CMS replaced the Acute Care Hospitalization (ACH) and Emergency Department (ED) Use claims-based measures with Potentially Preventable Hospitalizations (PPH) in the Home Health Value-Based Purchasing (HHVBP) Model. This transition began with the CY 2023 performance year and will affect payments starting in CY 2025.
This change is part of CMS’s efforts to refine the HHVBP Model by focusing on preventable hospitalizations through quality home health care to better align HHVBP incentives with efforts to reduce avoidable hospital utilization.
How PPH is Different from ACH and ED Use
There were concerns about the shift because the PPH measure takes into account the entire length of a patient’s stay, whereas ACH only considered the first 60 days. This broader focus could impact performance scores and require more work checking documentation accuracy, especially for agencies caring for higher acuity patients.
Unlike ACH and ED Use, which only evaluated the first 60 days of a home health episode, PPH considers the entire length of a patient’s stay—whether it is 30 days or 6 months. This broader focus allows for a more comprehensive understanding of hospitalization risk throughout the patient’s care.
PPH’s Risk Adjustment Model
PPH also introduces its own risk adjustment model, which benefits agencies that care for higher acuity patients. Those who previously felt penalized under the ACH measure now receive risk adjustments based on:
- Patient demographics
- Care received during prior proximal hospitalization
- Other care received within one year of stay
This provides a more equitable approach, particularly for agencies that care for high-acuity patients. What was once seen as a disadvantage under ACH is now addressed through these adjustments, offering fairer, more context-driven scores under PPH.
Strategies for Managing and Reducing PPH Risks
While the change in measures might feel overwhelming, home health agencies can still take concrete steps to manage and reduce PPH risks. Here are some actionable strategies:
- Focus on Key Outcomes – CMS has emphasized that improving functional ability, dyspnea management, and medication management are critical for reducing hospitalization risks. These outcomes are central to both HHVBP and Star Ratings, so improving them can help boost both performance measures.
- Address Social Determinants of Health (SDoH) – Unmet social needs are a significant driver of preventable hospitalizations. It is essential to screen patients for social risks and provide the appropriate support, whether it is through community resources or enhanced care coordination.
The Role of QA Review in Preventing Hospitalizations
Ensuring thorough and accurate documentation through QA review also helps prevent patient hospitalization. Proper assessment and documentation in the OASIS and ICD coding not only support effective care planning but also help clinicians address potential risks before they escalate. Key areas where QA review makes a significant impact include:
- Early Identification of Risks – QA reviews ensure that high-risk factors (e.g., falls, infections, medication mismanagement) are properly documented, allowing clinicians to intervene early.
- Proper Care Coordination – Ensures that care plans reflect necessary interventions, preventing complications that could lead to hospitalization.
- Medication Reconciliation – Identifies discrepancies in medications that could cause adverse effects, ensuring safer medication management.
- Compliance with Best Practices – Ensures documentation aligns with CMS guidelines, improving patient outcomes and reducing rehospitalization risks. By maintaining high-quality documentation and adherence to best practices, QQA supports home health agencies in delivering safe and effective patient care, reducing unnecessary hospitalizations.
The shift to PPH under HHVBP brings challenges but also opportunities for fairer agency performance evaluations. By focusing on key outcomes, leveraging OASIS-E1, and ensuring accurate documentation, agencies can improve performance and reduce preventable hospitalizations.
