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Home Health Resources

OBQI Update

Past issues of Stratis Health's newsletter for home health care professionals and others interested in quality improvement in home health care.

  • OBQI Update July 2008 (St. Luke’s Home Health Services in Duluth, MN, partners with University of Minnesota pharmacy students to improve medication reconciliation)
  • OBQI Update March 2008 (Heartland Home Care, in Roseville, MN, uses successful model for coordinating client care as clients transition from hospital to home care. Attention to assessment at admission, having a strong interdisciplinary team, and clinical education help keep Heartland’s acute care hospitalizations low)
  • OBQI Update August 2007 (Preston Good Samaritan Home Care, in Preston, MN, uses phone monitoring, teletriage, and telemonitoring successfully to improve care, reduce avoidable hospitalizations, and increase client satisfaction)
  • OBQI Update May 2007 (Austin Medical Center, in Austin, MN, demonstrates that building and supporting an organizational culture focused on leadership, teamwork, and care coordination is essential to making process improvements stick and ultimately improve outcomes)

QualityNet This site is a national knowledge forum and searchable online resource center for health care and quality improvement professionals. Sponsored by the Centers for Medicare & Medicaid Services (CMS), QualityNet supports providers of health care services to Medicare beneficiaries in finding, using, and sharing quality improvement resources. QualityNet provides access to resources and to a community of professionals sharing knowledge and experiences to accelerate health care quality improvement across the nation. Health care providers can adapt and use the various tools, literature, and success stories provided at this site to study and implement their own quality improvement efforts.

STAR: Setting Targets to Achieve Results This site allows home health agencies to set targets for improving the following publicly reported quality measures: acute care hospitalization, emergent care, discharge to community, ambulation, bathing, dyspnea, management of oral medications, pain interfering with movement, status of surgical wounds, transferring, and urinary incontinence.

NOTE: The ability to create a new account is temporarily suspended. Please visit the site again in the future to create an account for Home Health STAR.

Polish Your Practice tools, webinars, and other resources on data analysis, health literacy, wound management, diabetes, and more.


Ready, Aim, Improve tools were developed to guide home care providers' quality improvement efforts.

Acute Care Hospitalization

Best Practice Intervention Packages (BPIP) were designed to support home health agencies in their efforts to reduce avoidable acute care hospitalizations in their agencies. BPIPs are a compilation of leadership guides and discipline-specific best practice information, tools, resources, and examples of excellence. Each package includes tracks specific to leaders, nurses, therapists, medical social workers, and home health aides, along with a condensed "Fast Track" to help agencies jump start their improvement efforts. The BPIPs cover the following topics:

  • Hospitalization risk assessment
  • Patient emergency plan
  • Medication management
  • Phone monitoring and front loading visits
  • Teletriage
  • Telemonitoring - immunization
  • Physician relationships
  • Fall prevention
  • Patient self-management
  • Disease management
  • Transitional care coordination

Sample Plan of Action A worksheet that can be used to develop a quality improvement plan of action for acute care hospitalization. (4-page Word doc)

Immunization Toolkit 2007-2008 Sample policies, forms, educational materials, posters and references, as well as information on avian vaccine and pandemic influenza.

Immunization Assessment Form Sample form for recording immunization assessment data.(PDF)

Disease Management Tools Tools to improve the management of heart failure, COPD, cancer, and diabetes through telehealth technology. Each disease topic includes patient selection criteria, decision support and patient encounter documentation tools, a patient self-care workbook, and a staff education guide. These tools may be easily adapted for the non-telehealth patient as well.

Home Telehealth Reference 2006/2007 Educational resources on home telehealth planning, implementation, and utilization. Home Telehealth Reference 2006/2007 expands on the educational resources that were presented in Home Telehealth Reference 2005.

Home Telehealth Reference 2005 Educational resources on home telehealth planning, implementation, and utilization.

Depression Zone Tool Red, green, and yellow zones for designating appropriate agency interventions for clients with depression. (1-page Word doc)

Psychosis Zone Tool Red, green, and yellow zones for designating appropriate agency interventions for clients with psychosis. (1-page Word doc)

Oral Medication Management Sample Plan of Action A worksheet that can be used to develop a quality improvement plan of action for oral mediation management. (4-page Word doc)

Quick Guide for Oral Medications Tips for accurate MO780 assessment. (1-page PDF)

Staff Competency for Oral Medications Staff competency and answer key provided by OASIS Answers, Inc. in conjunction with a "Best Practices for Improvement in Management of Oral Medications" Web Ex presentation. (3-page PDF)

OASIS (Outcome and Assessment Information Set)

CMS OASIS Provides policy and technical information related to OASIS, OBQI (Outcome Based Quality Improvement), and OBQM (Outcome Based Quality Management) for use in home health agencies, including an overview, regulations, OASIS data sets, user manuals, Q&As, etc.

OASIS Answers Reference Book A CMS-based reference for data collectors, with cited documents, guidelines, and Q&As for OASIS and PPS 2008 changes. Information is organized by MO item.

CMS OASIS Users Manual, Chapter 8, Attachment B Guidance in answering OASIS questions. Clarifies OASIS coding by MO item. Includes Q&As and identifies the PPS, OBQI, and OBQM impact of each item.

OASIS Q&As from CMS Most recent CMS Q&As on OASIS, clarification of MOO numbers, 2005 ICD-9 codes, Tally Reports, implementaion manual revisions, PPS patients, etc.

OASIS training Provided by the Minnesota HomeCare Association and supported by the OASIS Certificate and Competency Board.

Accurately Responding to Process Items. These CMS OASIS training videos explain how home health agencies can accurately respond to process items in OASIS-C.

  • Intervention Synopsis (M2400). This video clarifies responses to M2250 at Resumption of Care, and relationship between verbal or supplemental orders and the Plan of Care. This video focuses on the OASIS-C process item M2400, the Intervention Synopsis. (14-minute video)
  • Falls Risk Assessment (M1910). This video clarifies the role of disciplines other than nursing in falls risk assessment, medication review and SBAR. It focuses on the OASIS-C process item M1910, the Falls Risk Assessment. (12-minute video)
  • Plan of Care Synopsis (M2250). This video explains how home health agencies can accurately respond to process items in OASIS-C. This video clarifies responses to M102 and M104, M1730, M1910, SBAR and validated/standardized assessments. This video focuses on the OASIS-C process item M2250, the Plan of Care Synopsis. (31-minute video)

Policies on skilled services Policies on skilled services related to OASIS Definitions, principles, and a training module for skilled and maintenance nursing, created by the Minnesota HomeCare Association Clinical Quality Team. (PDF)

OASIS Assistance Minnesota Department of Health OASIS Clinical Help Line/OASIS Education Coordinator
Telephone: 651-201-4314, Fax: 651-201-4110, Email:

OASIS Technical Help Minnesota Department of Health OASIS Technical Help Line/OASIS Automation Coordinator
Telephone: 651-201-3818 or 1-800-657-3879 (greater MN), Fax: 651-201-4304, Email:

Other Resources

Recorded Web Seminar: Health Coaching, An Exciting Strategy to Improve Patient Outcomes
Enhance client self-management and improve outcomes with this recorded Web seminar presented by Melinda Huffman, BSN, MSN, CCNS, Miller & Huffman Outcome Architects, LCC. To obtain a free copy of this recorded session, contact Amy Heikkinen.

The OBQI Process: 8 Quick Steps Provides an easy-to-use system for implementing the OBQI Process, including 8 quick steps, the process for each step, key points to remember, and available supporting resources. (2-page Word doc)

Minnesota Falls Prevention Initiative Provides information for older adults and professionals to help reduce falls in Minnesota.

Minnesota Hospital Association Safe Skin Campaign A safe skin toolkit shared with Minnesota hospitals.

Talking with your doctor, nurse, or therapist A reference sheet and checklist for clients to use in preparation for calling their health care professional.

Call Me First Magnet, Call Me First Window Cling, Call Me First Stickers Templates for agencies to use to produce Call Me First magnets, window clings, and stickers for their clients. (PDF)

POA Worksheet A worksheet that can be used to develop a quality improvement plan of action for any of the publicly reported home health measures. (6-page Word doc)

Best Practice Chart Audit Tool A worksheet for agencies to use to document compliance with stated clinical best practices. (1-page Word doc)

Tally Report Template , Tally Report Instructions An Excel workbook template with spreadsheets for importing patient tally data and selecting specific cases to review based on patient outcome and case mix characteristics. (Excel doc) (PDF 091906)

Contact Stratis Health for assistance with your quality improvement and patient safety needs.

If your agency has projects it would like to work on, contact us to discuss how we can work together to support new initiatives.

Kelly O'Neill, program manager

Janelle Shearer, program manager

Appeals information

Betsy Jeppesen, vice president, Program Integrity