Development of an HCBS Pressure Ulcer Measure, Volume 1

Publisher: Cambridge, MA: Mathematica Policy Research
Aug 26, 2015
Andrea Wysocki, Alex Bohl, Chris Fleming, and Jessica Ross

The final recommended HCBS pressure ulcer measure can be summarized as follows:

(1) Numerator specification. The measure numerator includes inpatient hospital admissions where a severe (Stage III, Stage IV, or unstageable) pressure is noted in any diagnosis code field on inpatient hospital claims. Each HCBS user will contribute up to one pressure ulcer event to the numerator, as opposed to the originally proposed numerator that allowed HCBS users to contribute more than one event to the numerator.

(2) Numerator exclusions. On claims where POA information is available (that is, those paid by Medicare), the pressure ulcer measure will exclude pressure ulcers acquired during the hospital stay. Any hospitalization where the date of admission is outside of a month of HCBS use or enrollment will be excluded from the numerator. The numerator excludes pressure ulcers that occur during months when a Medicaid beneficiary is using hospice care.

(3) Denominator criteria. The pressure ulcer denominator counts each month of HCBS use or enrollment in a given calendar year (or within the observation period of interest). Like the numerator, the denominator excludes months of HCBS use or enrollment when a Medicaid beneficiary is using hospice care. 

This is the first of two reports describing the iterative development of a measure to assess potentially avoidable hospitalizations due to pressure ulcers among Medicaid FFS beneficiaries using HCBS. This measure is intended to assess the quality of care for HCBS recipients under a shared accountability framework: the measure profiles the experience of the HCBS population and reflects care delivered by all providers (not just HCBS providers). This report (Volume 1) documents the iterative process to refining Agency for Healthcare Research and Quality's (AHRQ’s) pressure ulcer measure specification and summarizes (1) Mathematica’s preliminary investigation of several options for defining the pressure ulcer measure, (2) presentation of these preliminary analyses to a technical expert panel, and (3) final recommended measure specifications. The report concludes by reporting national- and state-level HCBS pressure ulcer rates for HCBS users in 2009 and 2010, as well as for policy-relevant subgroups of Medicaid beneficiaries who transitioned from institutional long-term care settings to HCBS. These results are descriptive and should be used to guide states or other stakeholders to further examine quality issues. This report does not address risk adjustment for the HCBS pressure ulcer measure. A subsequent report (Volume 2) details the risk adjustment model process for this measure, which represents the final phase of this work. The overarching goal of this work is to continue to develop quality measures that can be used to assess the care provided to Medicaid beneficiaries receiving long-term services and supports in the community. This report, as well as other reports related to developing quality measures for the HCBS population, can be found here.


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U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services

Time Frame


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Alex Bohl
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