A 2022 roadmap to Value-Based Purchasing in 2023

By Charles M. Breznicky, RN, MSN, MBA, HSC-D Director, Clinical Consulting 

Lower costs and better outcomes are driving the nationwide expansion of the Home Health Value Based Purchasing Program, or HHVBP, by the Centers for Medicare and Medicaid Services (CMS).

HHVBP was initially implemented as a model by CMS in 2016 to determine the impact financial incentives would have on home health agencies. Agencies were rewarded or penalized based on a Total Performance Score (TPS) compared to other agencies in the same state.

In the 4th Annual Report Evaluation of the HHVBP Model, released in May 2021, CMS indicated net Medicare spending decreased by $481 million while patient outcomes improved in HHVBP states when compared to non-HHVBP states.

Due to these findings, it is not surprising that CMS is expanding the model to all 50 states, territories, and the District of Columbia beginning next year, with payment adjustments coming in 2025. CMS had initially indicated in the proposed rule released in July 2021 that the first performance year for VBP would be 2022, but they moved that back a year based on comments and the ongoing public health emergency. Agencies should take this delay as an opportunity to fully understand the HHVBP model, how they would fare if it were currently active and where they need to improve to succeed under this model.

Change takes time to implement and re-evaluate. Waiting until 2023 or even the second half of 2022 may put agencies at a disadvantage compared to their peers. One of the biggest changes in the expansion from the model is that agencies will be compared against all other agencies in the nation rather than against agencies in their states; this makes the pool of competition much deeper and will require agencies to perform at a very high level to succeed.

This year should be seen as a chance to identify those areas in which your agency lags national averages, then developing action plans to improve in those metrics. Agencies can take this time to determine which methods of improvement will work best for their agency; these may include education, additional certifications, or more in-depth chart reviews. Finally, if the above-mentioned techniques are not as effective as anticipated, agencies will have the opportunity to adapt and try alternatives without being in a performance year that will impact reimbursement under VBP.

How will payment adjustments be determined?

Under the final rule released in November, 2021, agencies can receive payment adjustments of +/- 5% based on a Total Performance Score, which is derived from either achievement scores or improvement scores. These scores are based on an agency’s performance in each measure under HHVBP. The higher of the achievement or improvement score is selected to determine the payment adjustment.

CMS indicated they will provide agencies their benchmarks and achievement thresholds prior to 2023. The goal is to use these measures to develop quality improvement projects which may lead to higher payment adjustments.

When determining improvement scores, the baseline year will be 2019 as opposed to 2020 due to the potential effects of COVID-19 distorting the data. For improvement scores, each measure will receive a value of 0–9 to quantify an agency’s performance on that measure compared to its own performance in the baseline year.

Achievement scores are measured on a scale of 0–10 to quantify an agency’s performance on each measure compared to other agencies in the same cohort in the baseline year. Agencies will be grouped into large or small cohorts based on the volume of patients served; large cohorts are those agencies required to participate in the HHCAHPS survey, whereas small cohorts are exempt.

Each performance score is then weighted and summed to generate a Total Performance Score; this score is then compared to all other agencies in the cohort and will dictate the payment adjustment received by the agency.

What data is used to score agencies? 

  • Claims-Based Measures make up 35% of the Total Performance Score and are based on Acute Care Hospitalizations in the first 60 days of care and Emergency Department Use without Hospitalization in the first 60 days of care. 
  • OASIS-Based Measures contribute to 35% of the Total Performance Score and are based on the following OASIS items: 
    • Dyspnea 
    • Management of Oral Medications 
    • Discharged to Community 
    • This measure also includes two aggregate measures, which are called Total Normalized Composite (TNC) Self-Care and TNC Mobility. TNC measures include the following:


TNC Self-Care TNC Mobility
  • Grooming
  • Dressing Upper and Lower Body
  • Bathing
  • Toilet Hygiene
  • Eating
  • Toilet Transferring
  • Bed Transferring
  • Ambulation



  • The final 30% of the Total Performance Score is made up of five elements of the HHCAHPS survey
    • Professional Care 
    • Communication 
    • Team Discussion 
    • Overall Rating 
    • Willingness to Recommend

What can an agency do now? 

  • Agencies should review their current outcome scores, specifically how they compare to national and state benchmarks 
  • Trend data over the past 12 months to see if any measures significantly declined or improved.

DID MEASURES DECLINE? Consider events that may have led to the decline: 

  • New staff being hired may not fully understand the OASIS scoring 
  • Experienced staff leaving may mean their knowledge of the OASIS goes with them 
  • Process changes may reveal that the OASIS items are not being reviewed as thoroughly as they were in the past

DID MEASURES IMPROVE? Consider what may have led to the improvement and determine if it can be replicated. Look for: 

  • Education delivered on a specific measure several months prior to the increase 
  • Process changes in which the OASIS is reviewed in a more thorough manner or collaboration is occurring between clinicians after the SOC occurs 
  • Staff who completed the OASIS review may have become certified prior to the increase occurring. 


  • Staff may not understand how to score the OASIS item in question 
  • Evaluate your case mix weight against state and national averages and consider your patient population. Patients with chronic illnesses may not improve as much as those with an acute disease process. 
  • Evaluate how patient calls are handled. Are they sent to the hospital for evaluation because the agency does not have adequate staff to see the patient that day? Are they sent to multiple people before they can get an answer to a question? 

Depending on the number of areas identified for improvement agencies should select one or two measures at a time and develop a plan for improvement around those measures. 

This is an ongoing process that will require agencies to thoroughly evaluate how they provide care, how they measure the quality of that care and how they can improve the care they provide.

SimiTree can help

The SimiTree Healthcare Consulting team has experience in Leadership and Management, Organizational Change, QAPI, and Data Analytics. These skillsets can assist agencies in identifying outcomes to be improved, developing processes to be updated and implementing the changes that will lead to better outcomes and patient care delivery.

Some examples of how we can help you prepare for HHVBP are: 

  • Develop a personalized plan to improve your outcomes 
  • Track and summarize your data regularly, along with providing recommendations for improvement 
  • Create education plans and provide education to staff and managers on outcomes that will be impacted by HHVBP 
  • Oversee or assist in the management of specific action plans or your QAPI program

Learn more about SimiTree’s VBP consulting services here or use the link below to get started today.

Charles Breznicky Rn Simitree Health

Charles M. Breznicky, RN, MSN, MBA, HSC-D 
Director, Clinical Consulting

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