List of Quality Measures

Attachment X — CMS Quality Measures for Home Health Agencies
Summary Measures
Quality of patient care Star Rating
Patient survey summary Star Rating
Process of Care Measures
Timely initiation of care
Influenza immunization received for
current flu season
Pneumococcal polysaccharide vaccine
ever received
Diabetic foot care and patient education
implemented
Depression assessment conducted
Drug education on all medications
provided to patient/caregiver
Multifactor fall risk assessment
conducted for all patients who can
ambulate
Outcome Measures
Improvement in ambulation
Improvement in bed transfer
Improvement in pain interfering with
activity
Improvement in bathing
Improvement in management of oral
medications
Improvement in dyspnea
Improvement in status of surgical wounds
Acute care hospitalizations
Emergency department use without
hospitalization

Summary of quality of care measures (process of care
and outcomes measures)
Summary of patient survey/patient experience measures

How often the home health team began their patients’
care in a timely manner
How often the home health team made sure that their
patients have received a flu shot for the current flu
season
How often the home health team made sure that their
patients have received a pneumococcal vaccine
(pneumonia shot).
For patients with diabetes, how often the home health
team got doctor’s orders, gave foot care, and taught
patients about foot care
How often the home health team checked patients for
depression
How often the home health team taught patients (or
their family caregivers) about their drugs
How often the home health team checked patients’ risk
of falling

How often patients got better at walking or moving
around
How often patients got better at getting in and out of
bed
How often patients had less pain when moving around
How often patients got better at bathing
How often patients got better at taking their drugs
correctly by mouth
How often patients’ breathing improved
How often patients’ wounds improved or healed after
an operation
How often home health patients had to be admitted to
the hospital
How often patients receiving home health care needed
any urgent, unplanned care in the hospital emergency
room – without being admitted to the hospital

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Outcome Measures
Rehospitalization during the first 30 days
of home health

How often home health patients who have had a recent
hospital stay had to be readmitted to the hospital.

Emergency department use without
hospital readmission during the first 30
days of home health

How often home health patients who have had a recent
hospital stay received care in the hospital emergency
room without being readmitted to the hospital.

Patient Experience Measures
HHCAHPS Star Rating (Summary measure)
How often the home health team gave care in a professional way?
How well did the home health team communicate with patients?
Did the home health team discuss medicines, pain, and home safety with patients?
How do patients rate the overall care from the home health agency?
Would patients recommend the home health agency to friends and family?

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KEY TERMS
CMS quality measures: CMS home health quality measures include measures of clinical
processes and outcomes, patient experience with care, patient safety, resource use or cost of
care, and structural measures (such as a home health agency’s use of EHRs). These measures
are reported by home health agencies to the Centers for Medicare & Medicaid Services (CMS)
and can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HomeHealthQualityInits/Home-Health-Quality-Measures.html. Measures come from
patient assessment data that home health agencies routinely collect on the patients at specified
time intervals during their stay as well as Medicare claims data.
Accountable Care Organizations (ACO): ACOs are networks of healthcare providers and
organizations (usually hospitals and ambulatory care physician groups, and possibly including
nursing homes, home health agencies, and hospice organizations) that agree to take some
financial responsibility for reducing the costs and improving the quality of care for a defined
patient population.
Clinical decision support (CDS): CDS encompasses a variety of tools to enhance decisionmaking in the clinical workflow. These tools include computerized alerts and reminders to care
providers and patients; clinical guidelines; condition-specific order sets; focused patient data
reports and summaries; documentation templates; diagnostic support; and contextually relevant
reference information, among other tools.
Culture of safety: Organizations with a positive safety culture are characterized by
communications founded on mutual trust, by shared perceptions of the importance of safety,
and by confidence in the efficacy of preventive measures. The Agency for Healthcare Research
and Quality notes the following key features: acknowledgment of the high-risk nature of an
organization's activities and the determination to achieve consistently safe operations; a blamefree environment where individuals are able to report errors or near misses without fear of
reprimand or punishment; and encouragement of collaboration across ranks and disciplines to
seek solutions to patient safety problems; organizational commitment of resources to address
safety concerns.
Integrated Delivery System (IDS): An IDS is an integrated network of healthcare providers and
organizations such as nursing homes, primary and specialty care, hospitals, rehabilitation
centers, home health care agencies, and hospice services that provides or arranges to provide
a coordinated continuum of services to a defined population. It may own or be closely aligned
with an insurance product, usually a form of managed care.
Lean/Six Sigma Engineering: Redesign or re-engineering concepts that were originally
developed to increase the efficiency of production and reduction of errors within manufacturing
companies. Lean/Six Sigma has been adopted by healthcare organizations to identify problems
or inefficiencies and take actions to address these issues. “Lean” and “Six Sigma” emphasize
focusing on customer satisfaction, problem solving, and elimination of waste and involving
employees in identifying and resolving the problem.
Learning Organization: An organization that encourages and supports continuous employee
learning, critical thinking, and risk-taking with new ideas.
Plan, Do, Study, Act Improvement Cycles (PDSA): PDSA is a tool that is used for
accelerating quality improvement that involves developing a plan to test the change (Plan),

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carrying out the test (Do), observing and learning from the consequences (Study), and
determining what modifications should be made to the test (Act).
Situation Background Assessment Recommendation (SBAR): SBAR is a standardized way
of communicating that promotes patient safety by helping individuals communicate with each
other with a shared set of expectations. Staff and physicians can use SBAR to share patient
information in a concise and structured format.

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