New Claims-based Measures for Hospitalization and ED Use

As reported in the Final Rule for CY 2013, there are significant changes in how the home health hospitalization rates are calculated. On January 17, 2013, the hospitalization measures based on these new calculations were posted on Home Health Compare.  Specifically, the Acute Care Hospitalization (ACH) and Emergency Department (ED) Use Without Hospitalization are now based on Medicare claims-based data rather than on OASIS-based data.

Key points to note:

  • Claims-based measure is based on the Start of Care (SOC) date instead of the transfer/discharge date.
  • Numerator:  the number of home health stays for patients who have a Medicare claim for an admission to an acute care hospital or for an emergency department visit in the 60 days following the start of the home health stay.
  • Exclusions from the Measure Numerator
    • Planned hospitalizations are excluded from the acute care hospitalization claims-based measure numerator.
  • Observation stays that begin in a hospital emergency department but do not result in an inpatient stay within the 60 days after the start of home health care are counted in the ED Use without Hospitalization measure.
  • Observation stays that result in an inpatient stay within the 60 days after the start of home health care are counted in the Acute Care Hospitalization measure even if the patient is discharged from the home health agency.
  • Denominator:  the number of home health stays that began during the reporting period.
  • Exclusions from the Measure Denominator
    •  Home health stays for patients who are not continuously enrolled in fee-for-service Medicare during the 60 days following the start of home health stay. (Medicare lacks full information about the patients utilization of health care services and cannot determine if care was sought in an ED during the numerator window,  60 days time period)
    • LUPAs are excluded from claims-based measure
    • Home health stays in which the patient receives service from multiple agencies during the first 60 days are excluded from the denominator.
    • Home health stays for patients who are not continuously enrolled in fee-for-service Medicare for six months prior to the start of the home health stay. (This is excluded because Medicare lacks information about the patient’s health status that is needed for risk adjustment)
  • There is significant difference in the claims-data and the OASIS-data for the ACH measures so they are not comparable. To continue to track your ACH rate by OASIS-based data, this data will continue to be reported on the CASPER Reporting System.

For Specifications for Home Health Claims-Based Utilization Measures, Click Here

Return to www.thinkhomecare.org

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