Discharge to the Community (OASIS Based)
Identifying Attributes
Care Settings
Country
Publishing Organisation
Type of Quality Indicator
IOM Quality Dimension
Domain
Defining Attributes
Definition
Percentage of home health stays in which patients were discharged to the community and do not have an unplanned admission to an acute care hospital or long-term care hospital in the 31 days and remain alive in the 31 days following discharge to community.
Numerator
Number of home health stays for patients who do not have an unplanned admission to an acute care hospital or long-term care hospital in the 31-day post- discharge observation window, and who remain alive during the post-discharge observation window.
Denominator
Number of home health stays that begin during the 2-year observation period.
Exclusions
Patients under 18 years of age, discharged to a psychiatric hospital; discharged against medical advice or to disaster alternative care sites or federal hospitals, discharged to court/law enforcement; to hospice, those who experienced a short-term acute care stay or psychiatric stay for non-surgical treatment of cancer in the 30 days prior to PAC admission, those discharged to another home health agency and baseline nursing facility residents that return to their nursing home as a place of residence.
Use of Risk Adjustment
Risk Adjustments
Adjusted for where appropriate: age, sex, payment source, care start/admission source, risk of hospitalisation, available assistance, living arrangement, clinical factors (pain, pressure ulcer, stasis ulcer, dyspnoea, urinary status, bowel incontinence, cognitive function, anxiety, confusion, depression screening, behavioural symptoms), ADLs, medication management, supervision / safety assistance, health condition diagnoses.
Stratifications
None
Data Attributes
Type of Data Collection
Data Collection Methods
Outcome and Assessment Information Set (OASIS). Entry of home health service and the last 5 days of every 60 day period beginning with the start of care date.
Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Home Health Quality Reporting (CMS and providers). Not reported on CMS Care Compare or CMS Provider Data Catalogue.