Closing the Care Gap: A Playbook to Improve Clinical Outcomes and Reignite Home Health Growth

Home health has long been viewed as central to modern healthcare reform. By providing acute care, skilled nursing, and rehabilitation in patients’ homes, it promises lower healthcare costs, fewer hospital readmissions, and recovery with dignity for an aging population. 

CMS Data 

However, recent national data and quality assessments reveal a sobering truth: clinical outcomes across home health providers remain startlingly dismal. Despite advances in

remote patient monitoring, expanding telehealth infrastructure, and value-based reimbursement models, functional improvement rates and community discharge metrics across agencies continue to plateau or decline. 

CMS+ 1 

The key drivers behind these lagging outcomes point to structural vulnerabilities, staffing shortages, and policy shifts that are holding the home health sector back. 

1. The Numbers Behind the Plateau 

Tracking clinical metrics through the Centers for Medicare & Medicaid Services (CMS) Outcome and Assessment Information Set (OASIS) reveals widespread stagnation: 

CMS Data

• Functional Improvement Stagnation: Across key Activities of Daily Living (ADLs)—such as mobility, bathing, transferring, and dressing—fewer than six in ten home health patients achieve measurable clinical improvement during their episode of care. 

• Depression and Medication Management: Management of chronic symptoms (including dyspnea and oral medication compliance) continues to see inconsistent progress, leading to frequent care plan failures. 

• Unplanned Hospitalizations: Potentially preventable 30-day emergency department visits and acute hospital readmissions remain persistently high, undermining one of home health’s primary value propositions. 

2. Severe Staffing Shortages and "Visit Compression" 

A workforce crisis is the main driver of declining clinical effectiveness. Home health agencies nationwide face severe shortages of registered nurses (RNs), physical therapists (PTs), and home health aides. 

To manage staffing shortages and rising operating costs, agencies have adopted visit compression—fewer, shorter in-person visits per care episode. Telehealth and virtual check-ins have replaced some patient contacts, but clinical data show they cannot substitute for hands-on physical therapy or skilled wound care. With fewer in-person visits, subtle signs of clinical deterioration go undetected until emergency care is unavoidable. 

3. Increasing Patient Acuity vs. Shorter Stays 

Modern home health care ideals with a fundamentally different patient population than it did a decade ago. 

Health systems, pressured by acute care discharge policies, are sending patients home "sicker and quicker." Home health providers are managing patients with complex, multi-system chronic conditions—including heart failure, advanced diabetes, and cognitive decline—who previously would have spent additional days in a skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF). 

When high-acuity patients are discharged into home settings without continuous 24/7 care, home health clinicians are forced to act as emergency responders rather than long-term rehabilitators, leading to disappointing functional recovery rates. 

4. Policy Reforms and Reimbursement Hurdles 

Structural payment reforms have unintentionally strained resource allocation: 

• Patient-Driven Groupings Model (PDGM): Implemented to shift focus from volume to patient characteristics, PDGM eliminated payment incentives tied to therapy visit thresholds. Consequently, therapy utilization dropped sharply, correlating with stalled functional mobility gains. 

• Medicare Advantage (MA) Penetration: The rapid growth of Medicare Advantage plans has led to stricter prior authorization hurdles and significantly lower reimbursement rates per episode compared to traditional fee-for-service Medicare. Agencies operating on thin MA margins often lack the financial bandwidth to offer specialized disease-management programs or competitive clinician pay. 

5. The Path Forward: Elevating Clinical Performance 

Addressing the systemic slump in home health outcomes requires a re-evaluation of how home care is resourced and delivered: 

Key Strategy 

Value-Based Purchasing Alignment 

Objective-Expand CMS Value-Based Purchasing (HHVBP) incentives 

Expected Impact-Directly rewards agencies demonstrating verified functional gains over raw volume. 

Hybrid Technology Integration 

Objective-Combine AI remote monitoring with focused in-person visits

Expected Impact-Catches early clinical deterioration before emergency readmission occurs. 

Workforce Retention Investments 

Objective-Improve clinician retention through reduced caseloads and competitive pay

Expected Impact-Restores visit frequently and continuity of care. 

Specialized Chronic Care Pathways 

Objective-Train home care teams in specialized cardiopulmonary and wound care

Expected Impact-Reduces avoidable hospital transfers for high-acuity patients. 

Conclusion 

The disappointing trajectory of clinical outcomes in home health is not a failure of individual clinicians, but rather the result of a system operating under mounting pressure. As acute care continues to decentralize into the home, policymakers and healthcare leaders must address the gap between expected clinical performance and the financial and operational reality of home care delivery. Without systemic investment in workforce support, care delivery models, and comprehensive chronic disease education, home health will continue to struggle to deliver on its promise. 

If you are seeing high rehospitalization rates during services and after discharge and need help turning this around, contact Kenyon HomeCare Consulting at 206-721-5091 or email gkenyon@kenyonhcc.com. We are here to help.