Five Star Agency

The Centers for Medicare and Medicaid Services established the Home Health Compare (HHC) website on as a key tool for patients and referral sources to use when choosing a home health care provider.  It is designed to be an easy-to-access, convenient source of authoritative information on provider quality. During the years since the implementation of the Home Health Compare website, CMS has identified that patients and referral sources have struggled to make sense of the large amount statistical details presented for each agency. Many consumers expressed frustration to decipher the details, especially when faced with an urgent need to find a home health provider.

The star ratings program was added to make the information easier to use. The purpose of the program is to summarize certain measures of a home health agency’s performance that is already present on the Home Health Compare website. At this time, Star Rating results are strictly intended to support consumer choice when selecting a home health agency. The Star Ratings are not used in the determination of an agency’s compliance with the annual payment update requirements.

The Home Health Compare program includes two types of star ratings:

  • The Quality of Patient Care Star Rating is based on OASIS assessments and Medicare claims data.  These ratings were first published on Home Health Compare in July, 2015.

  • Patient Survey Star Ratings are based on the patient experience of care measures from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey instrument. These ratings are scheduled for publication on Home Health Compare in January 2016.

Both types of Star Ratings are updated quarterly on the Home Health Compare website.


Quality of Patient Care Star Ratings

The Quality of Patient Care Star Ratings apply to 9 of the 27 currently reported process and outcome quality measures.

Star Rating measures were chosen based on the following criteria:

  • They applied to a substantial proportion of home health patients.

  • There is sufficient data to report for a majority of home health agencies.

  • They show a reasonable amount of variation among home health agencies.

  • There is the possibility for a home health agency to show improvement in performance of the measure.

  • The measure has high face validity and clinical relevance.

  • The measure is stable and has not shown substantial random variation over time.

The nine Quality of Patient Care Star Rating Measures selected include the following three process measures:

  • Timely Initiation of Care

  • Drug Education on all Medications Provided to Patient/Caregiver

  • Influenza Immunization Received for Current Flu Season

And the following six outcome measures:

  • Improvement in Ambulation

  • Improvement in Bed Transferring

  • Improvement in Bathing

  • Improvement in Pain Interfering with Activity

  • Improvement in Shortness of Breath

  • Acute Care Hospitalization

CMS includes the following star rating details on the Home Health Compare website:

  • A 4- or 5-star rating means that the agency performed better than other agencies on the 9 measured care practices and outcomes.

  • A 1- or 2-star rating means that the agency’s average performance on the 9 measured care practices and outcomes was below the averages of other agencies.

Across the country, most agencies fall “in the middle” with 3 or 3½ stars.

CMS issues preview reports to agencies showing the Quality of Patient Care Star Ratings and rating calculations approximately 3.5 months before the ratings are published on Home Health Compare.  Agencies have several weeks to review the results. If they have data to support that the results are inaccurate, they can request that CMS review their rating.

Star Ratings Example

Patient Survey Star Ratings

The Patient Survey Star Ratings are based on the HHCAHPS data that are publicly reported on the Home Health Compare website. The Star Ratings are based on data from the HHCAHPS Survey, a national, standardized, 34-item survey of patients’ experience of care received from their home health agency.

Patient Survey Star Ratings are applied to each of the three publicly reported composite measures and from the HHCAHPS global item. These measures arise from specific questions on the survey.

The three HHCAHPS composite measures are:

  • Care of Patients (Q9, Q16, Q19, and Q24)

  • Communication Between Providers and Patients (Q2, Q15, Q17, Q18, Q22, and Q23)

  • Specific Care Issues (Q3, Q4, Q5, Q10, Q12, Q13, and Q14)

The HHCAHPS Global Item is:

  • Overall Rating of Care Provided by the Home Health Agency (Q20)

Summary Star Rating

In addition, the Patient Survey Star Ratings includes a Summary Star Rating that is based on the four HHCAHPS measures (the three composites and the one overall) that receive Star Ratings. The Survey Summary Star averages these ratings and rounds the score using normal rounding rules.

CMS assigns 1 to 5 stars for each HHCAHPS measure by applying statistical methods that analyze the relative distribution of scores from the survey results. To calculate the Patient Survey Star Ratings, the responses to the HHCAHPS Survey items are combined and converted to a 0-100 score, which is called the “Linear Score.” The 0-100 linear score is then adjusted for the effects of patient mix to account for the tendency of certain patient subgroups to respond more positively or negatively to the HHCAHPS Survey. Next, the four-quarter averages of HHCAHPS linear scores are rounded to whole integers using standard rounding rules. CMS assigns 1, 2, 3, 4, or 5 stars for each HHCAHPS measure by applying statistical methods that analyze the relative distribution of scores. The Star Rating for each of the four HHCAHPS measure is determined by applying a clustering algorithm to the individual measure scores across home health agencies.

HHCAHPS Star Ratings are assigned in a way that minimizes differences within star groups and maximizes differences between star groups. The clustering algorithm empirically determines the number of home health agencies in each Star Rating category independently for each HHCAHPS measure. For this reason, the number of home health agencies receiving stars may differ for each HHCAHPS Star Rating

Because the cluster distribution of agencies is recomputed with each 12-month public reporting period, the scores that designate each Star Rating cluster may change. For this reason, an agency’s Star Rating may change, even though its linear scores stay the same.

HHCAHPS scores, in general, are tightly clustered at the top end of the score range across most of the publicly reported measures. This means that a change of one percentage point on a particular HHCAHPS measure may be enough to move that agency from one cluster category to another. A 5-Star Rating denotes the highest category of home health agency performance across the measures included in the rating calculation. Not all home health agencies with above average HHCAHPS scores will attain this designation.

The first public reporting of the Patient Survey Star Ratings will be January 2016. The data that will be reported on Home Health Compare in January 2016 for both the HHCAHPS publicly reported measures and the associated Star Ratings will reflect HHCAHPS Survey data collected from July 2014 through June 2015.

Agencies Impacted by The Star Rating Program

While all Medicare-certified home health agencies are potentially eligible to receive a Quality of Patient Care Star Rating, currently, agencies must have at least 20 complete quality episodes for data for each measure to be reported on Home Health Compare. A quality episode spans from admission or resumption of care to discharge or transfer to an inpatient facility.

Because most quality measures are calculated at discharge, episodes must have an end-of-care date within the 12-month reporting period regardless of the start of care date. Agencies must also have reported data for 5 of the 9 measures used in the Quality of Patient Care Star Rating calculation.

Success Star RatingsHome health agencies that are subject to Patient Survey Star Ratings must have 40 or more completed surveys over the four-quarter reporting period for which survey data is reported. Agencies that do not have 40 or more completed surveys for calculating Star Ratings will still have their HHCAHPS data publicly reported on the Home Health Compare website.

At least 40 surveys are necessary to support statistical reliability. Caseloads at some small home health agencies may vary, which could mean that they meet the threshold for reporting a quality measure for some quarters and not others.

Preparing for Success

To be successful with the star rating program, agencies must continue to focus on quality and customer service. Clinicians need to be aware of the significance of this visual indicator and how they contribute to results. Whether it’s a movie, restaurant, hotel or home health agency, consumers demand high-quality services.