assesses a client’s current health status, focusing on symptoms, pain, and conditions that impact their ability to function and receive care at home. Key components of this category include: 

• Risk for Hospitalization 
• Pain Interview  
• Any Falls Since SOC/ROC 
• When is the client dyspneic or noticeably Short of Breath? 

Swallowing/Nutritional Status  

This section includes three items. Height and weight to calculate body mass, nutritional approaches, and assessment of the ability to eat, chew, and swallow food. This category assesses a client’s ability to swallow safely and maintain adequate nutrition. This section helps healthcare providers identify malnutrition, dehydration, aspiration, and choking risks, ensuring appropriate interventions are included in the care plan. Key components of this category include: 

• Height and Weight  
• Nutritional Approaches  
  • Identifies if the client uses any nutritional approaches 
    • Parenteral nutrition (TPN) 
    • Enteral nutrition (tube feeding) 
    • Intravenous (IV) infusion therapy 
• Feeding or Eating  

Skin Conditions 

This section includes items that assess the presence of pressure ulcers, stasis ulcers, and surgical wounds. This category considers the client’s skin integrity, identifying any wounds, pressure ulcers, surgical sites, or other skin issues that may require intervention. This section is essential for developing appropriate care plans, preventing complications, and ensuring proper wound management. Key components of this category include: 

• Unhealed Pressure Ulcer/Injury at Stage 2 or Higher 
• The Oldest Stage 2 Pressure Ulcer that is present at discharge 
• Current Number of Stage 1 Pressure Injuries  
• Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable  
• Does the client have a Stasis Ulcer? 
• Current Number of Stasis Ulcer(s) that are Observable  
• Status of Most Problematic Stasis Ulcer that is Observable  
• Does the client have a Surgical Wound? 
• Status of Most Problematic Surgical Wound that is Observable 

Medications 

The items in this category are intended to record whether: 

• The client is taking any medicines in high-risk drug classes, there is an indication noted, and the client/caregiver has been educated about the high-risk medications  
• A drug regimen review was conducted  
• The client can manage oral and injectable medications 
• Key components of this category include: 
  • High-Risk Drug Classes: Use and Indication  
  • Drug-Regimen Review  
  • Medication Follow-up 
  • Medication Intervention  
  • Client/Caregiver High-Risk Drug Education  
  • Management of Oral Medications   
  • Management of Injectable medications 
• Unique Treatments, Procedures, and Programs 
  • The OASIS category identifies whether clients receive specific medical treatments or interventions that may impact their care needs, clinical complexity, and overall home health plan. 
• Participation in Assessment and Goal Setting 

Key Changes and Updates in OASIS-E (3) 

The most significant change from OASIS-D to OASIS-E  is a complete restructuring of the data set with new assessment items added, including the Brief Interview for Mental Status (BIMS), the Cognitive Assessment Method (CAM) for delirium identification, and the Patient Health Questionnaire (PHQ-9) for depression screening, while also revising the organization of sections and item numbers to align with other post-acute care assessments; essentially aiming to standardize data collection across different care settings; most of the OASIS-D content remains but is reorganized within the new structure.  

Currently, the main reason for revising OASIS was to increase standardization across post-acute care (PAC) settings to collect social determinants of health data uniformly and to enable the calculation of standardized, cross-setting quality measures (QMs), according to the provisions of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. Standardized assessment data elements are assessment items and consistent response options across four PAC assessment tools.   

Several changes were made from OASIS-D to OASIS-E. Some of the key changes include: 

• Social Determinants of Health (SDOH) Questions  
  • Ethnicity 
  • Race 
  • Language 
  • Transportation 
  • Health Literacy 
• Cognitive Function & Mental Status Enhancements  
  • BIMS (Brief Interview for Mental Status) to assess cognition 
  • PHQ-2 to 9 Depression Screening 
• Standardized Mobility & Self-Care Assessments  
  • Self-care (dressing, bathing, feeding, toileting) 
  • Mobility (bed mobility, transfers, walking, wheelchair use) 
• Pain & Medication Assessment Changes  
  • High-risk drug classes requiring monitoring (opioids, anticoagulants, insulin) 
• Falls & Functional Ability Updates 
  • Pain interfering with activity 
  • Fall history since the start of care 

Items removed from OASIS-E include 

• Frequency of pain interfering with activity 
• Pressure Ulcers 
  • Some response options were removed for streamlining 
• Client/caregiver drug education intervention 

Modified/revised items include: 

• Dyspnea 
  • Revised to align with standardized post-acute care assessments 
• Risk of Hospitalization 
• Adjusted wording for clarity 
  • Types of Assistance Provided 
• Expanded response options 

Impact of OASIS-E Changes (3) 

• Improved Data Standardization  
  • Consistency with assessments 
  • Supports care coordination and client transitions 
  • Enhances communication between healthcare facilities 
  • Facilitates discharge planning 
  • Quality improvement initiatives 
• Better Identification of Client Needs 
  • Enhanced focus on mental health, functional mobility, and social determinants of health 
  • Improves client outcomes  
• Increased Administrative and Training Needs 
  • More detailed assessments require additional clinician training 
  • Potential increase in documentation time 
• Quality and Payment Model Adjustments 
  • Impacts Medicare reimbursement through PDGM 
  • Supports Home Health Value-Based Purchasing (HHVBP) program 
  • Quality Reporting  
  • Payment reform 

OASIS and Home Health Reimbursement 

PDGM (Patient-Driven Groupings Model) (7) 

Implemented in 2020, home health agencies had a new set of financial incentives to consider when admitting and continuing care for Medicare beneficiaries. The PDGM relies more heavily on clinical characteristics and other client information to place home health periods of care into meaningful payment categories. It lowers the financial incentive to provide therapy by removing the therapy service utilization payment thresholds, higher rates for beneficiaries admitted after an inpatient institutional stay (hospitals and skilled nursing facilities), and lower rates for those admitted from the community. One case-mix variable is assigning the principal diagnosis to one of 12 clinical groups to explain the primary reason for home health services. 

30-day periods are categorized into 432 case-mix groups to adjust payment under the PDGM. In particular, 30-day periods are placed into different subgroups for each of the following broad categories: 

• Admission source (two subgroups):  
  • Community 
  • Institutional admission source 
• Timing of the 30 days (two subgroups):  
  • Early 
  • Late 
• Clinical grouping (twelve subgroups): 
  • Musculoskeletal rehabilitation 
  • Neuro/stroke rehabilitation 
• Wounds 
• Medication Management, Teaching, and Assessment (MMTA) 
  • Surgical aftercare 
  • Cardiac and circulatory 
  • Endocrine 
  • Gastrointestinal tract and genitourinary system; 
  • Infectious diseases, neoplasms, and blood-forming diseases 
  • Respiratory 
  • Other 
  • Behavioral Health 
  • Complex nursing interventions 
• Functional impairment level (three subgroups):  
  • Low 
  • Medium 
  • High  
• Co-morbidity adjustment (three subgroups):  
  • None 
  • Low 
  • High based on secondary diagnoses 

Medicaid Reimbursement (8) 

For home healthcare agencies to be reimbursed from Medicaid, clients must meet specific criteria. 

• Enrolled in one of the following plans: 
  • Medicaid managed care plan 
  • MyCare managed care plan 
  • Program for the All-inclusive Care of the Elderly (PACE) or 
  • Hospice benefits for those who have elected hospice 
• Home health services include: 
  • Home health nursing, 
  • Home health aide 
  • Skilled therapies (physical therapy, occupational therapy, and speech-language pathology) 
• Services are part-time or intermittent  
  • Visit for up to 4 hours 
  • Daily up to 8 hours combined 
  • Weekly home health nursing and aide services are up to 14 hours 
• Obtain proper provider information  
  • Obtain certification of medical necessity from the treating physician 
  • Provide services specified in the plan of care, including amount, scope, duration, and type of home health services 
  • When applicable, follow the managed care entity care plan or person-centered services plan for an individual enrolled in a home-and-community-based services (HCBS) waiver administered by the Ohio Departments of Medicaid, Aging, or Developmental Disabilities. 

Medicare (9) 

To receive reimbursement from Medicare, the client must be enrolled in either Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance), and the care being provided must be part-time or intermittent skilled services 8 hours a day (combined), for a maximum of 28 hours per week. The client is “homebound,” which means: 

• Trouble leaving home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury. 
• Leaving home isn’t recommended due to medical conditions. 
• Typically, I cannot leave home because it’s a significant effort. 

 Covered home health services include: 

• Medically necessary part-time or intermittent skilled nursing care, like: 
  • Wound care for pressure sores or a surgical wound 
  • Client and caregiver education 
  • Intravenous or nutrition therapy 
  • Injections 
  • Monitoring serious illness and unstable health status 
• Physical therapy 
• Occupational therapy 
• Speech-language pathology services 
• Medical social services 
• Part-time or intermittent home health aide care (only if the client is also getting skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy at the same time), like: 
  • Help with walking 
  • Bathing or grooming 
  • Changing bed linens 
  • Feeding 
• Injectable osteoporosis drugs for women 
• Durable medical equipment 
• Medical supplies for use at home 
• Disposable harmful pressure wound therapy devices 

A doctor or other health care provider (like a nurse practitioner) must assess the client “face-to-face” before certifying that they need home health services. The doctor or other health care provider must also order care. 

 Home Health Value-Based Purchasing Model (10) 

Value-based purchasing home health,” also known as the “Home Health Value-Based Purchasing (HHVBP) Model,” is a payment system where Medicare-certified home health agencies receive financial incentives based on the quality of care they provide to clients rather than just the quantity of services delivered, aiming to improve client outcomes and efficiency in home healthcare delivery. The main goal is to encourage home health agencies to provide higher quality care by tying their reimbursement to performance on quality measures like client satisfaction, functional improvement, and prevention of hospital readmissions. Agencies are evaluated based on specific quality metrics, and their Medicare payments are adjusted accordingly. Higher quality leads to larger reimbursements. The goal is to improve client experience and health outcomes by ensuring home health agencies are focused on providing adequate care that addresses clients’ needs.  

In a fee-for-service health system, Medicare beneficiaries who qualify for home health care often receive inadequate, uncoordinated care for their chronic health conditions, resulting in more visits to the emergency room, more hospital admissions, or more placements in a skilled nursing facility. 

The new HHVBP Model of 2025 seeks to improve the quality and efficiency of home health care nationwide. This will enhance clients’ experience with care, strengthen their physical function, and address health issues before they require an emergency room visit. This expanded model builds on the success of the original HHVBP Model, which decreased unnecessary emergency room visits, improved patient mobility, and reduced Medicare spending. 

OASIS and Quality Measures Compliance (3) 

Quality Improvement  

Oasis uses a set of standard definitions that are required to be able to measure quality and then improve quality. The OASIS-based quality measures provide home health agencies with the framework needed for delivering care regarding what matters to clients and their caregivers. The home health quality measures include activities of daily living (ADLs), client status, and home health agency care processes. These include measures such as “Improvement in Ambulation- Locomotion,” “Stabilization in Grooming,” “Improvement in Bed Transferring,” etc. 

These measures are essential to clients as they define quality of life and independence in a home setting. Quality measures also benefit healthcare providers by promoting best-practice interventions. Home health care quality is reflected in measures of agency best practices. Agencies can measure their overall progress in each quality measure to determine if they are improving in the measure, worsening in the measure, or remaining unchanged. Through the Internet Quality Improvement and Evaluation System (iQIES) reports, agencies can compare, or benchmark, their current performance to their prior performance on each quality measure and compare their performance to national reference rates.  

Home healthcare agencies can use other quality improvement methodologies in addition to or in place of Outcome-Based Quality Improvement (OBQI). Many current home health quality measures are based on OASIS data. In addition to the OASIS-based quality measures, home health quality measures are derived from Medicare FFS claims data and Home Health CAHPS® (Consumer Assessment of Healthcare Providers and Systems) data. Some agencies may access additional quality measures through their health system or payer affiliations, other programs (such as benchmarking vendors, state collaboratives, etc.), or quality reports generated from their electronic health records. Home health agencies are encouraged to use any of these information sources systematically to monitor and improve the care provided to their clients continuously. However, CMS cannot provide guidance on data, analysis, or reports from software or data benchmarking from other sources, such as software vendors or data benchmarking companies.  

The OASIS-based quality measures are calculated using items from the OASIS assessments from Medicare FFS, Medicare Advantage, Medicaid, and Medicaid Managed Care. A logistic regression prediction model is created for these quality measures. Hundreds of risk factors are tested in the development of prediction models.  

Outcome and Process Measures  

Outcome and process measures are now standardized processes derived from OASIS data and represent evidence-based practice guidelines. An outcome is a health status change that occurs over time and is specific to the client. The change can be positive (improvement), negative (worsening), or neutral (no change). The definition of an outcome does not include an assumed direction; therefore, any deviation (or non-deviation) in health status between the initial and follow-up time points constitutes an outcome. 

Process quality measures evaluate the home health agency use rate of specific evidence-based care processes. The standardized home health quality process measures focus on high-risk, high-volume, problem-prone areas for home health care. These include measures about all or most home care clients, such as timeliness of home care admission/resumption of care and immunization rates. Process items represent actions taken by home health care providers designed to impact client outcomes favorably.  

Home Health Star Ratings (11) 

Home health star ratings summarize how well a home health agency provides client care. Star ratings are based on a scale of 1–5 stars. The star ratings offer consumers a tool to help them make healthcare decisions. Star ratings are calculated based on input from stakeholders and ongoing data analysis. There are two types of home health star ratings: 

• Quality of Patient Care Star Ratings 
  • Based on OASIS assessments and Medicare claims data 
  • HHAs must have data for at least 20 complete quality episodes for each measure to be reported  
    • Completed episodes are paired with the start or resumption of care and end of care OASIS assessments.  
    • Episodes must have an end-of-care date within the 12-month reporting period, regardless of the start date.  
  • HHAs must have reported data for 5 of the seven measures used in the Quality of Patient Care Star Rating  
  • Includes process and outcome quality measures  
  • 7 measures   
  • Timely Initiation of Care (process measure), 
  • Improvement in Ambulation (outcome measure), 
  • Improvement in Bed Transferring (outcome measure), 
  • Improvement in bathing (outcome measure), 
  • Improvement in Shortness of Breath (outcome measure), 
  • Improvement in Management of Oral Medications (outcome measure), 
  • Potentially Preventable Hospitalization (outcome measure). 
• Patient Survey Star Ratings are Patient Survey Star Ratings 
  • Based on the Home Health CAHPS Survey 
  • Based on the client’s experience with care measures  
  • HHAs must have 40 or more completed surveys over the four-quarter reporting period to receive Star Ratings  
  • Include four of the measures 
    • Care of Clients 
    • Communication Between Providers and Clients 
    • Specific Care Issues 
    • Overall Rating of Care Provided by the Home Health Agency 

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