Home Health Quality Measures

Home Health Quality Measures Staying Current with a Moving Target Presenters J non Griffin, RN, MHA, WCC, HCS-D, COS-C, HCS-C, HCS-H Home Health Solutions, LLC www.homehealthsolutionsllc.com Objectives Define the OASIS C2 and changes related to new CoPs and outcomes Discuss the new claims based outcomes and strategies for optimal outcomes. Describe changes to CMS publicly reported quality measures and 5- Star rating system Outline the CMS value-based purchasing demonstration project 1

Drug Regimen Review Conducted Item Intent: Identify if any potential clinically significant issues exist Defined as that in the care provider s clinical judgement requires physician/physician-designee notification by midnight of the next calendar day (at the latest) Includes an existing issue Includes: Medication reconciliation, a review of all medications a patient is currently using and review of the drug regimen (all medications prescribed and OTC, administered by any route) Issues Adverse Effect Ineffective Drug Therapy Drug interactions Issues Duplicate Therapy Omissions 2

Issues Dosage Errors nadherence Item Intent: Where potentially significant medication issues identified through a medication review addressed with the physician by midnight of the next calendar day following their identification? To enter Response 1: 2 way communication AND Completion of the prescribed/recommended actions by midnight of the next calendar day after issue identified tification of MD/Designee by midnight of next calendar day? Communication back from MD/Designee by Midnight next calendar day Prescribed/recommended actions completed by MIDNIGHT of next calendar day?- = M2003-1 Medication Issue Identified M2003 Coded: 0 M2003 Coded: 0 M2001= 0 M2003- Skipped 3

Three conditions must be met for positive outcome M2001-Complete BRR at beginning of care episode M2003-MD contact and FU if medication issues identified at SOC/ROC M2005-Physician contact and follow up EACH TIME significant medication issues are found throughout the care episode New Condition of Participation-Medications and Interdisciplinary team Skilled Professionals Interdisciplinary Team Clinical Manager Written information to the patient including medications (484.60) Comprehensive Assessment (484.55) Patient Centered Evidence Based Interventions HIGH ALERT MED TOOL A recent study found that four agents were responsible for 2/3 of all drug related hospitalizations: 1. Plavix 2. Coumadin 3. Insulin 4. Oral hypoglycemics Source: Budnitz, et al. NEJM, v 24, 2011 4

How else can we use OASIS C2? Outcomes Payment QAPI Claims Based Measures The Acute Care Hospitalization (ACH) measure National Quality Forum number 0171 stays in which patients were admitted to an ACH during the 60 days following the start of home health. Number of home health stays for patient who have an admission to the hospital in the 60 days after SOC Number of HH episodes that begin during 12 months 5

Emergency Department Use without Hospitalization (ED use) measure National Quality Forum number 0173. stays in which patients used the emergency department but were not admitted to the hospital during the 60 days following the start of home health ER visits with no ACH 60 days following HHA SOC Number of home health stays that begin during 12 month period Risk Factors Prior Care Setting Health Status Demographics Enrollment status Interactions terms One Agency using telephony with script 6

Compare to other 4.5 Star Agencies Agency #1 Agency #2 Agency #3 State National Today's Weight: terday's Weight: Difference: Do you keep a record of your weights? Cough: Dry Loose Changes persistent Frequency Sputum: Edema: Hands/Legs/Abdomen Do you wear compression stockings? Elevate lower legs while sitting? Shortness of Breath: Day Night At Rest with exertion/activity changes? Energy Level: Diet: Changes or NauseaHydration/Fluid Restriction: Balancing Rest and Activity: Following a exercise plan? Working with therapy in the home? How is that going? Heart Rate: Chest tightness or pain: congestion or wheezing Taking medications as scheduled: Sleeping Patterns: Hours of sleep, How many pillows or sleep in a recliner/chair CHF Zones: Flyer: Call First. Comments: 7

Discharge to Community-Post Acute Care IMPACT act requires standardization of the Discharge to the Community Discharged to the community from home health episode Do not have an unplanned readmission to an acute care hospital or LTCH in the 31 days following DC to community Remain alive following discharge to the community HH Compare-January 2019 Discharge to home/self care (01) or DC with planned hospital readmission (81) Patients who are discharged to the community are also considered to have an unfavorable outcome if they die in the post-discharge window, which includes the day of discharge and the 31 days following day of discharge. Death in the post-discharge window is identified based on date of death from Medicare eligibility files. Exclusions Under 18 years of age DC to psychiatric hospital Discharges against medical advice Discharges to disaster alternative care sites or federal hospitals Discharges to court/law enforcement Patients discharged to hospice t continuously enrolled in FFS Medicare ACH for non-surgical cancer treatment in the 30 days prior to PAC admission Post acute stays that end in transfer to the same level of care. Post-acute stays with claims data that are problematic Potentially Preventable Readmission Unplanned potentially preventable readmission for patients in the 30 days following home health discharge. 8

What measures can we put in place for these PAC discharges? Instruct patient to call agency even after discharged from services. Triage/telephony during service New CoP-Discharge summary/set up properly transition of care. Medicare Spending per Bene-PAC HH Measure HH Compare-January 2019 Risk adjusted/claims Based Risk adjusted Medicare Spending per Beneficiary X national average episode spending level across HHA Episode weighted national median of the MSPB-PAC amounts across all HHA s Proposed Measures for the Future/IMPACT Act 1. Application of percent of Long-term care hospital patients with an admission and discharge functional assessment and a care plan that addresses function. (NQF #2631) 2. Application of percent of patients experiencing one of more falls with injury (NQF #0674) 3. Changes in Skin Integrity-Post acute care-pressure ulcer/injury 9

PHQ2 Number change to M1731 Section I-Active Diagnosis Previously M1028- I0900-PVD or PAD I2900-DM I7900-ne of the above Section J Health Conditions Completed at DC J1800-Any falls since SOC/ROC J1900-Number of falls since SOC/ROC A- injury B-Injury (except major) Major injury 10

Section B-Hearing, Speech and Vision-M1200 and M1210 Section C-Cognitive Patterns C0100-Should brief interview for mental status be conducted? C0200-BIMS conducted C0300-Temporal orientation C0400-Recall C0500-Summary Score C1310-Signs and symptoms of Delirium (from CAM) for acute mental change 11

Section K-Swallowing/Nutritional Status A-Parenteral/IV feeding B-Feeding tube-ng or abdominal C-Mechanically altered diet-require change in texture food or liquids D-Therapeutic diet (low salt, diabetic, etc) Section O-Special Services, Treatments, and Interventions A-Chemotherapy A2a-IV A3a-Oral A10a-Other B-Radiation C-Oxygen- M1410 C2a-Continuous C3a-Intermittent D-Suctioning D2a-Scheduled D3a-As needed E-Tracheostomy Care F-Invasive mechanical ventilator- M1410 G-n-Invasive mechanical ventilator G2a-Bipap-M1410 G2b-CPAP-M1410 H-IV Medications H3a-Antibiotics H4a-anticoagulant H10a-Other I-Transfusions J-Dialysis J2a-Hemodialysis J3a-Peritoneal dialysis 12

Section O-Special Services, Treatments, and Interventions O-IV Access O2a-Peripheral IV O3a-Midline O4a-Central line (PICC, tunneled, port) O10a-Other Z-ne of the above GG categories GG0100-Prior functioning-(m1900) GG0110-Prior device use GG0130A-Eating GG0130B-Oral Hygiene GG0130C-Toileting hygiene GG0170B-Sit to lying GG0170C-Lying to sitting on side of bed GG0170D-Sit to stand GG0170E-Chair/bed-to-chair transfer GG0170F-Toilet transfer GG0170H-Does the patient walk GG0170J-Walk 50 ft with two turns GG0170K-Walk 150 ft GG-170Q-Does the pt use WC or scooter GG0170R-Wheel 50ft with 2 turns GG0170RR-Type of WC or scooter GG0170S-Wheel 150 ft. GG0170SS-Type of WC/scooter How is Utilization Helping/hurting your outcomes? 13

HH Reforms: Preparing for HHGM Programs CMS Volume to Value reforms rewire HH model Multiple areas of HH model address value HH Reforms mimic other CMS Part A Provider regs Solutions lie in HH Utilization Review management UR Model manages DRGs (Hosp), RUGs (SNF) UR assures value management of HH episode UR model - Medicare Guidance Manuel HH Chap 7 How Utilization Review creates value in Medicare Home Health How UR creates value in Home Health Assures accurate and evolved OASIS SOC profile Outlines clinical deficits (targets) that define value Assures CMS-compliant care - eliminates audits Employs SOC OASIS data for UR produced POC Creates Freq/Dur SOC orders for ALL disciplines Assures proportional, standardized HH program Real-time In-Episode Management (IEM) model 14

How UR creates value in Home Health Returns front-line clinician to care delivery role Creates individualized POC from OASIS data Re-wires episode weekly for care-to-date inclusion Assures qualified content in an ongoing manner Raises HH Compare Star Rating to 4.5 5.0 level Decreases unskilled care and related staffing Meets goals for all involved CMS, MD, HH, Client The Role of Utilization Review in Medicare Reform Models UR Role in CMS HH Reform Models UR Based Bundle Pilot was basis of CJR model Assured skill based programs for Bundle value Accepted as Plan of Correction for HH Focus Review Assures optimal Post-Acute programming More reliant on CMS philosophy than current HH Assures care outcomes with after-cost margin Employs HHGM required OASIS accuracy PAC PPS 15

Assess your Home Health care programs for UR Opportunities Assess HH programs for UR Opportunity Simple analysis of Case Mix questions vs. POC Current care with UR based care comparison Outlines best practice clinical paths for value Current Staffing with UR based comparison Identifies new staffing levels required for UR care Creates ROI projections for UR based HH caseload Places HH on the path to the future of care Home Health Strategic Management 1-877- 449 - HHSM www.homehealthstrategicmanagement.com 16

Questions J non Griffin, RN, WCC, MHA, HCS-D, COS-C, HCS-H Home Health Solutions, LLC 888-418-6970 www.homehealthsolutionsllc.com jnon@homehealthsolutionsllc.com 17

Home Health Quality Measures Outcomes tes: 1. Risk Adjustment: All outcome measures are risk adjusted. The risk adjustment methodology, using a predictive model developed specifically for each measure, compensates for differences in the patient population served by different home health agencies. The outcome measures for which the predictive models did not meet the arbitrary criteria R2 >= 0.10 or C-statistic >= 0.70 are designated with a pound sign (#) to highlight the fact that they have less robust risk adjustment. 2. Quality Episode Definition: Quality episodes are used in the calculation of the quality measures. Quality episodes are not the same as payment, or Prospective Payment System (PPS) episodes. A quality episode begins with either a SOC or ROC and ends with a transfer, death, or discharge for a patient regardless of the length of time between the start and ending events. 3. Home Health Stay Definition: A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days. OASIS-BASED OUTCOME MEASURES Type Functional Functional Functional Functional Measure Title Stabilization in Grooming Improvement in Upper Body Dressing Improvement in Lower Body Dressing Improvement in Bathing HH Compare NQF Status t endorsed t endorsed t endorsed Endorsed (0174) Risk Adjusted Measure Description Numerator Denominator Measure-specific Exclusions OASIS-C2 Item(s) Used patients improved or stayed the same in ability to groom self. patients improved in ability to dress upper body. patients improved in ability to dress lower body. the patient got better at bathing self. episodes where the value recorded on the discharge assessment indicates the same or less impairment in grooming themselves at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates less impairment in dressing their upper body at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates less impairment in dressing their lower body at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates less impairment in bathing at discharge than at start (or resumption) of care. start/resumption of care, was totally unable to groom self, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was able to dress upper body without assistance or supervision, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was able to dress lower body without assistance or supervision, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was able to bath self independently, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. (M1800) Grooming (M1810) Current Ability to Dress Upper Body (M1820) Current Ability to Dress Lower Body (M1830) Bathing Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 1 of 11

OASIS-BASED OUTCOME MEASURES Type Functional Functional Functional Functional Functional Functional Measure Title Stabilization in Bathing Improvement in Toilet Transferring Stabilization in Toilet Transferring Stabilization in Toileting Hygiene Improvement in Bed Transferring Stabilization in Bed Transferring HH Compare NQF Status t endorsed t endorsed t endorsed t endorsed Endorsed (0175) t endorsed Risk Adjusted Measure Description Numerator Denominator Measure-specific Exclusions OASIS-C2 Item(s) Used the patient improved or stayed the same in the ability to bathe. patients improved in ability to get to and from and on and off the toilet. patients improved or stayed the same in ability to get to and from and on and off the toilet. patients improved or stayed the same in ability to manage toileting hygiene. the patient improved in ability to get in and out of bed. the patient improved or stayed the same in ability to get in and out of bed. episodes where the value recorded on the discharge assessment indicates the same or less impairment in bathing at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates less impairment in getting to and from and on and off the toilet at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates the same or less impairment in getting to and from and on and off the toilet at discharge than at start (or resumption) of care. episodes where the discharge assessment indicates the same or less impairment in toileting hygiene at discharge than at start/resumption of care. episodes where the value recorded on the discharge assessment indicates less impairment in bed transferring at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates the same or less impairment in bed transferring at discharge than at start (or resumption) of care. start/resumption of care, was totally dependent in bathing, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was able to get to and from and on and off the toilet without assistance or supervision, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was totally unable to get to and from or on and off the toilet, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was totally unable to maintain toileting hygiene or supervision, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was able to transfer independently, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was totally unable to transfer in and out of bed, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. (M1830) Bathing (M1840) Toilet Transferring (M1840) Toilet Transferring (M1845) Toileting Hygiene (M1850) Transferring (M1850) Transferring Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 2 of 11

OASIS-BASED OUTCOME MEASURES Type Functional Functional Functional Health Health Health Measure Title Improvement in Ambulation- Locomotion Improvement in Management of Oral Medications Stabilization in Management of Oral Medications Improvement in Dyspnea Improvement in Pain Interfering with Activity Improvement in Status of Surgical Wounds HH Compare NQF Status Endorsed (0167) Endorsed (0176) t endorsed t endorsed Endorsed (0177) Endorsed (0178) Risk Adjusted # # Measure Description Numerator Denominator Measure-specific Exclusions OASIS-C2 Item(s) Used the patient improved in ability to ambulate. the patient improved in ability to take their medicines correctly (by mouth). the patient improved or stayed the same in ability to take their medicines correctly (by mouth). the patient became less short of breath or dyspneic. the patient's frequency of pain when moving around improved. the patient demonstrates an improvement in the condition of surgical wounds. episodes where the value recorded on the discharge assessment indicates less impairment in ambulation/locomotion at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates less impairment in taking oral medications correctly at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates the same or less impairment in taking oral medications correctly at discharge than at start (or resumption) of care. episodes where the discharge assessment indicates less dyspnea at discharge than at start (or resumption) of care. episodes where the value recorded on the discharge assessment indicates less frequent pain at discharge than at start (or resumption) of care. episodes where the patient has a better status of surgical wounds at discharge compared to start (resumption) of care. start/resumption of care, was able to ambulate independently, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was able to take oral medications correctly without assistance or supervision, episodes that end with inpatient facility transfer or death, or patient is nonresponsive, or patient has no oral medications prescribed. start/resumption of care, was totally dependent in taking oral medications, episodes that end with inpatient facility transfer or death, or patient is nonresponsive, or patient has no oral medications prescribed. start/resumption of care, was not short of breath at any time, episodes that end with inpatient facility transfer or death. start/resumption of care, had no pain reported, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, did not have any surgical wounds or had only a surgical wound that was unobservable or fully epithelialized, episodes that end with inpatient facility transfer or death. (M1860) Ambulation/ Locomotion (M2020) Management of Oral Medications (M2020) Management of Oral Medications (M1400) When is the patient dyspneic? (M1242) Frequency of Pain Interfering with Activity (M1340) Does this patient have a Surgical Wound? (M1342) Status of Most Problematic (Observable) Surgical Wound Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 3 of 11

OASIS-BASED OUTCOME MEASURES Type Health Measure Title Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened HH NQF Risk Compare Status Adjusted January (application 2019 of NQF #0678). Measure Description Numerator Denominator Measure-specific Exclusions OASIS-C2 Item(s) Used quality episodes in which patients with a Stage 2-4 pressure ulcers present at discharge that are new or worsened since the beginning of the quality episode. The number of quality episodes for which the assessment completed at the end of care (discharge) indicates one or more new or worsened Stage 2-4 pressure ulcers compared to the most recent SOC/ROC assessment. Where the discharge assessment: 1. Stage 2 (M1313a) > [0], OR Patients that expire while on the service with a home health agency Patients without an assessment completed at the start or resumption of care and an assessment completed at the end of care Patients are excluded if none of the assessments has a usable response for M1313a, M1313b, or M1313c (M1313a) Worsening in Pressure Ulcer Status since SOC/ROC: Stage 2, (M1313b) Worsening in Pressure Ulcer Status since SOC/ROC: Stage 3, (M1313c) Worsening in Pressure Ulcer Status since SOC/ROC: Stage 2. Stage 3 (M1313b) > [0], OR Health Health Utilization Outcome Utilization Outcome Improvement in Bowel Incontinence Improvement in Confusion Frequency Emergency Department Use with Hospitalization (OASIS based) Acute Care Hospitalization (OASIS based) t endorsed t endorsed t endorsed t Endorsed patient's bowel control improves. patients are confused less often. the patient needed urgent, unplanned medical care from a hospital emergency department, immediately followed by hospital admission. quality episodes that ended with the patient being admitted to the hospital. 3. Stage 4 (M1313c) > [0]. episodes where the patient has less frequent bowel incontinence at discharge compared to start (resumption) of care. episodes where the discharge assessment indicates the patient is confused less often at discharge than at start (or resumption) of care. episodes where the transfer to inpatient facility assessment indicates the patient required emergency medical treatment from a hospital emergency department, with hospital admission. episodes for which the assessment completed at the conclusion of the episode indicates the patient was admitted to a hospital for a reason other than a scheduled treatment or procedure. or transfer to inpatient facility or transfer to inpatient facility start/resumption of care, was continent, OR bowel incontinence was unknown, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. start/resumption of care, was not confused at any time, episodes that end with inpatient facility transfer or death, or patient is nonresponsive. which the emergency department use is unknown at transfer or discharge, the episode of care ended in death at home. Home health quality episodes that end in patient death. (M1620) Bowel Incontinence Frequency (M0100) Reason for Assessment (M2301) Emergent Care (M0100) Reason for Assessment (M2410) Inpatient Facility Admission (M2430) Reason for Hospitalization Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 4 of 11

OASIS-BASED OUTCOME MEASURES Type Utilization Outcome Measure Title Discharged to Community (OASIS based) HH NQF Risk Compare Status Adjusted t endorsed Measure Description Numerator Denominator Measure-specific Exclusions OASIS-C2 Item(s) Used episode after which patients remained at home. Number of home health episodes where the assessment completed at the discharge indicates the patient remained in the community after discharge. or transfer to inpatient facility Home health quality episodes that end in patient death. (M0100) Reason for Assessment (M2420) Discharge Disposition Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 5 of 11

CLAIMS-BASED OUTCOME MEASURES Type Utilization Outcome Measure Title Acute Care Hospitalization During the First 60 Days of Home Health (Claims-based) HH Compare NQF Status Endorsed (0171) Risk Adjusted Measure Description Numerator Denominator Measure-specific Exclusions stays in which patients were admitted to an acute care hospital during the 60 days following the start of the home health stay. Number of home health stays for patients who have a Medicare claim for an unplanned admission to an acute care hospital in the 60 days following the start of the home health stay. Number of home health stays that begin during the 12-month observation period. Home health stays that begin with a Low Utilization Payment Adjustment (LUPA) claim. Home health stays in which the patient receives service from multiple agencies during the first 60 days. OASIS-C2 Item(s) Used ne based on Medicare FFS claims Home health stays for patients who are not continuously enrolled in feefor-service Medicare for the 6 months prior to the home health stay Utilization Outcome Emergency Department Use without Hospitalization During the First 60 days of Home Health (Claims-based) Endorsed (0173) stays in which patients used the emergency department but were not admitted to the hospital during the 60 days following the start of the home health stay. Number of home health stays for patients who have a Medicare claim for outpatient emergency department use and no claims for acute care hospitalization in the 60 days following the start of the home health stay. Number of home health stays that begin during the 12-month observation period. Home health stays for patients who are not continuously enrolled in feefor-service Medicare for the 60 days following the start of the home health stay or until death. Home health stays that begin with a Low Utilization Payment Adjustment (LUPA) claim. Home health stays in which the patient receives service from multiple agencies during the first 60 days. ne based on Medicare FFS claims Home health stays for patients who are not continuously enrolled in feefor-service Medicare for the 6 months prior to the home health stay. Home health stays for patients who are not continuously enrolled in feefor-service Medicare for the 60 days following the start of the home health stay or until death. Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 6 of 11

CLAIMS-BASED OUTCOME MEASURES Type Utilization Outcome Measure Title Rehospitalization During the First 30 Days of Home Health (Claims-based) HH Compare NQF Status Endorsed (2380) Risk Adjusted Measure Description Numerator Denominator Measure-specific Exclusions stays in which patients who had an acute inpatient discharge within the 5 days before the start of their home health stay were admitted to an acute care hospital during the 30 days following the start of the home health stay. Number of home health stays for patients who have a Medicare claim for an admission to an acute care hospital in the 30 days following the start of the home health stay. Number of home health stays that begin during the 3-year observation period for patients who had an acute inpatient hospital discharge within the 5 days prior to the start of the HH stay. Numerator Exclusions: Inpatient claims for planned hospitalizations are excluded from the rehospitalization measure numerator. Planned hospitalizations are defined using the same criteria as the Hospital-Wide All-Cause Unplanned Readmission Measure as of January 2013. OASIS-C2 Item(s) Used ne based on Medicare FFS claims Denominator Exclusions: Stays for patients who are not continuously enrolled in fee-forservice Medicare during the measure numerator window (30 days following the start of the home health stay) or until death; Stays that begin with a Low- Utilization Payment Adjustment (LUPA); Stays in which the patient receives services from multiple HHAs in the first 30 days; Stays in which the patient is not continuously enrolled in Medicare fee-for-service during the previous six months; Stays in which the patient receives treatment in another setting in the 5 days between hospital discharge and the start of home health; Stays in which the hospitalization occurring within 5 days of the start of home health care is not a qualifying inpatient stay. Hospitalizations that do not qualify as index hospitalizations include admissions for the medical treatment of cancer, primary psychiatric disease, or rehabilitation care, and admissions ending in patient discharge against medical advice. Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 7 of 11

CLAIMS-BASED OUTCOME MEASURES Type Utilization Outcome Measure Title Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health (Claims-based) HH Compare NQF Status Endorsed (2505) Risk Adjusted Measure Description Numerator Denominator Measure-specific Exclusions stays in which patients who had an acute inpatient discharge within the 5 days before the start of their home health stay used an emergency department but were not admitted to an acute care hospital during the 30 days following the start of the home health stay. Number of home health stays for patients who have a Medicare claim for outpatient emergency department use and no claims for acute care hospitalization in the 30 days following the start of the home health stay. Number of home health stays that begin during the 3-year observation period for patients who had an acute inpatient discharge within the 5 days prior to the start of the home health stay. Stays for patients who are not continuously enrolled in fee-forservice Medicare during the measure numerator window or until death; Stays that begin with a Low- Utilization Payment Adjustment (LUPA); Stays in which the patient receives services from multiple HHAs in the first 30 days; OASIS-C2 Item(s) Used ne based on Medicare FFS claims Stays in which the patient receives treatment in another setting in the 5 days between hospital discharge and the start of home health; Stays in which the hospitalization occurring within 5 days of the start of home health care is not a qualifying inpatient stay. Hospitalizations that do not qualify as index hospitalizations include admissions for the medical treatment of cancer, primary psychiatric disease, or rehabilitation care, and admissions ending in patient discharge against medical advice. Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 8 of 11

CLAIMS-BASED OUTCOME MEASURES Type Utilization Outcome Measure Title Discharge to Community (Claims-based) HH NQF Risk OASIS-C2 Item(s) Measure Description Numerator Denominator Measure-specific Exclusions Compare Status Adjusted Used January t ne based on 2019 Endorsed Medicare FFS claims stays in which patients were discharged to the community and do not have an unplanned readmission to an acute care hospital or LTCH in the 31 days and remain alive in the 31 days following discharge to community. The term community, for this measure, is defined as home/self-care, without home health services, based on Patient Discharge Status Codes 01 and 81 on the Medicare FFS claim. Number of home health stays for patients who have a Medicare claim with Patient Discharge Status codes 01 and 81, do not have an unplanned readmission to an acute care hospital or LTCH in the 31-day postdischarge observation window, and who remain alive during the post-discharge observation window. Number of home health stays that begin during the 2-year observation period. Denominator Exclusions: Excludes claims for patients who are: Under 18 years of age Discharged to a psychiatric hospital Discharged against medical advice Discharged to disaster alternative care sites or federal hospitals Discharged to court/law enforcement Discharged to hospice t continuously enrolled in Parts A and B FFS Medicare for the12 months prior to the PAC admission date, and at least 31 days after post-acute discharge date Experience a short term acute care stay for non-surgical treatment of cancer in the 30 days prior to PAC admission Transferred to another home health agency Received care from an agency/facility located outside of the United States, Puerto Rico or a U.S. territory Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 9 of 11

CLAIMS-BASED OUTCOME MEASURES Type Outcome: Cost/Resource Use Measure Title Medicare Spending Per Beneficiary - Post-Acute Care (MSPB-PAC) Home Health Measure (Claims based) HH Compare January 2019 NQF Status t Endorsed Risk Adjusted Measure Description Numerator Denominator Measure-specific Exclusions The assessment of the Medicare spending of a home health agency s MSPB-PAC HH episodes, relative to the Medicare spending of the national median home health agency s MSPB-PAC HH episodes across the same performance period. te: An MSPB-PAC HH measure score of less than 1 indicates that a given home health agency s resource use is less than that of the national median home health agency during the same performance period. The numerator is called the MSPB-PAC Amount. This is the average observed over expected (as predicted through risk adjustment) Medicare spending for a home health agency s MSPB-PAC HH s episodes, multiplied by the national average MSPB-PAC HH spending. MSPB-PAC HH episodes include the Medicare spending for Parts A and B services during the episode window, subject to certain exclusions for clinically unrelated services. These exclusions are for services that are clinically unrelated to postacute care treatment or services over which home health agencies may have limited to no influence (e.g., routine management of certain preexisting chronic conditions). The episode window consists of a treatment period (days 1-60 of the home health Medicare FFS claim, or day 1 to discharge for a claim subject to a PEP adjustment) and an associated services period (day 1 of the home health claim through to 30 days after the end of the treatment period). The denominator is the episodeweighted national median MSPB- PAC Amount across all home health agencies. Episodes triggered by a claim outside the 50 states, D.C., Puerto Rico, and U.S. territories Episodes where the claim(s) constituting the attributed HHA s treatment have a standard allowed amount of zero or where the standard allowed amount cannot be calculated Episodes where the patient is not continuously enrolled in Medicare FFS for the 90 days before the episode trigger (lookback period) through to the end of the episode window, or is enrolled in Part C for any part of this period. This includes cases where the beneficiary dies during this period. Episodes in which a patient has a primary payer other than Medicare during the 90-day lookback period or episode window Episodes where the claim(s) constitution the attributed HHA s treatment include a non-pps related condition code Episodes triggered by a RAP claim Episodes with outlier residuals below the 1 st percentile or above the 99 th percentile of the residual distribution OASIS-C2 Item(s) Used ne based on Medicare FFS claims Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 10 of 11

CLAIMS-BASED OUTCOME MEASURES Type Utilization Outcome Measure Title Potentially Preventable 30-Day Post-Discharge Readmission Measure (Claims based) HH Compare January 2019 NQF Risk Measure Description Numerator Denominator Measure-specific Exclusions Status Adjusted Number of home health stays for Number of home health stays Denominator Exclusions: stays in which patients who had patients who have a Medicare that begin during the 3-year Excludes claims for patients who: an acute inpatient discharge claim for unplanned, potentially observation period for patients within the 30 days before the preventable readmissions in the who had an acute inpatient Are under the age of 18 years start of their home health stay 30-day window beginning two hospital discharge within the 30 and were admitted to an acute days after home health days prior to the start of the HH Died during the home health stay care hospital or LTCH for discharge. stay and were discharged to the Did not have a short-term acutecare unplanned, potentially community from HH. stay within 30 days prior to a preventable readmissions in the HH admission date. 30-day window beginning two days after home health Are transferred at the end of a stay discharge. to another HHA or short-term acute care hospital OASIS-C2 Item(s) Used ne based on Medicare FFS claims Are not continuously enrolled in Parts A and B FFS Medicare (or those enrolled in Part C Medicare Advantage) for the 12 months prior to the post-acute admission date, and at least 31 days after the postacute discharge date. Are not discharged to the community. Are discharged against medical advice (AMA). The prior short-term acute-care stay was for nonsurgical treatment of cancer. Are transferred to a federal hospital from the HHA. Received care from a provider located outside of the United States, Puerto Rico, or a U.S. territory. Home Health Outcome Measures February 2017 OASIS-C2 (effective 01/01/2017) Centers for Medicare & Medicaid Services Page 11 of 11