Webinar Recording: The VBP Clock Is Ticking - How to Improve Quality Scores Before It's Too Late

Your quality scores are tied directly to your bottom line.

With Value-Based Purchasing (VBP) in full effect, underperformance isn't just a regulatory risk—it's a revenue loss. And if you're waiting until the next quarter to act, you may already be behind.

Join Maxwell TEC and QAPIplus for a tactical session on how top agencies are protecting their revenue using real-time dashboards, data-driven insights, and AI-powered performance improvement tools. This isn't about just tracking data. It's about turning it into action that moves your metrics.

Key Takeaways:

• A clear path to improving Star Ratings and VBP metrics this quarter
• How to use real-time dashboards to surface risks early and act with confidence
• Why AI-generated PIPs are accelerating how teams close performance gaps
• What top-performing agencies do differently to stay ahead under VBP

WEBINAR TRANSCRIPT

Welcome, and thank you for joining us for the "The VBP Clock Is Ticking: How to Improve Quality Scores Before It's Too Late" webinar. You'll hear from two industry experts helping agencies across the country turn data into measurable improvement.

First, we have Laura Martini, Senior Consultant at Maxwell TEC. Joining her is Armine Khudanyan, CEO and Co-Founder of QAPIplus.

Together, Laura and Armine will walk through how leading organizations are using real-time dashboards, data-driven insights, and AI-powered tools to protect your revenue and drive sustainable performance improvement under VBP. Let's get started.

Thank you. Our objectives today include review of the home health value-based purchasing model, the history and the most recent adjustments to the model. We will review how to use your information to monitor the approach and achieve improvement in your outcome measures. And finally, we will demonstrate use of data and tools to enhance your QAPI efforts.

First, we wanna start with some background. The home health industry has been hearing about value-based purchasing for many years. Today, I want to start by reviewing a bit of the history and the points that have occurred to get us to where we are today.

The original model for VBP was developed and implemented by CMS in 2016, nine years ago, and started as a pilot in nine states.

They set goals for the program that included provision of a financial incentive for those agencies demonstrating improvement in the quality outcome measures. The higher the quality, the higher the financial bonus, up to 5%.

The pilot would be used to review and study the selected measures to determine if they were appropriate indicators for the program.

And the information was intended to be included in the public reporting process to increase transparency of information and provide the consumer with a view of the quality provided by an agency. The results of the pilot were favorable. The model was shown to have an average of 4.6% improvement in the quality scores and a savings to Medicare of $141 million on average annually.

In addition, the review of the model also found reductions in unplanned hospitalization, which in turn resulted in further reductions in spending. In 2021, CMS announced the decision to expand the model to include all states. With the announcement in 2021 came the plan for implementation. 2022 was determined to be the pre-implementation year or baseline. This gave the home health agencies a year to review their current scores, make plans to improve, and essentially get organized in preparation for VBP.

The first performance year was planned to be 2023, followed by evaluation and payment for those results in 2025. It's important to note that CMS determined agencies would be placed in categories based on their size. There are two categories, small cohort and large cohort.

This allows for agencies to be in a group of their peers with similar resources to devote to these initiatives. After the results are reviewed from the performance year, a financial adjustment will be assigned for the claims submitted in the payment year. Depending on the agency performance, the adjustment can be as high as plus 5% for high quality or as low as minus 5% for low scores.

After this announcement, there were many concerns expressed across the industry, and we all had the opportunity to comment during the final rule process. In the fall of 2023, the final rule for calendar year 2024 was finalized, and there were adjustments made to the VBP model. The original set of outcome and claims-based measures were updated to begin with performance year 2025. This is the set that is being used now as we work our way through 2025.

In addition, the baseline model year was updated to 2023, and this will be used to compare the 2025 performance year. In theory, this should be advantageous to agencies if improvement activities and organization were underway. With 2023 being the baseline year for this year, 2025, let's look at the definitions of how agencies are being evaluated.

Improvement scores will reflect the percent of improvement between the baseline year and the performance year. The score will earn points for VBP based on the amount of improvement. Achievement scores reflect the level of performance and will be compared to the CMS thresholds and percentiles. So for example, if your agency was performing at a higher level and did not have a lot of room to increase in improvement, you will still earn points based on what level of improvement or percentile ranking you have achieved. And these achievement thresholds used for agency ranking are calculated separately for the small and large size agencies.

This chart depicts the updates to the measures. The categories have remained the same to include OASIS-based, claims-based, and HHCAHPS-based measures. The OASIS-based category dropped discharge to community, mobility, and self-care measures while maintaining dyspnea and management of oral medications.

The mobility and self-care measures were based on M1800 OASIS questions. The new measure added is the discharge function score, which is derived from GG questions.

In the claims-based category, the acute care hospitalization and emergency department use without hospitalization have been replaced. The new items, still claims-based, will now include potentially preventable hospitalization and a combination discharged to community and post-acute care measure. The HHCAHPS survey-based measures are unchanged and will include the five measures for patient experience. Let's take a closer look at the 2025 performance year measures.

Improvement in dyspnea and improvement in management of oral medications are longstanding measures, and agencies have spent time educating and auditing these measures. The key is accuracy and OASIS question knowledge to have them scored correctly at the time of the assessment. The new discharge function score is a composite score, as I mentioned, of the GG questions, addressing self-care and mobility, 13 questions in the GG130s and the GG170s. This measure will report the percentage of patients that meet or exceed the expected discharge function score.

What is important to know: if the items are skipped, dashed, or coded activity not attempted, which is acceptable practice when completing the OASIS, statistical imputation will be used to ensure validity.

Statistical imputation uses patient characteristics from elsewhere in the assessment plus data from groups of patients with similar characteristics to produce the most likely value for the missing GG information.

We talked to quality departments across the United States, and understanding and/or answering of the GG questions continues to be problematic. Best practice will be to educate your staff on the GG items and completing the items during the assessment. For more information on this item, please search discharge function score on the CMS website. There is a detailed teaching sheet to understand how this item is scored.

Now let's look at the claims-based measures. The previous measures for hospitalization and ED use looked at the first 60 days of the patient stay on home health. The new measures have different timeframes. The home health within stay, potentially preventable hospitalization, otherwise known as PPH, considers the entire home health stay.

Hospitalizations and observations are counted. However, planned admissions will be excluded. This measure accounts for 26% of the weight of the total VBP score. Agencies will need to evaluate your population, your hospitalization events, clinical care, care practices and responses to prevent these hospitalizations.

The discharge to community post-acute care measure will measure the percent of patients discharged to the community, and they do not have an unplanned hospital admission in the 31 days following the discharge. This measure is a lower weighting towards the total VBP score at 9%. Agencies need to review discharge readiness assessment and potentially look at post-discharge follow-up to keep tabs on the patient for the 31 days. These two measures together will account for one-third of your VBP score.

The HHCAHPS measures have not changed. However, they need to continue to be a point of focus to ensure the patient experience is favorable with your agency. Agencies need to act and take charge of your VBP scores. If you haven't already, you need to access your interim and annual performance report at iQIES. Be sure to view all of the tabs, achievement points, improvement points, care points, annual payment adjustments.

These reports will provide you with a retrospective review and guide you to the areas that require focus. The entire webinar could be spent on how to read your reports, but that's not our focus today. I have included the link, the HHVBP calendar year 2024 annual performance report. This was a very informative teaching on how to access your reports and a guide for interpreting your reports, which was conducted by CMS, and I would encourage you to look that up if you're having difficulty understanding the reports.

So let's face it, we know improving and even sustaining quality outcome indicators is hard. It takes a focused approach with a plan.

It is important to monitor results and pivot to make adjustments if the improvement isn't evident. Knowing that VBP is focused on OASIS, claims and patient experience, agencies can focus their plans accordingly. OASIS education and auditing can bring results. Claims-based measures can be impacted by clinical care practices focusing on delivery of care and how your staff follow up with patients. And HHCAHPS measures can be impacted by how the care is delivered, ensuring the patient and caregivers are having a good experience.

Once agencies review their results, put a plan together to impact the results, it is important to monitor, to manage your plan. There are several ways to do this, including EMR functionality, manual spreadsheets, and software. Our focus today is on software. I'm going to turn to Armine to share with us the use of QAPIplus software and how this can assist agencies to be efficient and effective when working on improvement.

Thank you, Laura.

So when we think about value-based purchasing, we're really talking about the intersection of quality and accountability. CMS is rewarding agencies that deliver measurable outcomes, not just completed visits. The challenge is that many organizations collect mountains of data but struggle to turn that data into action, and that's where technologies like QAPIplus come in.

QAPIplus transforms real-time operational and clinical data into actionable insights that drive measurable improvement in all of the VBP domains. The platform helps agencies identify risk patterns early, and that's the key, such as high acute care utilization, poor patient experience, or documentation gaps affecting outcome measures. Using QAPIplus dashboards, leaders can track performance across branches or among different clinicians, allowing proactive interventions before quarterly CMS submissions. The result is not just compliance but strategic quality management aligned with financial incentives.

So in other words, QAPIplus helps agencies move from reactive compliance to proactive performance, exactly what CMS is looking for under value-based purchasing. As we move into 2025, VBP isn't just the care we deliver. It's about how that care is measured and compared across the nation. CMS is no longer rewarding activity. It's rewarding measurable outcomes.

This means your reimbursement will depend directly on your ability to prove performance, and that requires clarity, consistency, and the data you can trust. Many organizations still struggle to connect daily operations to the metrics CMS is scoring them on. Teams know they need to improve VBP, but they don't have a clear line of sight into what actions truly move the needle, whether that's reducing acute care hospitalizations or improving patient satisfaction. In too many agencies, data is reactive. By the time leadership sees it, it's already outdated. And performance improvement plans are often generic, not targeted to the actual deficiencies in outcomes, and this really leads to wasted effort and limited impact.

Also, education is often broad, covering compliance checkboxes rather than addressing real performance gaps tied to VBP measures. Without precision in training, clinicians can't influence the very metrics that affect reimbursement.

So far, we talk about improvement, but we have to acknowledge this reality: agencies can't fix what they can't clearly see. That's why the right technology and analytics are so critical, and they can turn performance blind spots into actionable insight. In a traditional reactive approach, we start by looking at our VBP results after they've already been posted. We then move to root cause analysis. We launch a PIP, we assign training or education and then measure data again. The issue is that by the time we take action, it's often too late.

The performance period has closed, and all we can do is explain what went wrong. That is the reactive approach. What agencies are able to accomplish with a proactive approach is very different. In this proactive approach, the order is reversed.

We start with ongoing analysis, spotting risk trends before they impact outcomes. We launch targeted PIPs early, assign focused education, and continuously measure our data in real time. By the time CMS releases results, we already know where we stand because we've been managing performance and not just reacting to it.

When we talk about reactive, we go from insight to intervention, and this is responding to data that's already there, versus a proactive approach where you go from intervention to insight, which is acting early to influence the next quarter's data. Real-time visibility turns quality improvement from a retrospective audit into a predictive process. Proactive agencies don't chase results, they shape them. It is an active process.

The real goal under VBP isn't to fix what happened, it's to prevent it from happening again. And the key to making the shift is technology, the ability to see trends, act early, and measure outcomes dramatically. So let's take a look at a concrete example of how a proactive cycle works inside key performance areas, and we can start with the OASIS-based outcomes.

We'll take a closer look at the OASIS-based measures that drive your VBP performance in 2025. These indicators go beyond documentation. They tell CMS how effectively your team manages patients, function, symptoms, and medication safety. Today, we'll focus on three critical areas: improvement in management of oral meds, improvement in dyspnea, and of course, the discharge function score.

When we think about improvement in management of oral medications, this measure looks at how well patients are able to take their medications correctly from the start of care to discharge. It's a direct reflection of patient self-management and adherence and has a major influence on outcomes like readmissions and medication errors. Often, this ties back to your medication reconciliation process and the education your clinicians provide. It's derived from OASIS items M2020, and when your patients show improvement here, your agency earns higher scores within the functional domain of VBP.

That's one of the major measures that in 2025 VBP is focusing on. The next measure is improvement in dyspnea, which tells us how your team manages shortness of breath from the start to the end of care. This is also critical and reflects how effectively your clinicians teach, for example, energy conservation and symptom management. This measure comes from OASIS M1400, which looks at breathlessness during daily activities or during exertion.

Strong performance here signals that your care is not just treating conditions, but improving the patient's quality of life. Finally, the discharge function score.

This evaluates the patient's functional ability at discharge across self-care and mobility domains, not just how they improved, but the final level of independence they reached. It's one of the strongest predictors of both readmission risk and post-acute outcomes.

CMS calculates this by combining GG self-care and mobility OASIS discharge items. Accuracy and completeness at discharge are key.

These are the measures—medication management, functional independence, and symptom control—that tell CMS how effective the organization truly is in taking care of their patients. So, what are some of the interventions that can be done? We start with audits that target OASIS items tied to VBP measures. For example, if you notice inconsistent documentation on medication management or incomplete GG items at discharge, those are early warning signs that more education is needed. These audits tell you where clinicians may need more support before outcomes are impacted.

Also, when QAPIplus detects dips in areas like oral medication management, it will automatically flag those trends and generate focused AI-powered performance improvement plans. For example, if M2020 scores are low, the PIP might focus on clinician reeducation for medication reconciliation and patient teaching techniques.

The software also has the ability to assign tasks and education, so follow-ups can be assigned right away. This could mean refresher trainings on OASIS items or teaching nurses how to assess and coach patients with dyspnea more effectively. Each action is linked back to a measurable OASIS metric, so your team knows exactly what behavior or process needs to change.

QAPIplus's tasking functionality can be used to provide just-in-time micro training to clinicians, and this really impacts scores. This very focused training is called just-in-time because it happens at a very specific teaching moment, and that moment is not lost, because it can be captured right during the audit itself.

When these interventions are consistently applied, you'll see measurable improvement in your value-based purchasing results. Better performance in these measures means stronger functional domain scores, reduced readmissions, and higher overall quality rankings. By connecting OASIS data directly to daily operations, agencies can transform compliance activities into measurable outcomes. Next, we'll take a look at some of the claims-based measures, like hospitalization use, that can also strengthen VBP measures.

In 2025, some of the claims-based measures are at the heart of VBP scoring. These metrics tell CMS how effectively your organization prevents unnecessary hospital use and supports safe, sustained discharges back into the community. The two measures driving this are the potentially preventable hospitalizations and discharge to community, the post-acute care measure.

Again, when we follow our process of conducting root cause analysis, we begin with the why. Why did the hospitalization or readmission occur and what could have prevented it? For the PPH measure, we're looking at unplanned hospital stays and whether they could have been avoided through better care coordination, medication management, or earlier intervention.

The other measure focuses on how well patients transition out of home health and remain in the community without being readmitted within 30 days. QAPIplus helps identify those root causes by tracking trends in adverse events, missed visits, or incomplete discharge follow-ups.

This is what allows organizations to see, once those gaps are trended, that you can have real insight into some of those causes.

Some of the common contributing factors we've been able to see are missed escalation opportunities for symptom changes, medication or care coordination breakdowns, or poor discharge readiness or lack of follow-up planning. Those have been some of the ones that we have seen the data show.

Once those patterns are recognized, QAPIplus automatically generates a targeted AI-powered performance improvement plan. For PPH, your PIP might focus on early warning protocols such as flagging symptom changes that commonly precede hospitalization.

For the DTC measure, the plan might address discharge processes, ensuring patient education, medication reconciliation, and that post-discharge calls are consistently completed. Also, immediately assigning those interventions to the right team members when any of these red flags are seen. That could mean nurse retraining on clinical escalation, revising interdisciplinary communication workflows, or reinforcing the role of therapists in safe discharge planning.

That kind of interdisciplinary approach may make the difference and affect VBP scores. Again, education is not generic. It's linked directly to the data trends that you are seeing. This is where impact and adult learning come into play, because it is just in time.

Real-time measurement is what closes this loop. With QAPIplus, agencies can track preventable hospitalization rates by diagnosis, by branch or clinician, and monitor post-acute discharge outcomes week over week.

This continuous feedback keeps the team focused on both clinical and operational excellence. When your PPH rates decline and your discharge rates improve, your value-based purchasing scores reflect it. These measures are highly weighted under CMS because they represent patient safety and continuity of care. Reducing preventable hospitalizations and improving community discharges mean higher quality scores, stronger financial returns, and better patient trust.

In claims-based performance, prevention and transition are everything. By using data to predict and prevent avoidable events, agencies can protect both patients and performance.

That's more with claims-based. Next, we'll move to the final category of the VBP, which is the HHCAHPS. These are based on patient satisfaction and really what we call, in a large section of QAPIplus, patients' perception of care. Most often, it's how patients perceive the care. There is quite a bit of difference between care actually provided and the way patients perceive this care.

The third major category under VBP is the patient satisfaction scores, which basically represent the patient's voice or the patient's family voice. CMS uses these survey results to understand how patients perceive their care experience. Small improvements here can make a significant impact on your VBP score.

Patient perception isn't random. It's a reflection of our communication, our coordination, and our responsiveness to their needs. That's why it's critical to audit those interactions regularly.

QAPIplus helps agencies run perception of care audits monthly, pinpointing exactly where patient expectations are falling short, such as unclear medication management instructions or inconsistent follow-up communication. In the system, it also identifies declining scores in areas like communication or timeliness. It automatically flags the trends and generates focused improvement plans. This ensures that your team isn't guessing, but they're responding to real patient feedback and structured interventions.

With the tasking functionality, once those insights are identified, leadership can immediately assign tasks to the right people. For example, reinforcing call etiquette, revisiting how care plans are explained, or providing brief educational refreshers on bedside communication and, of course, empathy.

These small frontline changes have an outsized impact on how patients feel about their care and how they perceive their care. Measuring this information is also very important.

You can track HHCAHPS trends over time, across branches, clinicians, or specific question categories, right within a dashboard. This makes perception measurable and not just anecdotal. Month after month, seeing a single measure trend tells a lot about how education and communication provided to clinicians are impacting the patients. Under VBP, CMS directly rewards improvement in patient experience. Even modest gains in HHCAHPS domains, like care of patients or communication between providers and patients, can translate into meaningful reimbursement increases. With QAPIplus, you can stay proactive and patient-centered rather than waiting for survey results months later.

When you combine clinical accuracy and prevention of avoidable events with the patient experience, you're not just improving scores, but you're transforming your agency's culture of quality. We talk about culture of safety and culture of quality all the time. Now we're going to use all of this information to bring it all together and look at what your VBP advantage really is.

At this point, you can see how each category connects. OASIS-based measures reflect the clinical accuracy and functional outcomes. Claims-based measures represent care coordination and prevention, and HHCAHPS-based measures capture the patient experience of all of that care being provided to them. When agencies integrate all three through a consistent QAPI framework, value-based purchasing shifts from a reporting burden to a growth opportunity. You're no longer chasing metrics. You're using them to drive improvement and to build trust across every stakeholder, including clinicians, patients, and eventually payers. The agencies that succeed under VBP all have one thing in common: they act daily, not quarterly. That brings us to our next principle, which is to optimize, incentivize, and to thrive under VBP.

Agencies winning at value-based purchasing aren't waiting for their quarterly reports. They're acting daily and seeing real-time results. They understand what's driving their metrics, not just the outcomes, but the behaviors and the workflows that shape them. They make clinical education ongoing, not as a reaction to either survey findings or to VBP results, but as part of daily operations. This education is focused and it's just in time.

They also rely on detailed data and performance improvement projects, which take the guesswork out of quality improvement.

When performance drivers, actionable data, and continuous education align, outcomes really improve. Staff feel empowered and value-based purchasing becomes sustainable. This is exactly where technology and expertise come together. With that, I'm going to hand it back over to Laura, who will share how they partner with agencies to put these strategies into action.

Thank you, Armine. I appreciate that. The message that both Armine and I really want you to take away from today's webinar is to commit to improvement. It doesn't matter what quality model you use. I happen to like the plan, do, check, act. However, for success, agencies must have a focused approach to achieve results. Using tools such as QAPIplus will provide agencies with real-time information to achieve the necessary results in the most efficient manner.

As Armine described, relying solely on the CMS reports is looking backwards at what happened, or the manual approach will bury you under data, which prevents you from acting on the results. As we move forward, efficient results-driven information will be the key to success.

At Maxwell TEC, we partner with agencies to assist you to define your path to success. We work with agencies to review operational functions, to determine current state, and identify gaps or inefficient practice. We assist you to redesign your processes to provide the most efficient approach to achieve the best results.

This redesign is customized to your agency to work with you on change management and successful implementation of both new processes and new tools. We will stay with you to evaluate the effectiveness and assist with any modifications as needed. We do this through KPI monitoring, looking at the results. This is the plan, do, check, act model in action.

In addition, we are available to assist you with educational resources focused on HHVBP to assist you with your goals. I also want to share the NanaConnect platform that was developed by Maxwell TEC to address some of the challenges our industry faces.

This is a bi-directional texting patient engagement platform that can be customized to your agency. There are four different components. Notify, which is informing of upcoming visits and confirming acceptance. Engage is an in-between visit contact to check in on symptom development. Bereave, used in the hospice industry. And Reach. Reach is the one that I wanna discuss today. Reach provides agencies with an automated connection to patients post-discharge. The communication can be customized, so for example, your CHF patients can receive questions related to early symptom development that may prompt you to seek a new referral to prevent that ED or hospital visit in that first month post-discharge. The messaging is automated, information is collected and viewable in a dashboard, allowing decision-making by agency staff if further action is required. This type of tool is an example of low-effort, high-result intervention for your agency as you navigate all that you have in front of you to be successful under the home health VBP model.

I want to thank you for listening today, and we wish you much success as you navigate VBP. Please reach out to us if you are interested in a demo of QAPIplus or NanaConnect Reach, or if you are interested in an operational review of your quality processes. We are happy to partner with you.