Emergency Department Use Without Hospitalization
Emergency department (ED) use without hospitalization is a claims-based home health quality measure counting the percentage of home health stays during which the patient visited an ED but was not admitted to the hospital. It flags episodes where patients sought emergency care that a well-functioning home health plan might have prevented or handled in the home.
What the measure captures
CMS calculates the measure by linking home health claims with outpatient ED claims from Medicare fee-for-service data, counting stays with at least one ED visit that did not end in an inpatient admission, historically over the first 60 days of home health. Results are risk-adjusted for patient characteristics. The measure exists because ED visits without admission are a distinct signal: the patient was worried or symptomatic enough to seek emergency care, but not sick enough to be hospitalized, which often points to gaps in symptom management, patient education, or after-hours access rather than unavoidable clinical deterioration.
Where the measure stands in CMS programs
Like the acute care hospitalization measure, ED use was removed from the expanded Home Health Value-Based Purchasing measure set beginning with the CY2025 performance year, as CMS consolidated claims-based scoring around the Potentially Preventable Hospitalization (PPH) measure, which covers inpatient admissions and observation stays. Agencies should check current Care Compare documentation for exactly which utilization measures remain publicly reported. Regardless of program status, ED visits remain a metric that referral partners, ACOs, and Medicare Advantage plans watch, and an internal leading indicator that predicts hospitalization measure performance.
Why patients end up in the ED
Post-visit reviews across agencies surface the same recurring causes:
- Symptoms escalated on nights or weekends and the patient did not know to call the agency first
- The on-call response was slow or defaulted to advising an ED visit
- Medication confusion after a hospital discharge went uncaught
- Pain, breathing, or catheter and ostomy problems lacked a clear management plan between visits
- Caregivers panicked without specific guidance on what warranted emergency care
Most of these are process failures with process fixes, which is what makes this measure responsive to operational work.
Reducing avoidable ED visits
Give every patient a one-page plan naming the symptoms to watch and stating plainly to call the agency first, and rehearse it at the first visit. Staff on-call with clinicians empowered to make a same-day or next-morning visit rather than deflect to the ED. Schedule proactive touchpoints, by phone or telehealth, for high-risk patients between visits. Then review every ED visit like a near-miss: what did the patient experience, whom did they call, and what would have kept them home?
Frequently asked questions
Is ED use without hospitalization still part of HHVBP?
No. CMS removed it from the expanded HHVBP measure set starting with the CY2025 performance year, shifting claims-based scoring to the Potentially Preventable Hospitalization measure. It remains a useful internal indicator and one that referral partners still track.
Does an ED visit that leads to observation status count?
Observation stays are handled distinctly from ED-only visits in CMS measurement, and the PPH measure explicitly includes potentially preventable observation stays alongside inpatient admissions. For internal tracking, agencies should log ED-only, observation, and inpatient events separately since they have different causes and fixes.
How can an agency find out about ED visits it was never told about?
Options include hospital and health information exchange notification feeds, routinely asking patients and caregivers at each visit, and reconciling against payer or ACO data where partnerships allow. Claims-based results eventually reveal the full picture, but months too late to act on.