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Reach for the Stars

Panozzo, Gina, DNP, RN-BC

doi: 10.1097/NHH.0000000000000654

Star Ratings were implemented by the Centers for Medicare and Medicaid Services for home healthcare agencies with the first release of measures in 2015 and 2016. Hospital Compare also displays Star Ratings, and Hospice also will soon have the Hospice Information Set displayed on Hospice Compare. Star Ratings in home healthcare are determined by a specific methodology and are based on nine quality areas. One set of Stars designates the nine quality areas and a second set of Stars reflects consumer satisfaction. This article discusses quality of patient care Star Ratings but not those based on Consumer Assessment of Healthcare Provider and Systems outcomes. Few agencies reach above 3-Star Ratings; the majority fall within 3 and 3.5 with the national benchmark being 3.5. Agencies should strive for high Star Ratings as consumers, hospitals, and other referral sources may base their decisions on the number of stars received.

Gina Panozzo, DNP, RN-BC, is an Assistant Professor, Department of Nursing and Health, Benedictine University, Lisle, Illinois.

The author declares no conflicts of interest.

Address for correspondence: Gina Panozzo, DNP, RN-BC, 24358 Leski Lane, Plainfield, IL 60585 (



In addition to various outcome measures being displayed on Home Health Compare, Star Ratings were developed to assist healthcare organizations and consumers to select a home healthcare agency for services. Star Ratings, in a sense, are a conclusive summary representation of how home healthcare agencies are performing overall, assigning up to five stars presented in a quick visual image. Star Ratings include outcomes in two areas: quality of patient care and patient survey data. This article focuses on quality of patient care, not Consumer Assessment of Healthcare Provider and Systems. Star Ratings were first published in July 2015 for quality of patient care data, and in January 2016, for patient survey data. Ratings are updated quarterly. Nine of 24 measures on Home Health Compare are included in the consideration of Star Ratings for the quality of patient care ratings. These measures include timely initiation of care, drug education on all medications provided to patient/caregiver, influenza immunization received for current flu season, acute care hospitalizations, and improvement in the following: ambulation, bed transferring, bathing, pain interfering with activity, and shortness of breath. A specific methodology is utilized by the Centers for Medicare and Medicaid Services (CMS) (CMS, 2017a). Stressing the significance and relevance of quality care and survey data, Hospital Compare also uses a Star Rating system and hospice will soon also have Star Ratings for Hospice Information Set (Caron et al., 2016 ; CMS, 2016).

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Why Five Stars?

Star Ratings create a visual picture of quality, just as with restaurants, hotels, and movies. The consumer is interested in selecting a five-star experience. Consider the following: if there were an opportunity to stay at a five-star hotel over a four- or three-star hotel, and cost is the same, the five-star hotel is more likely to attract the business. Furthermore, the national average of stars received as of 2015 of 9,000 home healthcare agencies studied was only three; with a national benchmark being 3.5, representing a less than average performance (Rice, 2015). This suggests mediocre performances at best. The subpar performance of many agencies should be an alert to improve quality measures as eventually it will affect reimbursement levels (CMS, 2017a).

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How to Improve

Home healthcare agencies can improve their star status and reach five stars by focusing on nine measures. Of the nine measures, home healthcare agencies should start by addressing those on which they perform below the state and national average. Depending on the size of the agency and number of staff, it may be more feasible to improve in one quality area at a time versus all nine. Small privately owned home healthcare agencies, however, may be able to tackle numerous deficient areas at once.

The Visiting Nurse Associations of America (VNAA) recommends the generation of weekly or monthly reports regarding how the home healthcare agency is performing in the nine areas affecting Star Ratings (VNAA Blueprint for Excellence, 2016). Quality improvement or management staff can monitor performance and Outcome and Assessment Information Set (OASIS) scores and present findings at team meetings or during case conferences.

Comprehensive programs exist that have improved hospitalization rates such as the Home Health Universal Best Practice Protocol (Panozzo et al., 2017) (Figure 1). This protocol is comprehensive and educates home healthcare clinicians when to perform best practices linked to improved patient outcomes such as hospitalization rates. If it is not feasible to incorporate all aspects of a program or protocol, start with one and build upon it.

Figure 1

Figure 1

Technology components can be implemented into home healthcare agencies such as computers or tablets with internet access, and telehealth capabilities (Home Health Care News, n.d.; Panozzo et al., 2017). Telehealth may capture changes in patient status quickly regarding activities of daily living and medications, thus allowing timely communication with providers (Panozzo et al.). Timely and effective communication among the home healthcare team and improvement in outcomes are dependent on current patient assessment information. Electronic health records may be programmed to provide flu vaccination alerts for home healthcare clinicians (Homecare Direction, 2016).

One agency improved from three to five stars in less than a 2-year period by utilizing a web-based data analytics and benchmarking vendor. Management also provided OASIS education in addition to displaying posters at the agency to remind clinicians of the nine Star Rating focus areas. At least monthly, the agency alerted staff of OASIS best practices, and incorporated an OASIS game to gain employee engagement and buy in. The agency also had a nurse perform the start of care and toward the end of the visit, a therapist arrived for a therapy evaluation. The functional assessment was performed together by the nurse and therapist, which also provided consistency in OASIS documentation. This practice was recently approved as acceptable per the Oasis-C2 Guidance Manual regarding one clinician convention (CMS, 2017b).

The agency also brought a pain scale to the patient's home and discovered the Wong-Baker FACES Pain Rating Scale was easier for patients to follow and comprehend versus the traditional 0-10 numeric scale. Experts were invited to educate the agency's staff on diagnoses such as chronic obstructive pulmonary disease, and heart failure, as well as symptoms management for dyspnea and shortness of breath. Hospital partners typically are able to provide specialists to educate home healthcare members (Poltilove, 2017).

Another organization recommends the following tips to improve Star Ratings: focus on quality, do not chase numbers, go beyond what is required, focus on instilling clinical reasoning skills, scrutinize past performance, bolster communication, and be honest about shortcoming (Reaching for that Five-Star Quality Rating, 2016).

Star Ratings among hospitals have revealed a need to improve the discharge process. In 2015, per Hospital Compare, only roughly half of patients who left the hospital verbalized understanding of their discharge instructions (Star Ratings show hospitals need to improve the discharge process, 2015). If the hospital discharge process is not effective, the home healthcare agency is susceptible to not reaching high-quality standards. Home healthcare agencies have an opportunity to collaborate with hospitals regarding discharge planning and gaps in communication. This alarming statistic also stresses the importance of timely start of care by home healthcare agencies.

Home Health Quality Improvement (HHQI) provides a Performance Improvement Project Tool, which was updated in February of 2017 (2017). The tool stresses the importance of providing clinical education on medication OASIS items, creating a management plan, discussing potential barriers and opportunities among the home healthcare team, and implementing best practice guidelines. A comprehensive medication reconciliation plan is encouraged beyond the start of care keeping the three v's in mind: verify medications,validate current medications, and clarify medications at all OASISvisits. Medications should be faxed to providers and cross-setting collaboration should be used in reconciliation. Various tools are offered within the HHQI best practice guidelines to assist patients with medication management and comprehension, thus improving adherence. Simplifying medications when possible in collaboration with providers and pharmacists is encouraged. Utilizing teach back is also highly stressed. Clinicians should be able to access smart phones and medication applications to assist in educating patients as well as have medication competency annually (HHQI).

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Utilizing evidence-based and best practice protocols, tools, and established guidelines can assist home healthcare agencies in not only improving selected quality measures, but also potentially improving Star Ratings. As various quality measures such as Star Ratings and other components of Home Health Compare evolve, home healthcare agencies need to be innovative with strategies, and conscientious of performance to maintain viability in the competitive market.

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Caron J. B., McDonald K., Jackson M. E. (2016). CMS proposes increased transparency of hospice quality data in annual payment update. Retrieved from
Centers for Medicare & Medicaid Services. (2016). First release of the Overall Hospital Quality Star Rating on Hospital Compare. Retrieved from
Centers for Medicare & Medicaid Services. (2017b). Outcome and Assessment Information Set OASIS-C2 Guidance Manual. Retrieved from
Home Health Care News. (n.d.). How agencies can rise to the 5-Star Ratings challenge. Retrieved from
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