Discharge to the Community (OASIS Based)

Identifying Attributes

Care Settings
Home Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Home Health Quality Reporting Program
Type of Quality Indicator
Outcome
IOM Quality Dimension
Safety
Domain
Service Delivery / Care Planning

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
Yes
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
Standardised clinical data
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
60 days
Frequency of Data Collection in Days
60
Reporting Methods

Home Health Quality Reporting (CMS and providers). Not reported on CMS Care Compare or CMS Provider Data Catalogue.

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
Indicator Has Recommended Targets
No

Source and Reference Attributes

Technical Specifications
Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025