CMS has published preview reports for the upcoming January 2025 Care Compare refresh. HHAs can access this preview data as part of their October 2024 Care Compare Provider Preview Report in iQIES.
The January 2025 refresh of Care Compare will include three new home health quality measures:
- Transfer of Health Information (TOH) to the Provider
- Transfer of Health Information (TOH) to the Patient
- Discharge Function Score
Let’s review each measure and what they entail:
Transfer of Health Information (TOH) to the Provider
This measure evaluates how promptly health information, specifically a reconciled medication list, is transferred when a patient is discharged or transferred to another care provider.
Who is considered a subsequent provider? A subsequent provider includes any of the following:
- Short-term general hospital
- Skilled nursing facility (SNF)
- Intermediate care facility
- Home under the care of an organized home health service or hospice
- Hospice in an institutional setting
- Inpatient rehabilitation facility (IRF)
- Long-term care hospital (LTCH)
- Medicaid nursing facility
- Inpatient psychiatric facility
- Critical access hospital
How is the measure calculated?
The measure is calculated as a percentage, determined by:
- Numerator: The number of home health quality episodes ending in discharge or transfer where the agency provided a current, reconciled medication list to the subsequent provider at the time of discharge or transfer (as indicated in the OASIS).
- Denominator: The total number of quality episodes ending in discharge or transfer to one of the subsequent providers listed above.
OASIS Items Used:
- A2120 (Provision of Current Reconciled Medication List to Subsequent Provider at Transfer)
- A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge)
- A2122 (Route of Current Medication List Transmission to Subsequent Provider)
- M2420 (Discharge Disposition)
- M0100 (Reason for Assessment)
Transfer of Health Information (TOH) to the Patient
This measure evaluates how promptly a reconciled medication list is provided to the patient, their family, or caregiver when the patient is discharged from home health care to one of the following settings:
- Private home or apartment
- Board and care home
- Assisted living facility
- Group home
- Transitional living setting
How is the measure calculated?
The measure is expressed as a percentage, calculated as follows:
- Numerator: The number of quality episodes ending in discharge where the OASIS indicates that, at the time of discharge, the agency provided a current reconciled medication list to the patient, family, or caregiver.
- Denominator: The total number of quality episodes ending in discharge to a private home, apartment, board and care home, assisted living facility, group home, or transitional living setting.
OASIS Items Used:
- A2123 (Provision of Current Reconciled Medication List to Patient)
- A2124 (Route of Current Medication List Transmission to Patient)
- M2420 (Discharge Disposition)
- M0100 (Reason for Assessment)
Discharge Function Score
This measure tracks the percentage of home health patients who meet or exceed their risk-adjusted expected function score at discharge. Functional status focuses on a patient’s ability to perform daily self-care tasks (GG0130) and mobility activities (GG0170).
How is the measure calculated?
The measure is expressed as a percentage, determined as follows:
- Numerator: The number of home health quality episodes where the observed discharge function score for Section GG function items is equal to or greater than the calculated expected discharge function score.
- Denominator: The total number of home health quality episodes ending in discharge during the reporting period, excluding episodes that meet specific exclusion criteria.
Exclusions:
- Episodes ending in transfer, patient death at home, or those lasting fewer than 3 days.
- Episodes involving patients who are non-responsive due to conditions like coma, persistent vegetative state, complete tetraplegia, locked-in syndrome, severe anoxic brain damage, cerebral edema, or brain compression.
- Episodes where the patient is discharged to hospice (either home or institutional facility).
OASIS Items Used:
- (GG0130A) Eating
- (GG0130B) Oral Hygiene
- (GG0130C) Toileting Hygiene
- (GG0170A) Roll Left and Right
- (GG0170C) Lying to Sitting on Side
- (GG0170D) Sit to Stand
- (GG0170E) Chair/Bed-to-Chair Transfer
- (GG0170F) Toilet Transfer
- (GG0170I) Walk 10 Feet
- (GG0170J) Walk 50 Feet with 2 Turns
- (GG0170R) Wheel 50 Feet with 2 Turns
- (M1021) Primary diagnosis
- (M1023) Other diagnoses
- (M1700) Cognitive functioning
- (M2420) Discharge Disposition
- (M0100) Reason for Assessment
Agencies should review their performance data in the January 2025 Care Compare refresh to identify areas for improvement, particularly in the new measures, and use this insight to provide targeted education for staff. It’s essential for home health agency staff to fully understand how these new measures work and their significance. By aligning processes and documentation with the intent of these measures, agencies can improve quality reporting accuracy and optimize their performance in star ratings and HHVBP.
Ensure your QA team is well-versed in these new mechanisms, as they play a key role in helping clinicians maintain accuracy, especially with OASIS items that impact the new quality measures.
