Core Quality Measures

  • Measures also available in Portable Document Format (PDF)
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2–26–12
Baltimore, Maryland 21244–1850

SMD# 13–001
ACA #23

Re: Health Home Core Quality Measures

January 15, 2013

Dear State Medicaid Director:

The health home provision authorized by section 2703 of the Affordable Care Act provides an opportunity to build a person–centered care delivery model that focuses on improving outcomes and disease management for beneficiaries with chronic conditions and obtaining better value for state Medicaid programs. As part of this care improvement effort and after extensive consultation with states and other stakeholders, the Centers for Medicare & Medicaid Services (CMS) is sharing a recommended core set of health care quality measures for assessing the health home service delivery model that CMS intends to promulgate in the rulemaking process.

While CMS is not requiring states to use these measures until the regulations are promulgated, states requested that we share these measures in advance of rulemaking. In keeping with the collaborative process on the health home provision, CMS is sharing the core set to help states as they consider the design and implementation of their health home programs. This advance notice will also give states time to share information with their health care providers, which is important, since health home providers will be required to report health care quality measures in order to receive payment.

These recommended health home core quality measures are an integral part of a larger payment and care delivery reform effort that focuses on quality outcomes for beneficiaries. This effort is aligned closely with the Department of Health and Human Services´ (HHS) National Strategy for Quality Improvement in Health Care, as well as other quality initiatives.

CMS consulted with states considering health homes and conducted technical assistance calls, presentations, and webinars in order to identify the initial core set of health home quality measures for Medicaid–eligible children and adults. CMS also worked with federal partners, including the Office of the Assistant Secretary for Planning and Evaluation and the Substance Abuse and Mental Health Services Administration. The recommended core set of health home measures were chosen because they reflect key priority areas such as behavioral health and preventive care, and they align with the initial core set of health care quality measures for Medicaid–eligible adults, the EHR incentive "Meaningful Use" program measures, and with the National Quality Strategy.

The recommended health home core measures are listed below and described in more detail in Attachment A:

  1. Adult Body Mass Index (BMI) Assessment,
  2. Ambulatory Care – Sensitive Condition Admission,
  3. Care Transition – Transition Record Transmitted to Healthcare Professional,
  4. Follow–up After Hospitalization for Mental Illness,
  5. Plan– All Cause Readmission,
  6. Screening for Clinical Depression and Follow–up Plan,
  7. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment,
  8. Controlling High Blood Pressure.

To ease the reporting burden, CMS has aligned all but one of the recommended health home core set of measures with the initial core set of health care quality measures for Medicaid–eligible adults, which were published and posted for public comment on December 30, 2010, with final regulations published on January 4, 2012. CMS encourages states to report on the initial core set of children´s health care quality measures1 and the initial core set of health care quality measures for Medicaid–eligible adults.2

The recommended health home measures are drawn from claims data, to the extent possible, in order to reduce burden on states. However, CMS recognizes that certain measures in the core set require data extractions from medical records, and may require additional work for some providers and states. CMS will provide state Medicaid agencies with the technical specifications for the core measures (e.g., numerator, denominator, and coding information) and will encourage states to delay system programming for the health home quality measures until these specifications are released. The purpose of the recommended health home core set is to assess health outcomes specific to the health home program. The health home core set will require reporting at the health home provider level, while the full Medicaid–eligible adult core set of health care quality measures will be reported in the aggregate at the state level. CMS will provide technical assistance on the implementation of these recommended health home measures and intends to release guidance on when states should begin reporting on the measures, the frequency of reporting, and the reporting mechanism.

The health homes core set of quality measures will be used to evaluate care across all state health home programs. CMS expects that states will report on the health home core measures, as well as the specific goals and measures identified by individual states. The intent of the two–part quality reporting approach is to gain consistency across states while allowing states to use existing quality metrics to measure health home outcomes. All of the quality data will be utilized by CMS to work with states and other stakeholders to continually improve health homes. The data will also be used to inform the evaluations that section 2703 of the Affordable Care Act require, in both an interim survey of states and an independent evaluation in the 2014 and 2017 reports to Congress.

For states interested in health homes, more information is available here. States interested in receiving technical assistance may also e–mail the CMS health homes team at

If you have any questions regarding the health home core measure set, please contact Ms. Barbara Edwards, Director of the Disabled and Elderly Health Programs Group, at 410–786–0325.


Cindy Mann Director


CMS Regional Administrators

CMS Associate Regional Administrators
Division of Medicaid and Children´s Health Operations

Matt Salo Executive Director
National Association of Medicaid Directors

Alan R. Weil, J.D., M.P.P.
Executive Director
National Academy for State Health Policy

Heather Hogsett
Director, Committee on Health & Homeland Security National Governors Association

Ron Smith
Director, Legislative Affairs
American Public Human Services Association

Christopher Gould
Director, Government Relations
Association of State and Territorial Health Officials

Debra Miller
Director for Health Policy Council of State Governments

Joy Wilson
Director, Health Committee
National Conference of State Legislatures

Robert Glover, PhD Executive Director
National Association of State Mental Health Program Directors

Robert Morrison Executive Director
National Association of State Alcohol and Drug Directors


1. Initial core set of children´s health care quality measures State Health Official letter  1
2. Initial core set of health care quality measures for Medicaid–eligible adults, Federal Register / Vol. 77, No. 2 / Wednesday, January 4, 2012.  2