Quality Measures

CMS Reports on NEW Transfer of Health Quality Measures: 

What are the Transfer of Health (TOH) Process Measures and when can Home Health Agencies view their data?

Transfer of Health Process Measures (TOH)

Transfer of Health (TOH) Information to the Patient and Transfer of Health Information to the Provider are new process measures used in the Home Health Quality Reporting Program (HH QRP).

• 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.

• 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.

It’s important to know the definition of a “subsequent provider” to accurately code the OASIS items used to calculate these measures. For the TOH measures, a subsequent provider is identified at Transfer when the patient has transferred to any inpatient facility (M0100: Assessment Reason = RFA 6 or 7).

At Discharge, a subsequent provider is identified when the patient has been discharged from your agency and remained in a non-inpatient setting receiving skilled services from another Medicare-certified home health agency or home hospice.

Remember that although your patient may receive care from other providers after discharge, such as their primary care physician, out-patient clinics, etc., these locations are not considered to be a subsequent provider. Read the Outcome and Assessment Information Set OASIS-E Manual from CMS.

Transfer of Health Measures on iQIES Process Measure Report

CMS defines process measures as a way to “…evaluate the rate of home health agency use of specific evidence-based processes of care.” (Home Health Quality Measures | CMS) Process measures are derived from OASIS data agencies have collected and submitted to CMS.

Quality measures are calculated using a completed quality episode, beginning with a start of care (SOC) or resumption of care (ROC) and ending with a discharge, transfer, or death at home OASIS time points.

Process measures are not risk-adjusted as process measures are appropriate for all patients in a measure denominator. The CMS Process Measure Table provides a brief overview of all of the process measures that are included in the HH QRP: Home Health Process Measures Table (cms.gov)

Agencies have been collecting data for the TOH measures since data collection began for OASIS-E on January 1, 2023. Beginning in January 2024, agencies can view their performance in their Process Measure Report. Currently, agencies have access to the measure results from these measures on their confidential iQIES Review and Correct Reports. Find more information on this report and how to access it here: iQIES Reports User Manual (cms.gov).

Transfer of Health Process Measure on Care Compare

The Transfer of Health (TOH) Process Measures will be first publicly reported on Care Compare beginning in January 2025, as finalized in the CY2024 Home Health Final Rule (2023-24455.pdf govinfo.gov). 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.

Public reporting on Care Compare was then also delayed until January 2025. OASIS data that will be used to first report these measures on Care Compare will be taken from quality episodes that end between April 1, 2023, through March 31, 2024.