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New Transfer of Health (TOH) Measures, Explained

    The two Transfer of Health (TOH) process measures are new additions to the Home Health Quality Reporting Program (HH QRP). They will be publicly reported on Care Compare starting in January 2025, as outlined in the CY2024 Home Health Final Rule. The initial data for reporting on Care Compare will be derived from quality episodes ending between April 1, 2023, and March 31, 2024.

    To recall, these measures were adopted in the CY2020 Home Health Final Rule, but in response to the public health emergency, data collection was delayed until January 1, 2023.

    Learning more about TOH

    1. Transfer of Health Information to the Patient measure (TOH) – This measure assesses how timely home health agencies provide a patient’s reconciled medication list to the patient, family, or caregivers when the patient is discharged from home health.
    2. Transfer of Health Information to the Provider measure (TOH – Provider) – This measure assesses how timely home health agencies provide a patient’s reconciled medication list to a subsequent provider when the patient was transferred or discharged from home health to another provider.

    To accurately respond to OASIS items used to calculate the TOH measures, let’s define what is a ‘subsequent provider’ in this context.

    In OASIS Transfer, a subsequent provider refers to any inpatient facility where the patient was transferred (M0100: Assessment Reason = RFA 6 or 7). In OASIS Discharge, it could be another non-inpatient Medicare-certified home health agency or a home hospice setting providing skilled services for the patient after discharge from your agency. Other care programs or settings, such as primary care physician care or an outpatient clinic, will not be considered as subsequent providers.

    Home Health Process Measures

    Process measures in home health evaluate how frequently specific evidence-based care processes are used by home health agencies. These measures focus on high-risk and high-volume areas prone to issues in home health care, covering aspects like the timeliness of home care admissions.

    Data for process measures are collected from the OASIS submitted by home health agencies and are calculated based on a complete quality episode, starting from admission to a home health agency (or resumption of care after an inpatient facility stay) and concluding with discharge, transfer to an inpatient facility, or death.

    Unlike outcome measures, process measures are not risk-adjusted because the processes being assessed are deemed appropriate for all patients in the denominator, excluding those for whom the measure is not applicable.

    CMS started collecting TOH measure data with OASIS-E on January 1, 2023. From January 2024 onwards, agencies can check their performance in the Process Measure Report. Currently, you can view the results on the confidential iQIES Review and Correct Reports. For additional details and access instructions, refer to the iQIES Reports User Manual on