Health Home Quality Measure Reporting and Evaluation Activities
A goal of Medicaid health home programs is to improve health outcomes for beneficiaries with chronic conditions through coordinated care provided by an interdisciplinary team linking primary, behavioral health, and long term services and supports. The Centers for Medicare & Medicaid Services (CMS) established a core set of health home quality measures that states will report through the MACPro system according to the schedule below. These quality and utilization measures will be used for ongoing monitoring and evaluation purposes across all state health home programs and the results will be reported to Congress. In addition to the core measures, CMS expects that states will report specific goals and measures identified by their individual programs.
- For technical assistance related to calculating, reporting, or using the health home quality measures, submit your questions to the TA Mailbox at MACQualityTA@cms.hhs.gov.
- For assistance with using MACPro, contact the MACPro Helpdesk at MACPro_Helpdesk@cms.hhs.gov.
General Resources for Reporting Health Home Quality Measures
- Health Homes SMD Letter 13-001 (PDF, 236.71 KB) (CMS/January 2013) - Describes the core quality measures and approach to reporting.
- Substance Use Disorder (SUD)-focused Health Homes Informational Bulletin (PDF, 154.51 KB) (November 2019) - Provides a description of new Quality Measures for SUD-focused Health Homes.
- 2021 Core Set of Health Care Quality Measures for Medicaid Health Home Programs (Health Home Core Set) (PDF, 161.66 KB) - Provides an overview of the quality and utilization measures for FFY 2021 Health Home Core Set reporting.
- Technical Assistance to Support Child, Adult, and Health Home Core Set Reporting for FFY 2020: FFY 2020 Updates and Reporting Resources – April 2020
- Technical Assistance Webinar: Introduction to the Core Set of Health Care Quality Measures for Medicaid Health Home Programs (PDF, 253.71 KB) (CMS/April 2014) - Provides an introduction to health homes quality measurement, the 2013 core measures set, and the 2013 reporting process.
- Expected Health Home Core Set Reporting Periods, by Effective Date of SPA (PDF, 577.44 KB) - Provides a list of states, by SPA, required to report in each of the following years: FFY 2020 - FFY 2022.
- Screenshots of Health Home Quality Template in MACPro (PDF, 7.78 MB) (Truven/December 2015) - Shows screenshots from the MACPro system to provide users with a visual orientation to the system’s contents.
- 2021 Health Home Core Set HEDIS Value Set Directory (ZIP, 2.02 MB) Provides value sets and codes needed to calculate and report HEDIS measures included in the 2021 Health Home Core Set.
- 2021 PQI92-HH Value Set (ZIP, 105.28 KB) - Provides ICD-10 codes needed to calculate and report PQI92: Chronic Conditions Composite (PQI92-HH) measure included in the 2021 Health Home Core Set.
- 2021 AIF-HH Value Set (ZIP, 25.21 KB) - Provides codes needed to calculate and report Admission to an Institution from the Community (AIF-HH) measure included in the 2021 Health Home Core Set.
- 2021 OUD-HH Value Set (ZIP, 27.93 KB) – Provides codes needed to calculate and report Use of Pharmacotherapy for Opioid Use Disorder (OUD-HH) measure included in the 2021 Health Home Core Set.
- Technical Assistance Resource: Allowance of Telehealth in the 2021 Child, Adult, and Health Home Core Set Measure Specifications (PDF, 440.2 KB) (May 2021)
- Technical Assistance Resource: Calculating the Plan All-Cause Readmissions (PCR) Measure in the 2021 Adult and Health Home Core Sets (PDF, 549.77 KB) (Updated May 2021)
- Technical Assistance Resource: Calculating the Admission to an Institution from the Community (AIF-HH) Measure in the 2021 Health Home Core Set (PDF, 544.96 KB) (Updated May 2021)
- Technical Assistance Resource: Calculating the Controlling High Blood Pressure (CBP) Measure in the Adult and Health Home Core Sets (PDF, 358.78 KB) (Updated May 2021)
- Technical Assistance Resource: Overview of Substance Use Disorder Measures in the 2021 Adult and Health Home Core Sets (PDF, 514.49 KB) (Updated May 2021)
- Technical Assistance Resource: Calculating State-Level Rates Using Data from Multiple Reporting Units (PDF, 426.28 KB) (Updated March 2020)
- Archived Health Home Core Set Measure Lists and Reporting Resources (ZIP, 6.25 MB) - For technical specifications and value set directories from previous reporting years, please email MACQualityTA@cms.hhs.gov.
|Reporting Start Date (Targeted)||September 2021|
|Measurement Year (Generally, see Technical Specification for specifics)||January 1, 2020 to December 31, 2020|
|Technical Specifications Manual||Health Home Core Set of Quality Measures: Technical Specifications and Resource Manual 2021 (PDF, 642.64 KB)|
|Summary of Updates||Summary of Updates in FFY 2021 (PDF, 34.73 KB)|
|Data Quality Checklist||Data Quality Checklist for States 2021 (PDF, 793.61 KB)|
|Core Set Measurement Period Table||Health Home Core Set Measurement Period Table 2021 (PDF, 210.66 KB)|
Resources for Using MACPro
- MACPro Portal – Describes the Medicaid and CHIP Program (MACPro) portal and functionality
- Training and Help – Provides trainings, reference materials, and a Help Desk to assist MACPro users in learning the system.
- Technical Assistance to Support Adult, Child, and Health Home Core Set Reporting for FFY 2019 – October 17, 2019
- Core Set Presentation slides (PDF, 2.09 MB)
- MACPro Presentation slides (PDF, 463.64 KB)
- Pt 1: Introduction to the MACPro Quality Measures FFY 2019 State Update (12:18)
- Pt 2: Updates to Quality Measures FFY 2019 Reporting (16:53)
- Pt 3: MACPro Access and Roles for Quality Measures (10:08)
- Pt 4: MACPro FFY 2019 QM System Updates and Additional Resources (6:35)
Annual Reporting on the Quality of Health Care for Medicaid Health Home Enrollees
- 2020 Annual Reporting on the Quality of Care for Health Home Enrollees in Medicaid (FFY 2019)
- Criteria for Using the Health Home Core Set Measures to Assess Performance and Trends in Performance in Medicaid Health Homes (PDF, 159.62 KB) (January 2021)
- 2020 Health Home Core Set Chart Pack, FFY 2019 (PDF, 3.57 MB) (December 2020)
- Performance on the Health Home Core Set Measures, FFY 2019 (ZIP, 558.62 KB) (December 2020)
- Health Home Core Set Measure Summaries, FFY 2019 (ZIP, 1.4 MB) (January 2021)
Resources from Federal Evaluation Activities
- Report to Congress (RTC) on the Independent Evaluation of Health Homes (PDF, 400.35 KB), the optional Medicaid State Plan benefit, conducted by the Assistant Secretary of Planning and Evaluation (ASPE) through a contract with Urban Institute.
- Interim Report to Congress: Phase II Evaluation Activities (NORC-University of Chicago) - Describes the web survey, stakeholder interviews, site visits, and focus groups that are part of Phase II of the Medicaid health home evaluation.
- Interim Report to Congress on the Medicaid Health Home State Plan Option (PDF, 364.94 KB) (NORC-University of Chicago/2014) - This baseline report describes each health home program, challenges and best practices in design and implementation, and baseline hospital admission rates.
- Section 2703 Health Home Long-Term Evaluation Activities - Describes the aims of the long-term Health Home evaluation and the types of data that will be collected by the evaluation team.
- Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Final Annual Report - Base Year (Urban Institute/December 2012)
- Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Final Annual Report - Year Two (Urban Institute/June 2014)
- Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Final annual Report – Year Three (Urban Institute/July 2015)
Resources from State Reporting and Evaluation Activities
States have begun to publish findings from their own health home program evaluations. View state findings from their health home program reporting and evaluation activities.
- Experiences of Adults and Children in the Iowa Medicaid Integrated Health Home Program (The University of Iowa Public Policy Center/July 2017)
- Outcomes for Iowa Medicaid Chronic Condition Health Home Program Enrollees 2012-2015 (The University of Iowa Public Policy Center/February 2017)
- Evaluation of Iowa Medicaid's Integrated Health Home Program: Outcomes and Costs of Care SFY 2013 - SFY 2015 (The University of Iowa Public Policy Center/February 2017)
- Evaluation of the Integrated Health Home (IHH) Program in Iowa: Qualitative Interviews with Site Administrators (The University of Iowa Public Policy Center/September 2015)
- Early Lessons Learned in Implementing MaineCare Health Homes (University of Southern Maine/September 2014)
- MaineCare Stage A Health Homes Year 1 Report: Implementation Findings and Baseline Analysis (University of Southern Maine/March 2014)
- Health Home 2016 Evaluation Report (The Hilltop Institute/June 2016)
- Evaluation of the State of Minnesota’s Health Care Homes Initiative: Evaluation Report for Years 2010-2014 (University of Minnesota School of Public Health (December 2015)
- 2013 Missouri Primary Care Health Homes: Interim Evaluation Review Summary (MO HealthNet/May 2014)
- MO HealthNet PCHH Progress Report 2014-2017 (MO HealthNet/May 2014)
- An Examination of New York State's Integrated Primary and Mental Health Care Services for Adults with Serious Mental Illness (New York State Health Foundation/2014)