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Essential Home Healthcare Quality Measures for Value-Based Care

Based on CMS home healthcare quality measures for Medicare home health agencies, payers can establish strong quality measures with their home healthcare partners.

Kelsey Waddill
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Published: 31 Aug 2021

As home healthcare becomes more common, payers pursuing value-based care arrangements with home healthcare providers will need to establish strong home healthcare quality measurements.

The coronavirus pandemic spotlighted the untapped potential of home healthcare. 

Although the healthcare industry as a whole has been slowly adopting remote patient monitoring technologies and other elements of home healthcare, the pandemic pushed this form of care delivery from an optional benefit to a necessary component of healthcare.

“What COVID may have done is accelerate everyone's thinking about: how do you provide that optimal set of services in the home?” Joe Agostini, MD, chief medical officer at UnitedHealthcare Retiree Solutions, explained to HealthPayerIntelligence. 

“We on the health plan side are thinking about moving more quickly and aggressively in terms of supporting those older adults in their own home. So, it has given us an opportunity to move faster on many of the ideas that we've been thinking about in recent years.”

In 2021, major payers have revealed plans to expand their home healthcare programs, signaling a desire to build on the momentum gained during the pandemic. 

For example, Humana is in the process of acquiring Kindred at Home, a home healthcare company of 43,000 providers that serves 550,000 patients across 40 states. Anthem announced its plans to acquire myNEXUS, a company that offers integrated nursing management for home healthcare services. Regence BlueShield formed a partnership to provide acute care in the home.

Not all of these agreements were value-based care contracts. But as the industry moves towards quality-based payment and home healthcare solutions, payers who plan to enter into home healthcare value-based care agreements should be aware of the best quality measures to assess provider outcomes.

CMS has often paved the way for value-based care improvements in the past. While private payers may not identically mimic CMS measures in their own value-based care agreements, CMS home healthcare standards highlight two sets of key quality measures that may further reinforce payers’ value-based home healthcare efforts.

Member outcome home healthcare quality measures

CMS has outlined several quality measures for Medicare home healthcare programs. Not all of these measures have been finalized as part of the home health quality reporting program nor are they all based on publicly available data points. However, the list may prove useful for payers looking to establish value-based care agreements in home healthcare.

A key metric for determining home health quality of care is patient outcomes. CMS accepts home health outcomes metrics from the Outcome and Assessment Information Set (OASIS) and from Medicare claims.

Since each home health agency serves a diverse set of patients, outcomes measures are often risk-adjusted in home healthcare. 

Outcomes quality measures cover quality improvement, potentially avoidable events, utilization of care measures, and cost and resource metrics.

As in other areas of healthcare, potentially avoidable events—such as preventable hospital readmissions—are important indicators of quality of care because they point to a negative change in health which providers may have deterred with higher quality care. 

However, these measures must be adjusted for member characteristics, since the reasons for readmission can vary broadly.

Utilization metrics could include the quantity of hospitalization and emergency department services that the member received that were connected to a change in health during the episode of care starting with the first home healthcare claim. CMS relies on claims data as evidence for its utilization of care quality measures.

The agency tracks utilization measures in acute care hospitalizations and emergency department use in the first 60 days of home healthcare, discharge to community, and potentially preventable readmissions within the first 30 days of discharge.

Claims data can also reinforce cost measures and resource usage. Comparing a home healthcare agency’s healthcare spending to the national average can help inform conversations about low-value spending patterns. Primarily, CMS uses Medicare Spending per Beneficiary – Post-Acute Care Home Health as its metric for this category of quality measurement.

Process measures tend to cover areas of home healthcare that are most vulnerable to quality of care issues. Whereas utilization measures are risk-adjusted, CMS does not apply risk-adjustment to its process quality measures.

“Risk adjustment is not considered to be necessary for process measures because the processes being measured are appropriate for all patients included in the denominator (patients for whom the measure is not appropriate are excluded),” CMS explained.

Process quality measures for home healthcare include timely initiation of care, depression assessment, fall risk assessment, drug education, influenza immunization status, and more. 

Member experience home healthcare quality measures

In addition to its patient outcomes quality measures, CMS has instituted two sets of star ratings systems to indicate the quality of patient experience. For both systems, home healthcare agencies may receive up to five stars and, as in Medicare Advantage Star Ratings, five stars indicates the highest quality of care.

The Quality of Patient Care Star Rating system uses OASIS data to inform its star rating assignment.

For this star rating system, CMS wanted to select measures that would apply to the patient population broadly and that home healthcare agencies would have a significant amount of evidence to support. The agency intended these quality measures to be improvable, clinically relevant, and immune to unpredictable variation.

The Quality of Patient Care Star Rating system leverages mostly outcomes measures, ranging from improvement in bed transferral to oral medication management, as well as one process measure—timely initiation of care.

The Patient Survey Star Rating system offers another set of metrics to gauge the value and quality of a home healthcare program.

These measures are based on the results of the Home Health CAHPS Survey, indicating member experience. CMS uses data from the CAHPS survey related to four areas to determine patient experience.

Care of patients is one area which the star rating system covers. This includes data on the frequency of member engagement on the part of the home healthcare agency. It also addresses the manner of treatment, whether it was gentle and respectful.

Communication is the second area that the Patient Survey Star Rating system addresses, which evaluates the quality of member engagement and outreach strategies. 

The star ratings system also assesses data points that may be specific to a beneficiary's type of care. For example, this metric examines whether or not a home healthcare agency representative discussed in-home mobility with the respondent or interacted with the member about prescription medications.

Finally, the Patient Survey Star Rating system uses question 20 of the CAHPS survey to determine the overall quality of home healthcare that home healthcare agencies provided Medicare beneficiaries. The question asks participants to rate the home healthcare agency’s quality of care on a scale of one to ten, with ten being the highest quality.

After compiling all of these data points, CMS can provide a more comprehensive assessment of a home healthcare agency's quality of care in member experience.

Although private payers may not seek to mirror Medicare home healthcare quality measures, these CMS guidelines can offer a good starting point for assessing quality in value-based home healthcare arrangements.

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