Agencies should consider using some of the following process and outcome measures as part of a Quality Assessment and Performance Improvement (QAPI) program. 

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OASIS Outcome and Process measures

• M1400 – When is the patient dyspneic or noticeably short of breath – outcome measure
• M1242 – Frequency of pain interfering with activity or movement – outcome measure
• M1720 – When is the patient anxious (reported or observed in last 14 days) – outcome measure
• M1730 – Depression Screening – process measure
• M2000 - Drug regimen review – process measure
• M2002 – Medication follow-up – process measure
• M2020 – Management of Oral medications – outcome measure

Home Care Patient/Caregiver Outcomes

1. Patient/caregiver demonstrates ability to take medications correctly (OASIS).
2. Patient/caregiver is able to verbalize medication actions, what to expect, administration schedule and side effects to report.
3. Patient/caregiver is able to verbalize understanding of weight gain parameters and weighs self daily.
4. Patient/caregiver is able to verbalize signs and symptoms of worsening heart failure and promptly report to physician.
5. Patient/caregivers demonstrate healthy meal planning.
6. Patient/caregivers demonstrate progressive independence in self-care management of care needs.
7. Patient maintains a daily record of fatigue, dyspnea – other symptoms individualized to patient and demonstrates appropriate interventions.
8. Patient participates in an exercise program of at least 30 minutes of aerobic exercise 3 times per week.
9. Patient has received flu and pneumonia immunizations.
10. Patient maintains a Personal Health Record and reviews it with each physician at each appointment.
11. Patient/caregiver is able to state signs of HF exacerbation.
12. Patient/caregivers demonstrate understanding of chronic nature of condition and preventative measures to minimize risks of exacerbation.
13. The "Advanced Planning & Palliative Care" conversation has occurred with all patients as appropriate and with all patients who have had more than 3 hospitalizations in 6 months.