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INSIGHTS: By Barbara McCann, CHAP Interim CEO and President

 Medicare Certified Home Health Utilization Benchmarking Can Start the Road to QAPI:  Looking to the future, the use of benchmarking or dashboard to regularly assess your home health agency is a must, if you are not already doing it.  What role does utilization have?  It can be the indicator if you are providing effective and efficient care = value = quality.A key element of these efforts is utilization, or the number of visits per episode by discipline.  These utilization data determine cost, the effectiveness of clinical oversight and should always be considered  when looking at your outcomes. T

The following data is taken from the recently published proposed rule for the CY 2018 Home Health PPS payment, (need Federal Register Citation)  The data includes complete PPS episodes in 2015, abstracted from Medicare claims for episodes ending in 2015 that were  non-LUPA and tied to OASIS assessments.


2015 Avg. No Visits

Skilled Nursing


Physical Therapy


Occupational Therapy


Speech Pathology


Medical Social Work


Home Health Aide


Total Visits/ Episode



2016 Claims


Although these are averages, the number of claims is significant and therefore useful for benchmarking.  The claim year is CY 2015, but unless you believe that your staffing patterns have changed in the past year, this is still valid for use. 

  • Think of these averages as lights on the dashboard, you decide how much deeper  you need to investigate. 
  • Compare this CMS  data to your data for a 12 month period, if possible all non-LUPA Medicare FFS episodes ending in CY 2015, then replicate the data for non-LUPA episodes in Cy 2016. 
  • Key questions:
  • The number of skilled nursing visits/episode has hovered at 8 for some years what is your average number of nursing visits/PPS episodes. and has it
  • Did it change from CY 2015 to CY 2016?  If so, do you know why?  Does it make sense from a clinical practice standpoint?
    •   If <8.9, what is your admission rate, look at all the current measures for hospitalization.  Is that the % you want to be - your statement of expected quality in your organization in a QAPI plan.  If not, this can be a QAPI project, namely if your average is above expectations for Emergent Care or Hospitalization, and knowing that your data is risk adjusted, are patients receiving enough nursing care to avoid admissions?
    • If > 9 average visits/episode-the question is efficiency - namely are those visits warranted - or is the utilization appropriate to the clinical profile of the patient?  Yes, you will need to audit charts.  However, with the proposed changes for reimbursement in 2019-2020, this is important to understand.  One more item if > 9 visits/episode, look at the duration of each visit vs. skilled care offered.  CMS is now looking at nursing visits by minute-what is the in and out time for your nursing visits? 
    • Remember this project is limited to Medicare FFS patients only.

Questions?  E-mail them to: