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 are those of the authors. 

 No endorsement by MedPAC

 is intended or should be inferred.

A study conducted by

Outcome Concept Systems, Inc. for the

Medicare Payment Advisory Commission

March 2004 • No.0 4 - 1
 

The Effect of the Prospective Payment System on 

Home Health Quality of Care 

A comparison of overall outcomes pre-PPS (1999) and under the PPS (2002) 

Submitted to the Medicare Payment Advisory Commission 

by 

Outcome Concept Systems, Inc. 

March 2004
This report was prepared by staff from Outcome Concept Systems, Inc. 

Amanda Twiss, President 

Christine Lang, Product Manager 

Matt Pierce, Manager, Server Software Development 

Tina Schwien, BSN, MPH, MN, Data Project Manager 

Tim Ottersburg Data Associate 

Tra Khuc, Data Associate 

under contract with the Medicare Payment Advisory Commission 

(Sharon Bee Cheng, Project Officer) 
Executive Summary

Background 

Since the implementation of the home health prospective payment system (PPS) on October 1,

2000, there has been both industry and federal interest in the impact of this change in

reimbursement policy on the quality of care delivered by home health agencies. In particular, the

Medicare Payment Advisory Commission (MedPAC) has expressed interest in comparing the

overall quality of care provided by agencies prior to the implementation of PPS to the overall 

quality of care provided under the current system. 

Method 

In an effort to compare the overall quality of care provided in pre-PPS and PPS eras, a single 

measure of overall home health quality, referred to as a standardized quality index (SQI), was

developed. This method incorporates twenty different quality outcome measures that have

already been established for their utility in judging home health quality. In addition, it discounts 

the SQI based on whether patients experienced unplanned care events while on home health 

service. 

Analysis 

The method was applied to OASIS data submitted to CMS for 1999 and data submitted for 2002

to calculate a SQI for each time period. The SQI derived from the 1999 data provides an overall 

quality measure for care provided prior to the implementation of PPS. The SQI derived from the 

2002 data provides an overall quality measure for care provided after the implementation of

PPS. Additional analyses were conducted for each individual measure used to calculate the SQI

scores. This involved comparing the admission status of patients during 1999 and 2002,

calculating average scores for the individual items, and breaking out the percent of patients 

improved or declined for each measure. 

Findings 

There appears to be little difference in the overall quality of care provided by the home health 

industry in the pre-PPS and PPS eras. If anything, it would appear there has been a slight

increase in overall quality as the 1999 average SQI was 0.6328 and the 2002 average SQI was 

0.6843. This slight up-tick is also evident when comparing the SQI of different percentiles 

between the two timeframes. 

More detailed analyses of the individual measures used to calculate the SQI scores indicate that 

there was little difference in the percent of patients that improved, had no change, or declined

for each measure between the two time frames. 

Discussion 

Using a single measure of overall quality of care, such as an SQI, can facilitate analyses and 

discussions regarding overall quality of care provided by the home health industry. In particular, 

a single measure allows studies that seek to cross reference quality of care with other issues of

concern in the home health industry, such as profitability and staffing. A single measure,

however, provides only a general or “high level” insight into changes in quality. More detailed

analyses of the individual measures used to calculate a single measure can provide additional 

insight.
Background 

From 1990 to 1997, Medicare expenditures for home health services increased three times 

faster than spending for the program as a whole1

. In addition, during this period, there was 

dramatic growth in the use of home health services evidenced by a near doubling of the

percentage of Medicare beneficiaries receiving home health care and a jump from 36 to 73 in 

the annual number of home health visits2. Concerns regarding the skyrocketing Medicare costs

associated with this rapid growth prompted Congress to enact legislation that replaced

Medicare’s fee-for-service payment system to home health agencies with a more restrictive

prospective payment system (PPS). Specifically, in accordance with the Balanced Budget Act of 

1997 (BBA), an interim payment system was instituted in October 1997 that applied

reimbursement caps to the fee-for service system. This system was then replaced by the 

current PPS in October 2000. 

Under PPS, home health agencies receive a single payment for each 60-day episode of care for

a Medicare beneficiary. To determine base payments, Medicare requires home health agencies,

as a condition of participation, to collect and submit data using a standardized assessment tool 

called the Outcome and Assessment Information Set (OASIS)

3

 on all their patients. They use 

select data items from the OASIS that capture a patient’s anticipated therapy needs and other 

characteristics that can affect service use to calculate a base payment. This base payment is

then adjusted for differences in labor costs across geographic areas. 

Select data items collected in OASIS assessments are also used by Medicare to evaluate the 

quality of care provided by Medicare-certified home health agencies. Medicare calculates for

each agency what percentage of their patients improved, stabilized, or declined on a series of 

functional activities referred to as outcome measures. For instance, Medicare calculates what

percent of patients have improved in their ability to dress themselves, move about without pain,

or manage their own oral medications. In addition to calculating agency specific outcomes, 

Medicare also uses OASIS data to calculate national and state benchmarks for each outcome

measure to provide a frame of reference for use in analyzing agency outcomes. Agencies 

receive this information from CMS through outcome-based quality improvement (OBQI) reports 

or by accessing CMS’s Home Health Compare web site. 

 1

 Source: GAO Report, Medicare Home Health Care, May 2002. 2

 Source: CMS Health Care Industry Market Update: Home Health, June 28, 2002. 3

 OASIS was developed as a result of the Omnibus Budget Reconciliation Act of 1987 in which Congress mandated

CMS to create a standardized patient assessment tool to assist in monitoring agency quality. In 1999, CMS began 

requiring home health agencies to collect and submit OASIS data on their patients.

The Effect of the Prospective Payment System on Home Health Quality of Care
Since the implementation of PPS, there has been both industry and federal interest in the 

impact of this change in reimbursement policy on the quality of care delivered by home health 

agencies. In particular, the Medicare Payment Advisory Commission (MedPAC) has expressed 

interest in comparing the overall quality of care provided by agencies prior to the implementation

of PPS to the overall quality of care provided under the current system. 

Currently, Medicare does not use a standardized measure of overall quality in home health 

care. Quality is typically measured by individual outcome measures leading to quality

comparisons on specific measures, such as improvement in walking, rather than on an overall 

level. Theoretically, a single measure representative of overall quality in home health would be 

beneficial, rather than trying to balance the analysis of several individual outcome measures to 

understand overall quality of care. Using one measure could facilitate Medicare analyses that

seek to compare the quality of different groups of home health agencies to each other or for 

during different timeframes. Furthermore, using a single measure could facilitate the 

interpretation of these findings for researchers as well as policy-makers. 

The Effect of the Prospective Payment System on Home Health Quality of Care
Purpose 

Given the potential benefits of a single measure of overall quality and an interest in investigating 

whether or not the implementation of the PPS has impacted the quality of care delivered by the

home health industry, MedPAC contracted with Outcome Concept Systems, Inc. (OCS)4

 for the

following two purposes: 

1) To create a method for calculating a standardized quality index (SQI) – a single measure

that represents the overall quality of home health care at a national level 

2) To compare the overall quality of home health care prior to the implementation of PPS to

the level of quality under the current system 

Methodology

A single measure of overall home health quality, referred to as a standardized quality index

(SQI), was developed. This method incorporates twenty different quality outcome measures that 

have already been established for their utility in judging home health quality. In addition, it 

discounts the SQI calculation based on whether patients experienced unplanned care events

while on home health service. 

Outcome Measures 

According to both the CMS-sponsored OBQI program and the CMS Home Health Compare web

site, quality in the home health industry can be judged by how well an agency performs on a 

select set of outcome measures. These outcome measures are derived by looking at the

change in a patient’s health or functional status between two points in time. When calculating

outcome measures for the home health industry, CMS and other organizations typically 

compare a patient’s status at the time of discharge to that at the time of admission. This change 

in status is then used to reflect the quality of care delivered by the home health agency during 

that patient “case.” For instance, upon discharge, improvement or stabilization in a patient’s 

status on a specific measure can indicate that an agency is providing higher quality care than if 

a patient’s status had declined during that case. 

 4

 OCS is a pioneer in home health outcomes and benchmarking, providing clients with access to a national data 

warehouse benchmarking clinical, functional, visit utilization, and cost data to quantify and analyze the outcomes of 

home health services and the resources associated with achieving those outcomes 

The Effect of the Prospective Payment System on Home Health Quality of Care
Publications by various research organizations, such as AHRQ5,6, CHSPRC7

, and CMS8, have 

suggested criteria by which to select outcome measures that effectively represent quality care in 

the home health industry. Most notably, these include the following two suggestions: 

1) Home health outcome measures should capture changes in a patient’s status that can

be realistically impacted by home health services 

2) Outcome measures should be calculated based on objective data 

Based on CMS’s use of the term outcome measure and the two criteria noted above, twenty 

outcome measures that can be calculated from OASIS data were selected and incorporated into 

the SQI methodology. These outcome measures are listed in Table 1. 

Table 1. 

Outcome Measures and Associated OASIS Data Field 

M0-Number Outcome Measure

M0420 Pain

M0464 Status of most problematic pressure ulcer 

M0476 Status of most problematic stasis ulcer 

M0488 Status of most problematic surgical wound 

M0490 Dyspnea

M0530 Urinary Incontinence

M0540 Bowel Incontinence

M0570 Confusion

M0580 Anxiety

M0650 Upper body dressing

M0660 Lower body dressing

M0670 Bathing

M0680 Toileting

M0690 Transferring

M0700 Ambulation/locomotion

M0780 Management of oral medications 

M0790 Management of inhalant medications 

M0800 Management of injectable medications 

M0810 Patient management of medical equipment 

M0820 Caregiver management of medical equipment 

 5

 Source: http://www.cms.hhs.gov/quality/hhqi/HHQIAHRQ.pdf:, AHRQ Report on Home Health Quality Measures For 

CMS Public Reporting: Results of Technical Expert Panel Meeting and AHRQ Recommendations 6

 Source: http://www.qualityindicators.ahrq.gov/ 7

 Source: Shaughnessy PW, Crisler KS, Schlenker RE, Arnold AG, Kramer AM, Powell MC. and Hittle DF, Measuring 

and Assuring the Quality of Home Health Care. Health Care Financing Review, 16, No. 1, 35-65. 8

 Source: http://www.cms.hhs.gov/medicaid/survey-cert/sc0313.pdf, CMS Memorandum regarding Home Health 

Survey Protocol Enhancements, February 13, 2003 

The Effect of the Prospective Payment System on Home Health Quality of Care
Unplanned Non-Home Health Care Services 

In addition to helping patients maintain or improve their health status on certain objective 

measures, it has been suggested in AHRQ, CHSPRC, and CMS publications noted earlier that

reducing or preventing further patient health problems while the patient is being cared for by

home health also indicates that a patient has received quality care. In other words, when quality

care is provided, the unplanned need for non-home health care services is prevented or 

avoided. It is recognized, however, that external services cannot always be avoided, indeed 

they are sometimes the result of appropriate care and not the result of inappropriate or

inadequate care for the home health agency. 

Given these suggestions, the SQI methodology incorporates some incidents of urgent or

emergent care provided by non-home care providers in addition to outcome measures.

Specifically, unplanned hospitalizations or emergent care events for the following four reasons 

were selected to be included in the SQI calculation: 

• Injury caused by a fall or accident at home 

• Wound infection, deteriorating wound status, new lesion/ulcer

• Improper medication administration, medication side effects, toxicity, anaphylaxis 

• Hypo/Hyperglycemia, diabetes out of control 

Unplanned hospitalizations and emergent care for these reasons can be considered “sentinel” 

as they raise concern about quality for CMS surveyors. In other words, home health agencies 

providing high quality care should be more effective at reducing or preventing hospitalizations or

emergent care events for these specific reasons.

The Effect of the Prospective Payment System on Home Health Quality of Care
Standardized Quality Index (SQI) 

Having established which outcome measures and which unplanned care events are 

incorporated into the SQI calculation, this section describes the steps involved in the calculation:

• For each of the twenty measures, the patient’s start of care score for that measure is

subtracted from the score at discharge 

• Depending on whether the difference between the two scores is positive, negative, or 

there is no difference, a value is assigned to each patient case—The assignment of 

these values follows the logic that quality care is demonstrated by either improving or 

stabilizing a patient’s status on these measures during their home health stay 

• When the patient’s status improves, a value of +2 is assigned 

• When the patient’s status declines, a value of –1 is assigned 

• When the patient’s status stays the same, a value of +1 is assigned 

• When the data is missing, or the measure doesn’t apply to the patient (for example,

status of pressure ulcer for a patient with no pressure ulcers), a value of 0 is 

assigned 

• For every instance of unplanned non-home health care experienced by a patient for one 

of the four pre-defined reasons during their stay on service, a –1 is also assigned 

• The values assigned for outcome measures and unplanned care events are summed 

and divided by 20 to calculate an SQI value for each patient case 

• The SQI value for each patient case is then summed and divided by the total number of

cases, thus calculating the overall SQI for the group of interest 

The Effect of the Prospective Payment System on Home Health Quality of Care
Limitations 

The SQI methodology described above incorporates both outcome measures and unplanned 

care into a standardized quality index, theoretically capturing a broad range of quality indicators.

A possible limitation to this approach is that it adds outcome measures and unplanned care

events, which are dissimilar types of data. Specifically, the twenty outcome measures are based

on start of care and discharge information while unplanned care (hospitalization or emergent

care) are isolated events that occur at a point in time during the course of a patient’s stay on

service. The difference in data type raises some methodological questions. Should instances of 

unplanned care and outcome measures carry the same weight when being summed into an 

overall score? Can you add apples and oranges? Are these unplanned care events

preventable? Should agencies be “dinged” for linking patients to needed care? 

Pre-PPS SQI with PPS Home Health Quality 

With a SQI methodology, it is now possible to discuss the method for comparing the overall 

quality of home health care prior to the implementation of PPS to the level of quality under the

PPS system. 

Case Selection 

To make such a comparison, a SQI can be calculated for two groups of patient cases, one for

cases receiving care prior to the implementation of PPS and one for cases receiving care after 

its implementation. With access to OASIS data for all Medicare and Medicaid patients cared for 

by Medicare-certified home health care agencies in 1999 and 2002 provided by MedPAC, cases 

were selected for each group based on the criteria listed in Table 2. 

The Effect of the Prospective Payment System on Home Health Quality of Care
Table 2. 

Case Selection Criteria

Inclusion Criteria Rationale 

Pre-PPS Group • All Medicare and Medicaid cases 

that had both an admission 

assessment (Start of Care) and 

an end assessment (transfer or 

discharge) between August 1, 

1999 and December 31, 1999 

• This captures cases prior to the 

implementation of PPS on 

October 1, 2000 

• The requirement to collect OASIS 

data was not implemented until 

July 19, 1999 and submission 

was not required for assessments 

collected prior to August 1. 

PPS Group 1 • All Medicare and Medicaid cases 

that had both an admission 

assessment (Start of Care) and 

an end assessment (transfer or 

discharge) between January 1, 

2002 and December 31, 2002 

• This captures cases from the 

most recent timeframe for which 

data was made available 

PPS Group 2 • All Medicare and Medicaid cases 

that had both an admission 

assessment (Start of Care) and 

an end assessment (transfer or 

discharge) between August 1, 

2002 and December 31, 2002 

• This captures cases from the 

most recent timeframe for which 

data was made available, 

matching the date restrictions of 

the pre-PPS group 

The Effect of the Prospective Payment System on Home Health Quality of Care
Limitations of Case Selection 

The approach to selecting the pre-PPS and PPS groups described above presents some

limitations. By selecting only cases that have both start of care and discharge information within

a given time frame, cases that were admitted during one time frame and discharged during the

following time frame were excluded from analysis. As a result, the SQI scores ultimately 

calculated for the pre-PPS and PPS groups may not adequately reflect the quality of care 

provide to these types of patients—primarily those being cared for in winter weather months in

the northern states and “snow birds” in the southern states. Unfortunately, due to the OASIS 

implementation timelines in 1999, the pre-PPS data set is further limited in that it only includes 5 

months worth of data. This increases the impact of this limitation by eliminating more winter 

patients, all spring patients, and some summer patients. 

Similarly, the method of case selection excludes many cases in which patients have longer-term 

stays. This limitation results in excluding every patient with a length of stay greater than a year 

in the PPS group 1 and every patient with a length of stay greater than 5 months in the pre-PPS

group and PPS group 2. 

By applying the same standards to the two data sets, the effect of these limitations is minimized

in comparing the difference in quality between the two time frames. 

The Effect of the Prospective Payment System on Home Health Quality of Care
Analysis

Pre-PPS and PPS Quality Comparisons 

After selecting cases to represent the pre-PPS and PPS groups, the SQI methodology was 

applied to calculate a standardized quality index score for the cases of the pre-PPS and PPS 

groups. These scores were then compared. The findings are presented in the Findings section

of this report. 

Individual Outcome Measures and Unplanned Care Events 

In addition to calculating SQI for the pre-PPS and PPS groups, a more detailed analysis was 

conducted for each individual outcome measure and for unplanned care events. This involved

comparing the admission status of patients during 1999 and 2002, calculating average scores 

for the individual items, and breaking out the percent of patients improved or declined for each 

measure. These findings are presented in Appendix I. 

The Effect of the Prospective Payment System on Home Health Quality of Care
Principle Findings 

Table 3. 

Average SQI for 1999 and 2002

Pre-PPS 

Aug. – Dec. 

1999 

PPS-1 

Full Year 2002 

PPS-2 

Aug. – Dec. 

2002 

Total Cases Used in Analysis 648,070 2,302,632 792,704

Average SQI 0.6328 0.6843 0.6840 

Minimum SQI -0.75 -1.00 -0.75

Maximum SQI 1.60 1.65 1.60

Median SQI 0.70 0.70 0.70

Standard Deviation 0.271152928 0.263270473 0.262374789 

10th Percentile 0.3 0.4 0.4

20th Percentile 0.5 0.55 0.55

25th Percentile 0.55 0.6 0.6

30th Percentile 0.6 0.6 0.6

40th Percentile 0.65 0.65 0.65

50th Percentile 0.7 0.7 0.7

60th Percentile 0.7 0.75 0.75

70th Percentile 0.75 0.8 0.8

75th Percentile 0.8 0.85 0.85

80th Percentile 0.85 0.9 0.9

90th Percentile 0.9 0.95 0.95

The Effect of the Prospective Payment System on Home Health Quality of Care
Discussion and Concluding Remarks 

Through development and use of a methodology for calculating a single measure of quality, an 

SQI, it appears that, in general, there is little difference in the overall quality of care provided by 

the home health industry in the pre-PPS and PPS eras. If anything, it would appear there has 

been a slight increase in overall quality as the 1999 average SQI was 0.6328 and the 2002 

average SQI was 0.6843. This slight up-tick is also evident when comparing the SQI of different 

percentiles between the two timeframes. Furthermore, this trend appears to hold when

comparing the median SQI for both timeframes, which in both instances is nearly identical to the

average. 

Although overall quality has apparently not declined, to a layperson this finding may not look 

very positive. Since +2 indicates improvement, +1 indicates no change, and –1 indicates decline

for each measure, one might wonder whether an overall measure of quality of 0.6843 indicates 

that, on average, patients in 2002 experienced a slight decline. In other words, one might ask 

“Has overall quality stayed the same or somewhat improved since 1999, but, in general, this 

quality was not high to begin with as patients on average still did not improve by the time of 

discharge (+2 indicates improvement)?” 

To further understand this finding and how overall quality may have changed between the prePPS and PPS eras, it is also important to examine 1) how many patients could improve or 

decline and 2) how many did improve, stay the same, or decline during these two timeframes.

These findings are presented for the pre-PPS group and the PPS group 1 in Table 4 of 

Appendix 1. In addition, one can gain insight by understanding if there are differences in

average start of care scores for each measure, between the two timeframes—were patients 

more functionally dependent or independent in 2002 as compared to 1999? These findings are 

presented for the pre-PPS group and the PPS group 1 in Table 5 of Appendix 1. 

Using a method to calculate a single measure of overall quality of care, such as a SQI, can 

facilitate analyses and discussions regarding overall quality of care provided by the home health

industry. In particular, a single measure can facilitate future analyses that seek to cross 

reference quality of care with other issues of concern in the home health industry, such as 

profitability and staffing. A single measure, however, provides only a general or “high level”

insight into changes in quality. More detailed analyses of the individual measures used to 

calculate a single measure can provide additional insight.

The Effect of the Prospective Payment System on Home Health Quality of Care
Appendix I: Findings for Individual Outcome Measures and Unplanned Care Eve

Table 4. Percent Improved, Stayed the Same, and Declined for Individual Outcome Measures and Unplanned Carand 2002 

Percent Improved Percent No Change 

= +2 points = +1 points

Percent Declined

= -1 points 

Perce

Aug.-Dec. Aug.-Dec. 

1999 

Aug.-Dec. 

2002 1999 

Aug.-Dec. 

2002 

Aug.-Dec. 

1999 

Aug.-Dec. 

2002 

Aug.-

19

Pain 30.5% 34.7% 53.3% 52.3% 10.4% 8.8%Status of most problematic pressure ulcer 2.3% 3.0% 0.6% 0.8% 0.1% 0.1% 97.Status of most problematic stasis ulcer 1.1% 1.1% 0.3% 0.3% 0.1% 0.1% 98.Status of most problematic surgical wound 11.0% 17.0% 4.5% 7.2% 0.3% 0.5% 84.Dyspnea 27.7% 30.5% 53.7% 54.9% 12.9% 10.3%Urinary Incontinence 4.3% 4.9% 7.4% 11.8% 0.9% 1.1% 87.4Bowel Incontinence 4.4% 5.0% 84.7% 86.2% 2.7% 2.6%Confusion 12.7% 14.4% 71.7% 72.0% 9.4% 8.9%Anxiety 17.7% 18.7% 63.5% 65.6% 12.3% 10.6%Upper body dressing 27.8% 31.4% 60.7% 59.4% 5.8% 4.8%Lower body dressing 32.2% 36.8% 56.1% 54.0% 5.9% 4.9%Bathing 41.8% 46.8% 42.5% 40.4% 9.9% 8.5%Toileting 15.7% 18.3% 74.6% 73.9% 3.9% 3.5%Transferring 26.2% 30.3% 61.4% 59.8% 6.6% 5.6%Ambulation/locomotion 24.3% 26.9% 63.8% 64.0% 6.1% 4.8%Management of oral medications 15.9% 17.1% 69.6% 71.0% 6.6% 6.1% 7.9Management of inhalant medications 1.9% 2.0% 9.7% 10.7% 0.9% 0.8% 87.Management of injectable medications 1.3% 1.3% 6.5% 7.2% 0.5% 0.5% 91.Patient management of medical equipment 2.5% 2.5% 5.5% 5.8% 1.3% 1.2% 90.Caregiver management of medical equipment 1.4% 1.4% 4.7% 5.3% 0.9% 0.9% 93.

1 Event 2 Events 

= -1 point = -2 points 

3 Events 

= -3 points 

Aug.-Dec. Aug.-Dec. 

1999 

Aug.-Dec. 

2002 1999 

Aug.-Dec. 

2002 

Aug.-Dec. 

1999 

Aug.-Dec. 

2002 

Aug.-

19

Emergent Care 5.2% 4.0% 0.2% 0.2% 0.01% 0.01% 0% Unplanned Hospitalization 5.1% 3.8% 0.2% 0.2% 0.02% 0.02% 0% 

The Effect of the Prospective Payment System on Home Health Quality of Care
Table 5. 

Opportunity for Improvement/Decline in Individual Outcome Measures 

Percent Could Improve Percent Could Decline 

Aug.-Dec.

1999 

Aug.-Dec. 

2002 

Aug.-Dec. 

1999 

Aug.-Dec. 

2002 

Pain 57.3% 62.5% 92.8% 91.4%

Status of most problematic pressure ulcer 3.2% 3.9% 3.0% 3.5% 

Status of most problematic stasis ulcer 1.7% 1.6% 1.3% 1.1% 

Status of most problematic surgical wound 14.2% 22.3% 22.4% 29.4% 

Dyspnea 57.7% 59.1% 97.8% 97.7%

Urinary Incontinence 13.3% 18.7% 6.8% 9.1%

Bowel Incontinence 8.0% 8.7% 97.0% 95.7%

Confusion 32.0% 37.2% 97.3% 97.4%

Anxiety 36.3% 37.8% 98.1% 98.5%

Upper body dressing 49.2% 52.9% 93.0% 93.6% 

Lower body dressing 57.3% 62.5% 90.6% 90.4% 

Bathing 78.3% 85.1% 94.5% 95.5%

Toileting 28.6% 32.1% 95.0% 95.3%

Transferring 52.1% 64.7% 98.4% 98.7%

Ambulation/locomotion 76.1% 82.6% 98.8% 99.1%

Management of oral medications 48.1% 50.8% 80.2% 78.9%

Management of inhalant medications 7.7% 8.0% 17.9% 17.1%

Management of injectable medications 8.4% 9.3% 8.9% 8.4%

Patient management of medical equipment 10.6% 10.6% 9.6% 9.2%

Caregiver management of medical equipment 4.9% 5.2% 10.2% 10.6%

The Effect of the Prospective Payment System on Home Health Quality of Care
Table 6. 

Percent of Patients Who Did Improve/Decline of Those Who Could Improve/Decline 

Percent of patients who

did improve of those who

could improve

Percent of patients who

did decline of those who

could decline

Aug.-Dec.

1999 

Aug.-Dec. 

2002 

Aug.-Dec. 

1999 

Aug.-Dec. 

2002 

Pain 56.5% 57.9% 11.9% 10.0%

Status of most problematic pressure ulcer 79.4% 78.8% 4.1% 3.7% 

Status of most problematic stasis ulcer 72.0% 71.8% 4.6% 4.5% 

Status of most problematic surgical wound 82.6% 79.5% 1.6% 1.6% 

Dyspnea 50.9% 54.0% 14.0% 11.0%

Urinary Incontinence 34.2% 27.7% 13.8% 12.3%

Bowel Incontinence 62.5% 60.3% 3.1% 2.8%

Confusion 42.2% 40.4% 10.2% 9.6%

Anxiety 51.6% 51.9% 13.3% 11.3%

Upper body dressing 59.9% 62.0% 6.6% 5.4% 

Lower body dressing 59.6% 61.6% 6.9% 5.7% 

Bathing 56.7% 57.4% 11.2% 9.3%

Toileting 58.4% 59.7% 4.3% 3.8%

Transferring 53.4% 49.0% 7.1% 5.9%

Ambulation/locomotion 33.9% 34.0% 6.6% 5.1%

Management of oral medications 35.1% 35.1% 8.7% 8.0% 

Management of inhalant medications 26.7% 26.8% 5.3% 5.1%

Management of injectable medications 15.9% 15.1% 6.3% 6.6%

Patient management of medical equipment 25.5% 25.0% 9.5% 9.1%

Caregiver management of medical equipment 30.9% 28.4% 8.4% 7.8%

The Effect of the Prospective Payment System on Home Health Quality of Care