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Overview of OASIS Assessment Standards for Home Health | Maxwell TEC

Written by Cole Sorensen | Jun 19, 2025

Home Health Agency Consulting Expertise: A Guide to Industry-Leading Solutions

The Outcome and Assessment Information Set (OASIS) has long served as the foundation for assessing and improving the quality of care in the home health space. But starting July 1, 2025, its role is expanding in a big way. 

CMS is rolling out all-payer OASIS data collection, meaning OASIS will now apply to nearly every patient—not just Medicare and Medicaid beneficiaries. While the shift brings exciting opportunities for standardization and improved care insights, it also introduces operational complexities that many care-at-home agencies might not be prepared for. 

Here’s what you need to know—and how Maxwell TEC can help. 

What Is OASIS? 

The Outcome and Assessment Information Set (OASIS) is a standardized tool that care-at-home agencies use to collect and report data about patient health and quality of care. It plays a central role in not only shaping each patient’s care plan but also in determining reimbursement rates and publicly reported quality outcomes. 

OASIS assessments are conducted at multiple points throughout the care journey, including: 

  • Start of care (SOC) 
  • Resumption of care (ROC) 
  • Transfer to another setting 
  • Discharge 
  • Death at home 

The most recent version, OASIS-E, went into effect in January 2023. This update aligned the tool more closely with the IMPACT Act of 2014, which calls for consistent data elements across all post-acute care settings to support coordinated care, outcome tracking, and value-based payment models¹. 

Key features of OASIS-E include: 

  • New assessment items: Including measures for health literacy (B1300), social isolation (D0700), pain interference, and high-risk drug use. 
  • Expanded cognitive and mood screenings: The PHQ-9 now replaces the PHQ-2 alone, offering a deeper look into mental health needs. 
  • Interdisciplinary collaboration: OASIS-E emphasizes that assessments should be informed by multiple clinicians, including therapists, nurses, and physicians. 
  • Greater emphasis on discharge planning: New items like A2120/A2121 ensure medication reconciliation and communication during transitions of care². 

Ultimately, OASIS is more than a data collection tool—it’s a clinical and operational compass that helps agencies track progress, uncover gaps, improve outcomes, and meet compliance requirements. 

What’s Changing: The Move to All-Payer OASIS 

Until now, OASIS data collection has been limited to Medicare and Medicaid patients, meaning agencies were not required to complete OASIS assessments for patients with commercial insurance or other payer types. 

That’s changing on July 1, 2025, when CMS will require all-payer OASIS data collection. This initiative broadens the scope of the tool, aligning with CMS’s larger push toward standardizing quality reporting across all care settings and populations². 

What All-Payer Transition Means for Care at Home: 

  • OASIS assessments will be required for nearly every patient receiving skilled home health services—regardless of their insurance provider. 
  • Agencies will need to apply existing workflows and compliance practices to patients they previously excluded. 
  • CMS will use the expanded dataset to improve national benchmarking, payment models, and care standardization³. 

This transition supports CMS’s broader data goals and will give providers more complete insight into population health trends across payer groups. However, all-payer OASIS assessments are expected to stretch staff capacity, overwhelm current documentation systems, and require significant training and process adjustments⁴. 

What CMS Has Told Agencies to Expect⁵: 

  • More assessments: Agencies will need to complete OASIS for a larger patient volume, increasing the administrative burden. 
  • Timeline pressure: All assessments must be submitted timely and accurately, per existing OASIS compliance timelines. 
  • Tech readiness: EMRs must be updated to support all-payer functionality, and any errors in integration could delay reporting or affect payment. 

This is a pivotal change for care-at-home providers, but agencies that prepare now will be better positioned to adapt smoothly and avoid operational bottlenecks. 

How Agencies Can Successfully Transition to All-Payer OASIS 

The transition to all-payer OASIS is a strategic shift in how home health agencies deliver, document, and measure care. Acting early will enable agencies to minimize disruption and maintain care quality. 

Here’s how to get started: 

1. Educate and Align Your Teams

Training should go beyond a simple overview. Agencies must ensure that every clinician, quality leader, and operations team member understands: 

  • Who now requires OASIS assessments (all payers, not just Medicare/Medicaid) 
  • What specific changes OASIS-E and all-payer policies introduce 
  • Why accuracy and timeliness are more important than ever 

Use interactive training sessions, competency checklists, and job aids to reinforce best practices.

2. Update Your EMR and Tech Infrastructure

Work closely with your EMR vendor to confirm: 

  • Your system supports logic for all-payer OASIS identification 
  • New fields or flags are integrated into your documentation workflows 
  • Quality assurance tools reflect the updated scope of required assessments 

Missing even one update here can cascade into compliance issues, payment delays, or care interruptions⁴.   

3. Evaluate and Streamline Workflows

Audit your current intake, documentation, and discharge processes to identify where OASIS is—or isn’t—being consistently completed. Pay attention to: 

  • How patients are flagged for OASIS assessments at intake 
  • Who owns data entry and quality checks at each time point 
  • Where duplicate work or unclear handoffs might exist 

Use this transition as an opportunity to standardize and simplify your documentation practices. 

4. Reinforce Performance Improvement and QA

Use your QA teams and Performance Improvement Plans (PIPs) to: 

  • Track OASIS accuracy across all payers 
  • Monitor timeliness trends and submission rates 
  • Identify training gaps or workflow slowdowns 

This isn’t a “set-it-and-forget-it” process. Agencies need to plan for ongoing optimization through the remainder of 2025 and beyond³. 

5. Engage Leadership Early

This shift will involve clinical, operational, financial, and strategic teams. Executive and administrative leaders should be briefed on: 

  • Potential staffing and workload changes 
  • Impacts on reimbursement and public reporting 
  • Organizational readiness goals and KPIs 

If your key team members are not aligned with the new OASIS changes, your entire agency could suffer. Start with leadership teams, then engage the rest of your staff to ensure everyone is aware of and ready for the new changes.  

Expected Bottlenecks 

No major regulatory shift is without growing pains. The all-payer OASIS rollout is expected to trigger multiple pain points—especially for underprepared agencies. 

Here’s where trouble is most likely to surface: 

Cognitive Load on Clinicians 

Your clinical staff already face documentation fatigue. Asking them to assess, score, and submit OASIS for an even larger patient population may cause: 

  • Increased error rates 
  • Longer patient visits 

Assessment Delays 

Adding OASIS responsibilities to commercial patients will strain even the most efficient workflows. Without clear protocols, assessments may be: 

  • Missed entirely 
  • Delayed past CMS deadlines 
  • Completed incorrectly, impacting outcomes or reimbursement 

EMR Gaps or Glitches 

If EMR systems aren’t fully optimized for the new rules, agencies risk: 

  • Missing assessments for eligible patients 
  • Incomplete or non-compliant submissions 
  • Data loss between systems or during transitions⁴ 

Coordination Challenges 

Without role clarity and documentation expectations, collaboration can quickly stall. As interdisciplinary collaboration becomes more important under OASIS-E, agencies may face communication breakdowns between: 

  • Nurses and therapists 
  • Intake coordinators and clinicians 
  • QA teams and frontline staff 

Patient Experience Risks 

Longer, more complex assessments can affect patient satisfaction, especially if rushed or inconsistent. Patients may feel: 

  • Frustrated when repeatedly asked the same questions 
  • Confused about why they’re being assessed differently 
  • Disconnected from their care experience 

How Maxwell TEC Helps 

At Maxwell TEC, we understand that regulatory change—especially one as sweeping as the all-payer OASIS transition—can be overwhelming. That’s why our approach isn’t just about checking a compliance box. It’s about enabling agencies to thrive in the new data landscape, while keeping patient care at the center of everything. 

Here’s how we support your agency through every stage of the transition: 

OASIS Readiness Assessments 

We begin with a full-scale audit of your agency’s current documentation, staffing, and workflow processes. From there, we identify exactly where gaps exist and build a custom plan to ensure you're aligned with CMS guidance and your clinical goals. 

EMR Integration & Optimization 

Whether you're using a major platform or a specialized EMR, our consultants bridge the gap between tech and usability. We work alongside your vendor to: 

  • Map all-payer OASIS logic into your current workflows 
  • Reduce documentation duplication 
  • Test EMR updates and flag issues before go-live 

This means your staff spends less time navigating systems—and more time focused on providing exceptional care. 

Targeted Training for Frontline and Leadership Teams 

Change starts with people. Our team delivers interactive training sessions that go beyond policy memos. We tailor content for different roles, from field clinicians and coders to QA managers and executives, covering: 

  • What’s changing under all-payer OASIS 
  • How to document accurately, efficiently, and in compliance 
  • How OASIS data ties into quality scores, reimbursement, and patient outcomes 

Data-Driven Coaching and QA Support 

Broader OASIS requirements mean greater data complexity. Maxwell TEC helps your agency turn data into actionable insights with: 

  • On-demand coaching for your QA staff to interpret and act on that data 
  • Strategies for integrating OASIS metrics into your existing QAPI framework 

Expert Consultants That Stick With You 

We’re not here to drop a report and walk away. Maxwell TEC consultants embed themselves in your agency’s reality. We help solve real-time problems, adapt when things shift, and provide ongoing feedback so your OASIS implementation remains strong—weeks and months after go-live.  

Stay Ahead of the Shift 

The move to all-payer OASIS opens a new chapter in how care at home is measured, reimbursed, and experienced. Agencies that view OASIS assessments as a burden will scramble to keep up. Agencies that strategically embrace the shift will be well-positioned to lead. 

By expanding OASIS to cover every payer group, CMS is setting a new baseline for performance, equity, and transparency. That means: 

  • More standardized data across populations 
  • More pressure on agencies to get documentation right 

But it also means greater opportunity to showcase your agency’s strengths, uncover gaps before surveyors do, and unlock insights that fuel better outcomes across the board. 

Proactive agencies will: 

  • Lead with data—not assumptions 
  • Build confident, collaborative teams who own their part of the assessment 
  • Future-proof their operations by aligning documentation with care excellence 

Maxwell TEC enables home health agencies to do exactly that: lead proactively. Our strategic consulting and deep industry expertise empowers you to navigate all compliance changes, helping your agency succeed through changing regulatory mandates—including the transition to all-payer OASIS assessments. 

 

References  

  1. Centers for Medicare & Medicaid Services. OASIS – E Guidance Manual, Effective January 1, 2023. 
  2. Centers for Medicare & Medicaid Services. “OASIS All-Payer Transition Fact Sheet.” December 2024. https://www.cms.gov/files/document/oasisall-payer-transition-fact-sheetdec-2024.pdf 
  3. Home Health Care News. “CMS Lays Out Action Item Timeline for Transition to All-Payer OASIS Data Collection.” December 2024. https://homehealthcarenews.com/2024/12/cms-lays-out-action-item-timeline-for-transition-to-all-payer-oasis-data-collection/ 
  4. Centers for Medicare & Medicaid Services. “Home Health OASIS All-Payer Q&A.” November 2024. https://www.cms.gov/files/document/home-health-oasis-all-payer-qa-november-2024.pdf 
  5. OASIS Answers. “Countdown to OASIS Data Collection for All Patients.” Accessed June 2025. https://oasisanswers.com/countdown-to-oasis-data-collection-for-all-patients/ 

This blog was originally published as a 3-part series, "Embrace the OASIS-E" by Leigh Massey, RN, JD, WOCN, CHC, CHPC, in Fall 2022, for Maxwell Healthcare Associates. The Maxwell TEC editorial team has since updated this article to ensure accuracy and relevance.