Kaiser Permanente Medical Care Program

Home Care Quality Assessment and Improvement Program
California Division
Management of Pain

Home Health Indicator Worksheet

Important Aspects of Care / Assessment and Management of Pain/Comfort
Indicator (ID) / Assessment and Management of Pain
Rationale / Pain management is central to effective home health care. To maintain patient comfort and improve patient’s quality of life
Goal(s) /
  • At least 90% of visit documentation will include a pain rating obtained from the patient as defined in the pain standards.
  • At least 90% of actions taken in response to pain ratings will meet the criteria defined in the pain standards.

Functions & Dimensions / TX.1, TX.1.3, TX.4, TX.4.1, 4.2 & 4.3 (Plan of care); LD2.2 (Inpatient care)
Efficacy, appropriateness, effectiveness, safety, respect, and caring
Calculation of Measures /

Percent of visits by all disciplines visiting under the Plan of Care that included a pain rating as defined in the Divisional Home Health Pain Standards

Numerator: Total number of visits made under the Plan of Care that documented a pain rating
Denominator: Total number of visits where pain rating was required during the reporting period.
Percent of documented pain ratings requiring intervention where actions required by CHHAs, LVNs, and therapists are completed and documented, and interventions required by RNs and therapists in therapy only cases are completed and documented as defined in the Divisional Home Health Pain Standards.
Numerator: Total number of times where the actions taken in response to a pain rating requiring intervention met the criteria defined in the Divisional Home Health Pain Standards.
Denominator: Total number of documented pain ratings that were four or greater or that exceeded the threshold defined for the patient in the Plan of Care
Definitions /
  • Visit is any visit by staff visiting under the Plan of Care to an admitted patient. Staff includes RNs, therapists, LVNs, CHHAs, and social workers. Includes supplemental visits provided by contract personnel. Requirements to complete pain ratings during visits are defined in the Divisional Home Health Pain Standards.
  • Pain is any subjective physical uncomfortable feeling or uncomfortable physical sensation that a patient describes and requires relief from in order to improve quality of life.
  • For the purposes of this indicator, actions taken in response to pain ratings that were four or greater or that exceeded the threshold defined for the patient do not include follow-up assessment as appropriate for the needs of the patient.

Data Source(s) / The patient’s medical record.
Population / All patients admitted to service.
Exclusions / None
Sample Size / 10 cases per month or 5% of the cases per month, whichever is greater. For each case, 100% of all visits will be reviewed in each audit month.
Level of Analysis / Region, service area, agency
Responsibility / Chart reviews completed per agency practice. Results reported to Division QA&I by quality management representative for agency.
Frequency of Collection/ Reporting / Monthly
Improvement Activities / To identify opportunities to improve the assessment and management of pain in the Home Health population.

Home health Directors Approved 2/27/01

Revised: 3/29/01, 04/26/01, 04/01/02