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, depression screening, and risk for acute care hospitalization and emergency department use. 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. Teach staff to use techniques such as “lead in language” to identify a specific, meaningful, and measurable patient goal. Some examples of “lead in language” include “Tell me about what it’s like living with…” or “How has heart failure affected your life?”

Next, educate staff to further utilize tools such as motivational interviewing, pros and cons, and reflection/summarization to help the patient work towards that goal. Ensure the patient goal is documented in the medical record and shared with the entire care team.

In addition to this, we must also consider the industry standards used to benchmark home health agency outcomes. What does the home health agency need to do to demonstrate improvement with reportable clinical outcomes on home health compare? 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. Estimated utilization should be in line with industry benchmarks for patients of similar characteristics.  


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 HIPPS code, or Health Insurance Prospective Payment System code. The HIPPS code is made up of the admission source, period timing, clinical group, functional level, and comorbidity adjustment for the 30-day period of care as derived from answers to OASIS questions, as well as claims information. It is what Medicare (CMS) uses to determine agency reimbursement for patient care.

Position 1 is admission source and timing, position 2 is the clinical group, determined based on the primary diagnosis on the home health claim, position 3 is the functional level, determined based on responses to specific OASIS questions, and position 4 is the comorbidity adjustment based on the secondary diagnoses listed on the home health claim.

HIPPS codes with position 1 (admission source and timing) scores of 2 or 4 indicate that the patient was in an inpatient facility within 14-days prior to the start of the 30-day period and, therefore, may have higher clinical acuity.

HIPPS codes with position 2 (clinical group) scores of B (Neuro Rehab) or E (Musculoskeletal Rehab) as well as HIPPS codes with position 3 (functional level) scores of B (medium) or C (high) may indicate the need for therapy.

HIPPS codes with position 2 (clinical group) scores of C (Wound), D (Complex Nursing Interventions), H (Surgical Aftercare), I (Endocrine), K (Infectious Disease, Neoplasms, and Blood-Forming Diseases), and L (Respiratory) and position 4 (comorbidity adjustment) scores of 2 (low) or 3 (high) may indicate the need for Skilled Nursing.

A review of discipline utilization also consists of a review of 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 HIPPS code score indicated the possible need for therapy involvement.

88-year-old female with an HIPPS code of 1CC21. 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. Specific OASIS items, combined with claims data, is used by CMS to determine payment for each of the patient’s 30-day periods of care. CMS also uses OASIS to determine a patient’s clinical improvement or decline during the episode of care as well as to determine home health agencies value-based purchasing outcomes. 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 HIPPS code. 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 HIPPS code did not correlate to comprehensive assessment documentation including homebound status documentation and fall risk assessment. 

A 54-year-old male with HIPPS code of 3CA11. 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 HIPPS code 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 a HIPPS code of 1CC31. 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