DEPARTMENT OF HEALTH  & HUMAN SERVICES  
Centers for Medicare & Medicaid Services  
7500 Security Boulevard,  Mail  Stop S2-26-12  
Baltimore, Maryland    21244-1850  
 
 
 
 
CMCS Informational Bulletin  
 
DATE:  February 16, 2022 
 
FROM:  Daniel Tsai,  Deputy Administrator and Director of Center for Medicaid and CHIP  
services   
 
SUBJECT: 2022 Updates to the Health Home Core Health Care Quality Measurement Sets   
 
This Center for Medicaid & CHIP Services (CMCS)  Informational Bulletin describes the updates  
to the 2022 Health Home Core Set of quality measures for Medicaid individuals with chronic  
conditions who receive health home services.    
 
Background  
 
To help ensure that health home enrollees receive  high quality care and improved health 
outcomes, CMCS, along with stakeholder input, developed and released an initial Health Home  
Core Set in 2013.1  The purpose of the Health Home Core Set is to monitor and assess the overall  
quality of care for Medicaid health home enrollees through a uniform set of measures.  
 
Since the inception of the Health Home Core Set,  CMCS has collaborated with state Medicaid  
agencies to voluntarily collect, report, and use the core set of measures to drive quality  
improvement.  As of  December 2021, 21 states and the District of Columbia have 37 approved 
health home programs, with some states submitting multiple state plan amendments (SPAs) to  
target different populations.2   
 
Stakeholder Workgroup  
 
During 2021, a new  review process was implemented to ensure the Health Home Core Set of  
quality measures assess  equitable care and continue to reflect and be responsive to the needs of  
the health home population.  CMS convened a Medicaid Health Home  Core Set Annual Review  
Stakeholder Workgroup, which included 14 members representing a diverse set of stakeholders  
including state Medicaid agency representatives, health care providers, quality experts and 
federal partners with measure expertise.  This multi-stakeholder workgroup began the annual  
review of the Health Home Core Set by  assessing the 2021 Health Home Core Set and  
recommending measures  for removal  and/or addition, in order to strengthen and improve the  
Health Home Core Set for 2022.  Workgroup members were asked to suggest, discuss, and vote  
on the measures based on Health Home Core Set  measures which are reported at the program  
                                                 
1  SMD-13-001.pdf (medicaid.gov)  
2  Medicaid Health Homes: SPA Overview   level.  Additional information about the 2021 Health Home annual review  process including the  
workgroup recommendations can be found at:  
https://www.mathematica.org/features/hhcoresetreview  
 
2022 Health Home  Core Set Updates   
Based on the input received through this annual review process described above, CMCS will 
build upon the 2021 Core Set3  by adding two new  measures:   
   Follow-Up After Emergency Department (ED)  Visit for Mental Illness  (FUM), NQF 
#3489 which measures the percentage of ED visits for beneficiaries age six and older  
with a principal diagnosis of mental illness or intentional self-harm and who had a  
follow-up visit for mental illness.4   Two rates are reported for this measure:  (1) the  
percentage of ED visits for mental illness for which the beneficiary received follow-up 
within 30 days of the ED visit; and (2) the percentage of ED visits for mental illness for  
which the beneficiary  received follow-up within 7 days of the ED  visit.   
   Colorectal Cancer Screening (COL), NQF# 0034 which measures the percentage of  
patients 50 to 75 years of age who had appropriate screening for colorectal  cancer.5    
 
Effective Date of Revisions to the Core Sets   
 
The 2022 updates to the  Core Sets (see attachment) will take effect in the Federal  Fiscal Year  
(FFY) 2022 reporting cycle.  To support states, CMCS will release updated technical  
specifications for the Health Home Core Set in spring 2022.6  States with questions or that need 
further assistance with reporting and quality improvement regarding the Health Home Core Set  
can submit questions or requests to:  MACQualityTA@cms.hhs.gov.  
 
If  you have questions about this bulletin, please contact Sara Rhoades, Health Home Technical  
Director,  at sara.rhoades@cms.hhs.gov.  
 
 
 
 
 
 
 
 
 
 
 
                                                 
3  https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/downloads/2021-health-home-core-set.pdf   
4  Measure Steward: National Committee for Quality  Assurance (NCQA)  
5  Measure Steward: National Committee for Quality  Assurance (NCQA)  
6  Health  Home Quality Reporting |  Medicaid   2022 Core Set of Health Care Quality Measures for  Medicaid Health Home Programs  (Health Home 
Core Set)  
Measure 
NQF #   Steward   Measure Name   Data Collection Method  
Core Set Measures  
0004   NCQA   Initiation and Engagement of Alcohol and Other Drug Abuse or   Administrative or EHR  
Dependence Treatment (IET-HH)  
0018   NCQA   Controlling High Blood Pressure (CBP-HH)   Administrative, hybrid, or EHR  
0034   NCQA   Colorectal Cancer Screening (COL-HH)*  Administrative, hybrid, or ECDS  
0418**/   CMS   Screening for Depression and Follow-Up Plan (CDF-HH)   Administrative or EHR  
0418e**  
0576   NCQA   Follow-Up After Hospitalization for Mental Illness (FUH-HH)   Administrative  
1768**   NCQA   Plan All-Cause Readmissions (PCR-HH)   Administrative  
3400   CMS   Use of Pharmacotherapy for Opioid Use Disorder (OUD-HH)   Administrative  
3488   NCQA   Follow-Up After Emergency Department Visit for Alcohol  and Other   Administrative  
Drug Abuse or Dependence (FUA-HH)  
3489   NCQA   Follow-Up After Emergency Department Visit for Mental Illness    Administrative  
(FUM-HH)* 
NA   AHRQ   Prevention Quality Indicator (PQI) 92: Chronic Conditions Composite  Administrative  
(PQI92-HH)  
Utilization Measures  
NA   CMS   Admission to an Institution from  the Community (AIF-HH)   Administrative  
NA   NCQA   Ambulatory Care: Emergency Department (ED) Visits (AMB-HH)   Administrative  
NA   CMS   Inpatient Utilization (IU-HH)   Administrative  
* This measure was added to  the 2022 Health Home Core Set.   
** This  measure is no  longer endorsed  by NQF.  
AHRQ = Agency for Healthcare Research & Quality; CMS  =  Centers for Medicare & Medicaid Services; ECDS  = Electronic  Clinical Data Systems;  EHR =  
Electronic Health Record;  NA =  Measure is  not NQF endorsed; NCQA = National Committee for Quality Assurance;   
NQF = National Quality Forum.