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 can report through the Quality Measure Reporting (QMR) 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. The 2023 Health Home Core Set history table provides a history of the measures included in the Health Home Core Set.
- 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 QMR, contact the QMR Helpdesk at MDCT_Helpdesk@cms.hhs.gov.
General Resources for Reporting Health Home Quality Measures
- Health Homes SMD Letter 13-001 (CMS/January 2013) - Describes the core quality measures and approach to reporting.
- Substance Use Disorder (SUD)-focused Health Homes Informational Bulletin (November 2019) - Provides a description of new Quality Measures for SUD-focused Health Homes.
- Technical Assistance to Support FFY 2021 and FFY 2022 Reporting of the Child, Adult, and Health Home Core Sets in the Quality Measure Reporting (QMR) System – September 15, 2022
- Presentation slides
- Watch the presentation (MP4, 83.4 MB)
- Read the transcript
- Technical Assistance Webinar to Support State Reporting of the Child, Adult, and Health Home Core Sets: FFY 2022 Updates and Reporting Resources – May 18, 2022
- Presentation slides
- Watch the presentation (MP4, 35 MB)
- Read the transcript
FFY 2023 Health Home Core Set Reporting Resources
State Reporting Starts: Fall 2023
| Measure List and Technical Specifications | FFY 2023 Health Home Core Set Measure List |
| FFY 2023 Health Home Resource Manual and Technical Specifications | |
| Summary of Updates to the Health Home Core Set Resource Manual and Technical Specifications for FFY 2023 | |
| Value Set Directories | FFY 2023 Health Home Core Set HEDIS Value Set Directory |
| FFY 2023 Health Home Core Set Non-HEDIS Value Set Directory | |
| Additional Technical Assistance Resources | Expected Health Home Core Set Reporting Periods, by Effective Date of SPA: FFY 2022 – FFY 2023 (Coming Soon) |
| FFY 2023 Data Quality Checklist (Coming Soon) | |
| FFY 2023 Health Home Measurement Period Table (Coming Soon) | |
| Allowance of Telehealth in the 2023 Child, Adult, and Health Home Core Set Measure Specifications (Coming Soon) | |
| Calculating the Controlling High Blood Pressure (CBP) Measure in the Adult and Health Home Core Sets (Coming Soon) | |
| Calculating the Plan All-Cause Readmissions (PCR) Measure in the Adult and Health Home Core Sets (Coming Soon) | |
| Overview of Substance Use Disorder Measures in the 2023 Child, Adult, and Health Home Core Sets (Coming Soon) | |
| Calculating the Admission to an Institution from the Community (AIF-HH) Measure in the 2023 Health Home Core Set (Coming Soon) | |
| Guidance for Calculating the Colorectal Cancer Screening Measure in the 2023 Adult and Health Home Core Sets (Coming Soon) | |
| Calculating State-Level Rates Using Data from Multiple Reporting Units (Coming Soon) | |
| Guidance for Reporting in the Quality Measure Reporting (QMR) System | State Preview Reports, State-Specific Comments, and Additional Reporting Resources |
| Reporting Stratified Results in the QMR System |
Archived Reporting Resources
- 2021 Technical Specifications and Resource Manual, Value Set Directories, and Reporting Resources
- 2022 Technical Specifications and Resource Manual, Value Set Directories, and Reporting Resources
- 2015 - 2020 Archived Health Home Core Set Measure Lists and Reporting Resources
- For previous years' technical specifications and value set directories, please email MACQualityTA@cms.hhs.gov.
Annual Reporting on the Quality of Health Care for Medicaid Health Home Enrollees
- 2021 Annual Reporting on the Quality of Care for Medicaid Health Home Enrollees (FFY 2020)
- Criteria for Using the Health Home Core Set Measures to Assess Performance and Trends in Performance in Medicaid Health Homes (November 2021)
- 2021 Health Home Core Set Chart Pack, FFY 2020
- Performance on the Health Home Core Set Measures, FFY 2020 (November 2021)
- Health Home Core Set Measure Summaries, FFY 2020
- 2020 Annual Reporting on the Quality of Care for Medicaid Health Home Enrollees (FFY 2019)
- Criteria for Using the Health Home Core Set Measures to Assess Performance and Trends in Performance in Medicaid Health Homes (January 2021)
- 2020 Health Home Core Set Chart Pack, FFY 2019 (December 2020)
- Performance on the Health Home Core Set Measures, FFY 2019 (December 2020)
- Health Home Core Set Measure Summaries, FFY 2019 (January 2021
Resources from Federal Evaluation Activities
- Report to Congress (RTC) on the Independent Evaluation of Health Homes, 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 (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.
Iowa:
- 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)
Maine:
- 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)
Maryland:
- Health Home 2016 Evaluation Report (The Hilltop Institute/June 2016)
Minnesota:
- 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)
Missouri:
- 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)
New York:
- 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)