Episode management is a continuous, proactive episode review process consisting of ongoing weekly analysis of open home care episodes. Key components include risk assessments, goals of care, analysis of visit utilization, discipline utilization, OASIS accuracy, and care plans.

Risk Assessment

Risk assessments include fall risk, skin breakdown risk, pain assessment, and depression screening. Each of these tools provides vital information regarding the patient’s status and care needs. When reviewing an episode of care, it is important to take into consideration a patient’s risk assessment scores. This helps you to identify whether the most comprehensive plan of care has been established for the patient.

The fall risk assessment may not only provide clues as to the need for therapy. In addition, it may provide clues as to the need for SN evaluation and teaching regarding a complex medication regimen. Similarly, the pain assessment, combined with diagnostic history, may indicate the need for therapy or palliative care services. In each circumstance, the plan of care should include interventions to address the patient’s areas of risk. Risk assessments should be completed with each new episode of care, including SOC, ROC, and recertification time points.

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Goals of Care

When discussing goals of care, one of the most important aspects to consider is the patient’s goals. What does the patient hope to accomplish while on home health services? How can the agency help the patient to achieve this goal? In addition to this, we must also consider the industry standards used to benchmark by which home health agency outcomes. What does the home health agency need to do to demonstrate improvement in home health comparison? To demonstrate patient satisfaction on the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS)?

For episode management to be successful, build the plan of care by taking these goals and benchmarks into consideration. Without patient buy-in, demonstrating successful outcomes may be impossible. A successful episode management program should include staff education on communication techniques and patient care management. Without these tools, agencies may find that patients begin to refuse services and, as a result, satisfaction scores may suffer.

Visit Utilization

When analyzing visit utilization, it is important to consider the patient’s clinical needs as well as goals of care. Clearly identify the skilled need for service in the care plan and clinical notes. The predicted home health visit frequency should be reasonable and necessary based on the identified skilled need and clinical assessment of the patient.


While reviewing an episode of care it was noted that a patient’s skilled nursing (SN) visit frequency was higher than would be expected for the primary diagnosis and reason for services.

The 99-year-old female presented with a primary diagnosis of Z46.6: Encounter for fitting and adjustment of a urinary device. The patient had been on services with the agency for 60 days and was being recertified for ongoing monthly foley catheter changes. The facility predicted a visit frequency of 1 to 2 times per week for 9 weeks. The patient did not have any exacerbations or illnesses over the previous 60-day certification period. Upon episode of care review with the SN, the manager discovered that the patient had been having some issues with foley leakage. However, these issues have since been resolved.

After a discussion with the manager, the SN spoke with the physician about a frequency adjustment. Subsequently, the physician ordered a decrease in visit frequency to 1-2 times per month for routine foley catheter changes. This adjustment reduced the agency’s likelihood of ADR denial. Additionally, it increased the SN’s capacity to take on additional patients.

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Discipline Utilization

A review of discipline utilization includes an analysis of the HHRG score or Home Health Resource Grouper score. The clinical severity, functional status, and service needs of the patient determine the HHRG score, as derived from answers to OASIS questions, as well as patient characteristics such as age. It is what Medicare (CMS) uses to determine agency reimbursement for patient care. The HHRG score is made up of Clinical, Functional, and Service domains (CFS). The lowest HHRG score a patient can have is C1F1S1 and the highest HHRG score a patient can have is C3F3S5. HHRG scores demonstrating C2 or C3 indicate possible SN needs while HHRG scores demonstrating F2 or F3 indicate possible therapy needs.

A review of discipline utilization also consists of a review of primary diagnosis, co-morbidities, homebound status documentation, and comprehensive assessment findings which can be helpful in identifying what the patient’s service needs are. Early identification of service needs helps to improve the timeliness of additional discipline(s) involvement and decrease the risk of hospitalization.


While reviewing an episode of care it was noted that a patient’s HHRG score indicated the possible need for therapy involvement.

88-year-old female with an HHRG score of C2F3S1. The physician referred the patient to home health with an unstageable pressure ulcer of the left buttock and ordered SN services for wound care. Upon a brief discussion of the case, it was discovered that the patient has extremely limited mobility and is able to transfer, with assistance, from bed to wheelchair only. The SN did not order therapy at SOC.

After a discussion with the manager, the SN spoke with the physician and received an order for PT to evaluate. Therapy initiated care with the patient within 6 days of SN call to the physician. Early identification of the need for therapy services allowed for early intervention thus improving patient and caregiver knowledge and safety with transfers, mobility, and pressure reduction measures. With the implementation of appropriate discipline involvement and intervention, 31 days into care, the patient has remained free from hospitalization.

OASIS Accuracy

OASIS accuracy is an essential factor in successful episode management. The OASIS is what CMS uses to determine payment for the patient’s 60-day episode of care. CMS also uses OASIS to determine a patient’s clinical improvement or decline during the episode of care. Additionally, the OASIS is a useful tool in determining a patient’s clinical areas of need which, in turn, aids the assessing clinician in the development of the plan of care. As such, it is essential to accurately answer the OASIS questions based on the clinician’s comprehensive assessment of the patient. During episode management review, it is possible to quickly identify potential OASIS inaccuracies based on patient diagnosis, service needs, and HHRG score. Homebound status documentation and risk assessments play a key role in determining issues with OASIS accuracy.


While reviewing an episode of care it was noted that a patient’s HHRG score did not correlate to diagnosis, homebound status documentation, or fall risk assessment.

A 54-year-old male with an HHRG score of C3F1S1. The physician recertified the patient for a new 60-day episode for ongoing wound care to an abscess of the buttock. Upon a brief discussion of the case, the care team discovered that the patient has extremely limited mobility. The homebound status documentation indicated that the patient is chair fast and is a fall risk. Additionally, documentation revealed that the patient requires a motorized wheelchair and one person’s assistance to leave the home. The clinician scored M1850 for transfers as 1- Able to transfer with minimal human assistance or with the use of an assistive device. Additionally, the clinician scored M1860 for ambulation as 2- Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.

The manager provided one-on-one education to the clinician regarding the importance of OASIS accuracy including correlation to comprehensive assessment, homebound status, and fall risk assessment documentation. By continuing to identify issues with OASIS accuracy and providing early one-on-one education with clinicians, the agency has been able to build more appropriate, patient-centered plans of care as well as improve clinical and financial outcomes.

Care Plans

The home health plan of care, or care plan, is the framework on which the interdisciplinary team builds their care. Without an accurate and comprehensive care plan, the likelihood of successful patient outcomes decreases significantly. During episode management review, clues to patient needs and essential elements to a comprehensive care plan may be discovered.


While reviewing an episode of care it was noted that a patient’s HHRG score and primary diagnosis indicated a possible need for therapy services. The current care plan did not include orders for therapy services.

A 75-year-old female with an HHRG score of C3F3S1. The physician referred the patient for home health SN services for wound care to address a Stage 2 pressure ulcer of the buttock. Upon a brief discussion of the case, the home health team discovered the patient has limited mobility. In addition, the patient and caregiver required education in pressure reduction measures.

After a discussion with the manager, the clinician contacted the physician to request an order for a PT evaluation. PT services were initiated within 2 weeks of SOC. Initiation of PT services ensured the patient’s functional deficits were being addressed reducing the risk for further skin breakdown and decreasing the patient’s risk for hospitalization. The PT was able to provide the necessary education to the patient and caregiver on pressure reduction measures. The patient remained free from hospitalization and demonstrated no further skin breakdown during the 60-day episode of care.

Understanding the Benefits

Effective episode management services are needed to secure home health agency success in clinical, financial, and patient satisfaction outcomes. Key factors of an effective episode management program are analysis of visit utilization, discipline utilization, OASIS accuracy, care plans, risk assessments, and goals of care. Home health agency managers play a key role in maintaining effective episode management by providing the education necessary to field clinicians regarding episode management techniques. Ongoing real-time review of patient episodes is necessary to ensure continued success in the implementation of best practice measures and interventions.

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About The Contributor

Carissa McKenna, Clinical Consulting Manager

Carissa’s expertise includes assisting agencies in attaining clinical and financial goals as well as improving patient satisfaction through continuous, proactive episode management services & review processes. Agencies are thereby able to demonstrate the pursuit of CMS’ Triple Aim: To improve patient experience of care, improve patient health, and decrease the per capita cost of health care delivery.