Home Health Quality

The History of Home Health Quality Measurement

Today I will discuss the evolution of home health care measures over the past 15 years. The majority of the content comes from an article by Robert Rosati (2009).


Here is a link to a TIMELINE that briefly summarizes the key developments in home health care quality measurements.

Risk Adjustment

From the early development of OASIS, consideration was given to developing case mix or risk-adjusted outcome measures. Patient outcomes are adjusted based on start or resumption of care assessment information. For example, a statistical model was developed to risk adjust the improvement in dressing the lower body based on whether the patient lives alone, receives assistance provided by a caregiver, level of functional status at the start of care, and the presence of other specific clinical conditions [ICD-9 codes]…All 41 outcomes that can be generated from OAASIS have separate risk adjustment models.” Despite the sophistication of the risk adjustment models, these mechanisms only explain variance from 10% to 27%.

Case Mix Adjustment

As part of the home health, prospective payments are adjusted based on the severity of the episodes. These episodes are adjusted for a number of factors. First, the adjustments take into account the clinical and functional status of the patient. Next the episodes are adjusted for service use. Service use before 2008 consisted of whether the patient is expected to receive physical or occupational therapy visits during a home health episode of care.

In 2008 there were major changes to the payment system, including the case mix adjustments. “In 2008, there was a major revision of Prospective Payment System (PPS) with adjustments for early versus late episodes if patients remain open for extended periods (adjustment applies for the third or later contiguous 60-day episodes for a patient) and the amount of therapy services provided to a patient.” The number of case mix adjustment categories changed from 80 before 2008 to 153 in 2008. Now, “the range in an average payment from the top categories (~$8,000) to the bottom (~$2,000) is substantial.”

Quality for Public Consumption

Although public reporting measures were a subset of the home health quality metrics CMS tracked through OASIS, there were some differences. For instance, the phrasing of the measures differed. “Improvement in ambulation and locomotion was changed to percentage of patients who get better at walking and moving around on the CMS Web site.”

The NQF’s also released a report describing its efforts to develop consensus standards for home health care.



  1. Tough subject. My wife is a physical therapist in the Washington DC area and has provided in-home care for many patients. There are many variables out of the therapist’s control in a patient’s home… including family members.
    Regardless, it seems to me that patients routinely prefer in-home treatment as it is where they are most comfortable (usually).
    Thanks for the post.
    I’ll be sure to check back often.
    All the best,

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