Medication management plays a major role in patient health during transitions of care. At the time of discharge, patients might be able to eat, walk and brush their teeth on their own. But they often still face issues managing their medications. This can lead to negative health consequences for patients, including hospital readmissions.
In addition to patient health, medication management impacts quality measures that affect Star Ratings and reimbursement for home health agencies as part of the expanded Home Health Value-Based Purchasing (HHVBP) Model. These measures include OASIS M2020, Potentially Preventable Hospitalization (PPH), Discharge Function Score and Home Health Care CAHPS (HHCAHPS) Survey-based measures.
A more proactive, comprehensive level of pharmacy care is key to maximizing results for these measures. By optimizing medication management, this model of pharmacy promotes patient health and prevents readmissions, improving clinical and economic outcomes.
OASIS M2020
For 2025, OASIS M2020 results account for 9% to 12.86% of an agency’s Total Performance Score for the expanded HHVBP Model. This is an increase from the measure’s 5.83% to 8.33% weighting in 2024.
The Centers for Medicare and Medicaid Services use OASIS M2020 to assess management of oral medications on a scale ranging from zero—able to independently take the correct oral meds and proper dosages at the correct times—to three—unable to take medication unless administered by another person. With home delivery and personalized adherence solutions, more proactive, comprehensive pharmacy enables patients to independently and consistently access and take their medications as prescribed. This can help significantly improve OASIS M2020 scores.
Home Health Within-Stay Potentially Preventable Hospitalization
The Total Performance Score added the PPH measure and removed two claims-based measures for 2025: Acute Care Hospitalization During the First 60 days of Home Health and Emergency Department Use without Hospitalization During the First 60 Days of Home Health. The PPH measure accounts for 26% to 37.14% of the Total Performance Score.
Medication-related problems are a major contributor to hospital admissions and readmissions, with research indicating over 25% of hospital readmissions were potentially preventable and medication-related. More proactive, comprehensive pharmacy has been proven to enhance medication safety and efficacy, increasing adherence and reducing readmissions. As a result, this higher level of pharmacy care can be instrumental in optimizing performance for the PPH measure.
Discharge Function Score
The Discharge Function Score was added for calendar year 2025 and accounts for 20% to 28.57% of the Total Performance Score. It measures how successful a home health agency is at achieving or exceeding an expected level of functional ability for patients at discharge. More proactive, comprehensive pharmacy enhances patient health and wellbeing, allowing them to live more independently at home and supporting better Discharge Function Scores.
With proactive medication management, licensed clinical pharmacists identify issues related to drug duplications, drug interactions, contraindications, gaps in therapy and time-of-day of dosing. When duplications are removed and meds that cause side effects like drowsiness are timed appropriately, it can help patients become more stable in their movements and more lucid and alert, supporting self-care and mobility.
Home Health Care CAHPS Survey-Based Measures
HHCAHPS Survey-based measures collectively account for 30% of the Total Performance Score for agencies with larger cohorts, making patient satisfaction key to the expanded HHVBP Model. The HHCAHPS Survey assesses patients’ experiences with home health agencies. Measures include care of patients, communication between providers and patients, specific care issues, rating of care provided by the agency, and willingness to recommend the agency.
Non-traditional, comprehensive pharmacy with a high-touch, patient-centered approach has consistently received patient experience ratings that are considered “world class” as measured by Net Promoter Score methodology, a cross-industry benchmark used to evaluate overall customer satisfaction and loyalty. This model of pharmacy elevates care and supports proactive communication with patients to deliver a better home health patient experience.
Enhancing Outcomes with Comprehensive Pharmacy
As data show, home health agencies that use this comprehensive pharmacy model have consistently seen 40% fewer readmissions for patients, demonstrating the major role pharmacy plays in keeping patients healthy at home.
With updates to Total Performance Score weightings for 2025, pharmacy can make an even greater impact on home health agency performance and reimbursement. By having patients already established with more proactive, comprehensive pharmacy care before discharge, agencies help streamline medication management, reduce rehospitalizations, optimize Star Ratings, and ultimately improve clinical and economic outcomes.
