DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
               
            SMD# 13-001 
            ACA #23 
 
            Re: Health Home Core Quality Measures 
 
January 15, 2013 
 
Dear State Medicaid Director:  
 
The health home provision authorized by section 2703 of the Affordable Care Act provides an 
opportunity to build a person-centered care delivery model that focuses on improving outcomes 
and disease management for beneficiaries with chronic conditions and obtaining better value for 
state Medicaid programs.  As part of this care improvement effort and after extensive 
consultation with states and other stakeholders, the Centers for Medicare & Medicaid Services 
(CMS) is sharing a recommended core set of health care quality measures for assessing the 
health home service delivery model that CMS intends to promulgate in the rulemaking process.   
 
While CMS is not requiring states to use these measures until the regulations are promulgated, 
states requested that we share these measures in advance of rulemaking.  In keeping with the 
collaborative process on the health home provision, CMS is sharing the core set to help states as 
they consider the design and implementation of their health home programs.  This advance 
notice will also give states time to share information with their health care providers, which is 
important, since health home providers will be required to report health care quality measures in 
order to receive payment.  
 
These recommended health home core quality measures are an integral part of a larger payment 
and care delivery reform effort that focuses on quality outcomes for beneficiaries.  This effort is 
aligned closely with the Department of Health and Human Services (HHS) National Strategy for 
Quality Improvement in Health Care, as well as other quality initiatives.   
 
CMS consulted with states considering health homes and conducted technical assistance calls, 
presentations, and webinars in order to identify the initial core set of health home quality 
measures for Medicaid-eligible children and adults.  CMS also worked with federal partners, 
including the Office of the Assistant Secretary for Planning and Evaluation and the Substance 
Abuse and Mental Health Services Administration.  The recommended core set of health home 
measures were chosen because they reflect key priority areas such as behavioral health and 
preventive care, and they align with the initial core set of health care quality measures for 
Medicaid-eligible adults, the EHR incentive Meaningful Use program measures, and with the 
National Quality Strategy.   
  Page 2  State Medicaid Director 
 
The recommended health home core measures are listed below and described in more detail in 
Attachment A:   
 
1.  Adult Body Mass Index (BMI) Assessment,  
2.  Ambulatory Care - Sensitive Condition Admission,   
3.  Care Transition  Transition Record Transmitted to Health care Professional,  
4.  Follow-up After Hospitalization for Mental Illness,   
5.  Plan- All Cause Readmission,  
6.  Screening for Clinical Depression and Follow-up Plan,  
7.  Initiation and Engagement of Alcohol and Other Drug Dependence Treatment,  
8.  Controlling High Blood Pressure. 
 
To ease the reporting burden, CMS has aligned all but one of the recommended health home core 
set of measures with the initial core set of health care quality measures for Medicaid-eligible 
adults, which were published and posted for public comment on December 30, 2010, with final 
regulations published on January 4, 2012.  CMS encourages states to report on the initial core set 
of childrens health care quality measures1 and the initial core set of health care quality measures 
for Medicaid-eligible adults.2   
 
The recommended health home measures are drawn from claims data, to the extent possible, in 
order to reduce burden on states.  However, CMS recognizes that certain measures in the core set 
require data extractions from medical records, and may require additional work for some 
providers and states.  CMS will provide state Medicaid agencies with the technical specifications 
for the core measures (e.g., numerator, denominator, and coding information) and will encourage 
states to delay system programming for the health home quality measures until these 
specifications are released.  The purpose of the recommended health home core set is to assess 
health outcomes specific to the health home program.  The health home core set will require 
reporting at the health home provider level, while the full Medicaid-eligible adult core set of 
health care quality measures will be reported in the aggregate at the state level.  CMS will 
provide technical assistance on the implementation of these recommended health home measures 
and intends to release guidance on when states should begin reporting on the measures, the 
frequency of reporting, and the reporting mechanism. 
 
The health homes core set of quality measures will be used to evaluate care across all state health 
home programs.  CMS expects that states will report on the health home core measures, as well  
as the specific goals and measures identified by individual states.  The intent of the two part 
quality reporting approach is to gain consistency across states while allowing states to use 
existing quality metrics to measure health home outcomes.  All of the quality data will be 
utilized by CMS to work with states and other stakeholders to continually improve health homes. 
The data will also be used to inform the evaluations that section 2703 of the Affordable Care Act  
                                         
1 Initial core set of childrens health care quality measures State Health Official letter, 
http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SHO11001.pdf 
2 Initial core set of health care quality measures for Medicaid-eligible adults, Federal Register / Vol. 77, No. 2 / 
Wednesday, January 4, 2012.  https://www.federalregister.gov/articles/2012/01/04/2011-33756/medicaid-program-
initial-core-set-of-health-care-quality  Page 3  State Medicaid Director 
 
require, in both an interim survey of states and an independent evaluation in the 2014 and 2017 
reports to Congress.  
For states interested in health homes, more information is available at the following link: 
http://www.medicaid.gov/AffordableCareAct/Provisions/Quality-of-Care-and-Delivery-
Systems.html.  States interested in receiving technical assistance may also e-mail the CMS health 
homes team at healthhomes@cms.hhs.gov. 
If you have any questions regarding the health home core measure set, please contact  
Ms. Barbara Edwards, Director of the Disabled and Elderly Health Programs Group, at  
410-786-0325.   
 
Sincerely, 
 
            /s/   
 
            Cindy Mann 
              Director 
 
 
 
 
cc:  
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health Operations 
 
Matt Salo 
Executive Director 
National Association of Medicaid Directors 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy 
 
Heather Hogsett  
Director, Committee on Health & Homeland Security 
National Governors Association 
 
Ron Smith 
Director, Legislative Affairs 
American Public Human Services Association 
    Page 4  State Medicaid Director 
 
 
Christopher Gould 
Director, Government Relations  
Association of State and Territorial Health Officials 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Robert Glover, PhD 
Executive Director 
National Association of State Mental Health Program Directors 
 
Robert Morrison 
Executive Director  
National Association of State Alcohol and Drug Directors 
  Attachment A- Health homes Core Measure Set 
 
NQF #  Measure Title   Measure Description  Numerator/Denominator  Alignment with 
Other CMS 
Programs 
N/A  1. Adult Body Mass Index (BMI)  Percentage of members 18-74  Numerator Description  Medicaid Adult 
Assessment  years of age who had an outpatient  Body mass index documented during the  Core Set, 
  visit and who had their BMI  measurement year or the year prior to the  HEDIS 
documented during the  measurement year 
measurement year or the year prior   
to the measurement year  Denominator Description 
Members 18-74 of age who had an 
outpatient visit 
 
N/A  2. Ambulatory Care-Sensitive  Ambulatory care sensitive  Numerator Description    
Condition Admission  conditions:  age-standardized acute  Total number of acute care hospitalizations 
care hospitalization rate for  for ambulatory care sensitive conditions 
conditions where appropriate  under age 75 years 
ambulatory care prevents or   
reduces the need for admission to  Denominator Description  
the hospital, per 100,000  Total mid-year population under age 75 
population under age 75 years. 
 
648  3. Care Transition  Transition  Care transitions:  percentage of  Numerator Description   Medicaid Adult 
Record Transmitted to Health  patients, regardless of age,  Patients for whom a transition record was  Core set 
care Professional  discharged from an inpatient  transmitted to the facility or primary 
facility to home or any other site of  physician or other health care professional 
care for whom a transition record  designated for follow-up care within 24 
was transmitted to the facility or  hours of discharge 
primary physician or other health  Denominator Description  
care professional designated for  All patients, regardless of age, discharged 
follow-up care within 24 hours of  from an inpatient facility (e.g., hospital 
discharge.  inpatient or observation, skilled nursing 
  facility, or rehabilitation facility) to 
home/self-care or any other site of care  
   
NQF #  Measure Title   Measure Description  Numerator/Denominator  Alignment with 
Other CMS 
Programs 
0576  4. Follow-Up After  Percentage of discharges for  Numerator Description   Childrens Core 
Hospitalization for Mental  members 6 years of age and older  An outpatient visit, intensive outpatient  Set, 
who were hospitalized for  encounter, or partial hospitalization (refer to  Medicaid Adult 
Illness 
treatment of selected mental health  Table FUH-C in the original measure  Core Set, 
disorders and who had an  documentation for codes to identify visits)  HEDIS 
outpatient visit, an intensive  with a mental health practitioner within 7 
outpatient encounter, or partial  days after discharge.  Include outpatient 
hospitalization with a mental  visits, intensive outpatient encounters or 
health practitioner within 7 days of  partial hospitalizations that occur on the 
discharge.  date of discharge. 
  Denominator Description  
Members 6 years of age and older 
discharged alive from an acute inpatient 
setting (including acute care psychiatric 
facilities) with a principal mental health 
diagnosis on or between January 1 and 
December of the measurement year  
 
1768  5.  Plan- All Cause Readmission  For members 18 years of age and  Numerator Description  Adult Core set, 
older, the number of acute  Count the number of Index Hospital Stays  HEDIS 
inpatient stays during the  with a readmission within 30 days for each 
measurement year that were  age, gender, and total combination 
followed by an acute readmission  Denominator Description 
for any diagnosis within 30 days  Count the number of Index Hospital Stays 
and the predicted probability of an  for each age, gender, and total combination 
acute readmission.   
 
2 
   
NQF #  Measure Title   Measure Description  Numerator/Denominator  Alignment with 
Other CMS 
Programs 
0418  6.  Screening for Clinical  Percentage of patients aged 18  Numerator Description  PQRS, CMS 
Depression and Follow-up  years and older screened for  Total number of patients from the  QIP, Medicare 
Plan   clinical depression using a  denominator who have follow-up  Shared Savings 
standardized tool AND follow-up  documentation  Program,  
documented  Denominator Description  Medicaid Adult 
All patients 18 years and older screened for  Core set, 
clinical depression using a standardized tool  Meaningful Use 
  2 
   
3 
   
NQF #  Measure Title   Measure Description  Numerator/Denominator  Alignment with 
Other CMS 
Programs 
0004  7.  Initiation and Engagement of  Percentage of adolescents and  Numerator Description  Meaningful Use 
Alcohol and Other Drug  adults members with a new  Initiation of AOD Dependence Treatment:  1 and 2, 
Dependence Treatment  episode of alcohol or other drug  Members with initiation of AOD treatment 
(AOD) dependence who received  through an inpatient admission, outpatient  Medicaid Adult 
the following:  visit, intensive outpatient encounter, or  Core set, 
  Initiation of AOD  partial hospitalization within 14 days of  HEDIS 
treatment.    diagnosis.   
  Engagement of AOD  Engagement of AOD Treatment:  Initiation 
treatment.  of AOD treatment and two or more inpatient 
admissions, outpatient visits, intensive 
outpatient encounters, or partial 
hospitalizations with any AOD diagnosis 
within 30 days after the date of the Initiation 
encounter (inclusive).  Multiple engagement 
visits may occur on the same day, but they 
must be with different providers in order to 
be counted. 
 
Denominator Description 
Members 13 years of age and older as of 
December 31 of the measurement year with 
a new episode of AOD during the intake 
period, reported in two age stratifications 
(13-17 years, 18+ years) and a total rate. 
The total rate is the sum of the two 
numerators divided by the sum of the two 
denominators. 
4 
   
NQF #  Measure Title   Measure Description  Numerator/Denominator  Alignment with 
Other CMS 
Programs 
0018  8.  Controlling High Blood  The percentage of patients 1885  Numerator Description  Million Hearts, 
Pressure  years of age who had a diagnosis  The number of patients in the denominator  Medicaid Adult 
of hypertension (HTN) and whose  whose most recent, representative BP is  Core set, 
blood pressure (BP) was  adequately controlled during the  Meaningful Use 
adequately controlled (<140/90)  measurement year. For a members BP to be  2, ACO 
during the measurement year.  controlled, both the systolic and diastolic  Measure 
BP must be <140/90mm Hg. 
 
 
Denominator Description 
Patients 18-85 with hypertension. A patient 
is considered hypertensive if there is at least 
one outpatient encounter with a diagnosis of 
HTN during the first six months of the 
measurement year. 
 
 
 
 
 
 
 
 
5