Common Links for Home Health, Hospice, and CAP/PCS General Info

National Links
This is the main CMS web site
This is a one-stop resource for Home Health Agencies. 
This is where the OASIS Grouper software is found
Listserv archives of HH PPS articles maintained by the National Institutes of Health (NIH)
ICD-10 info sheet

PGBA (All except Virginia and Michigan send Medicare claims here)
PGBA home page - the main link we will use is Regional Home Health & Hospice Intermediary (RHHI)
Then look under EDI for other links that are handy.

State-Specific Links

Michigan Medicare, click here

North Carolina
This is the home page for the North Carolina Department of Health and Human Services Division of Medical Assistance. 
Click on Medicaid Providers.
NC DMA site to look up NPI and Carolina Access numbers

South Carolina
SC Hospice Services Manual

Cahaba GBA (Virginia Medicare claims are sent here)

CMS Links

General Sources, Publications, and Web Sites
CMS Internet-Only Manuals (IOMs)
Conditions of Participation
HHA Center
Home Health Compare
Med Learn Network
NPI Registry
OASIS Archives
OASIS Data Specifications and
Open Door Forum
Home Health PPS Payment
OASIS Privacy Rights Notice
Home Health Quality
Quality Measures Management Information System (QMIS) Frequently Asked Questions
OASIS Regulations
State OAC/OEC information
State by State Comparison of Measures
CMS Survey and Certification
OASIS Q&A’s Submit and Review questions
Q&A Tracking Table
Mailbox (to be updated in association with OASIS C)

Guidelines and Best Practices
Home Health Best Practice Intervention Packages (QIO)
Falls Prevention Best Practice Intervention Package (A comprehensive Best Practice Implementation Package from the Home Health Quality Improvement Campaign that helps home health agencies to design and implement a fall prevention program for their patients.)
Evidence-Based Practice Guidelines, University of Iowa, College of Nursing
National Guideline Clearinghouse™ (NGC):
VNSNY Geriatric Home Care Excellence

Healthcare Technology
Office of the National Coordinator for Health Information Technology (ONC)

Infection Control and Immunizations

Medical Resources
Activities of Daily Living Definitions
Congestive Heart Failure
Diabetic Foot Care
MEDLINE Medications

Mental Health Resources
BIMS’ performance in national testing in community setting is included in a final report to CMS. Saliba D, Buchanan J. 2008. “Cognitive Patterns” Chapter 5 in Development & Validation of a Revised Nursing Home Assessment Tool: MDS 3.0.
Depression Recognition & Assessment in Older Home Care Patients e-learning module, Weill Medical College of Cornell University:
Brown EL, Raue PJ, Roos BA, Sheeran T, Bruce ML. 2009. “Training Nursing Staff to Recognize Depression in Home Healthcare.” Journal of the American Geriatrics Society.

CMS website. Available:
Chodosh J, Edelen MO, Buchanan JL Yosef JA, Ouslander JG, Berlowitz DR, Streim JE, Saliba D. “Nursing Home Assessment of Cognitive Impairment: 2008. Development and Testing of a Brief Instrument of Mental Status.” Journal of the American Geriatrics Society 56(11): 2069-2075.
Cognitive assessment tools (clock test)
Mini-Mental Status exam

Risk Assessment Tools and Condition-Specific Resources
American Heart Association Statements and Practice Guidelines
PHQ-2 resources
PHQ-2 resources (University of Washington Impact Program)

Falls Risk
Home Care Fall Reduction Initiative risk Assessment Screening Tool (A multi-factor falls risk screening tool from the Missouri Alliance for Home Care, specifically designed for home care patients at Start of Care and Re-certification)
Timed Up and Go (TUG) Test Demonstration video (Demonstration of how to administer the Timed Up and Go (TUG) test -- can be used as one component of a multi-factor risk assessment used to identify persons that are at risk of falling due to balance or gait problems)
Get-up and Go Test (A brief assesment of gait and balance – University of Iowa, Iowa Geriatric Education Center)
National Heart Lung and Blood Institute
Body Mass Index guidelines

Non-verbal patient pain assessment:
Geriatric Pain:

Pressure Ulcers
Established, validated pressure ulcer risk tools include the Braden Scale for Predicting Pressure Sore Risk and the Norton Scale (both of which are available at

Norton scale
NQF Framework
National Pressure Ulcer Advisory Panel (NPUAP) 
( )
Pressure ulcer definitions:
Pressure ulcer pictures:
NPUAP 's Pressure Ulcer Scale for Healing (PUSH)
Wound Ostomy and Continence Nurses Society (WOCN)
Leg ulcers:
OASIS guidance (Look for the upcoming OASIS-C Guidance Document)

Professional Organizations
ANA Releases Revised Scope and Standards of Practice for Home Health Nurses (11/21/07)

Quality Resources
Agency for Healthcare Research and Quality
AHRQ's Health Care Innovations Exchange Web site (Innovations and QualityTools classified by disease or clinical category, patient population, stage of care, setting of care, and more. )
AHRQ's Quality Measures Database - National Quality Measures Clearinghouse (NQMC).
Commonwealth Fund Commission on a High Performance Health System:
Diversity:The Provider’s Guide to Quality and Culture
Institute for Clinical Systems Improvement
Institute for Healthcare Improvement
Institute of Medicine
National Transitions of Care Coalition (NTOCC)

Safety Resources
AHRQ Patient Safety
Joint Commission
Joint Commission National Patient Safety Goal
Fall Risk/Safety
Medication Safety Institute for Safe Medication Practices (ISMP)
QualityNet -- Tools for evaluating potential inappropriate medications
TJC - Medication Management:
Teamwork/TeamSTEPPS Training Curriculum Materials
VA National Center for Patient Safety