While many home health agencies work hard to improve HHCAHPS survey scores, they should also focus on techniques to improve their HHCAHPS survey response rate.

As an industry-leading HHCAHPS survey provider, we are often asked, “How many responses do I need?” CMS requires at least 20 completed surveys per reporting period for public reporting on Home Health Compare. Home health agencies should take extra measures to increase the number of surveys completed and returned. The more responses you receive, the more data you have, and the more representative and meaningful it will be for analysis. Ultimately, more responses = more data = better quality results = meaningful improvement initiatives = higher scores.

HEALTHCAREfirst has one of the largest HHCAHPS databases, from which we analyze and report statistics about HHCAHPS survey response rates. Here is what we have found in our most recent analysis regarding who responds:

HHCAHPS Survey Response Rate Data

(Based on HEALTHCAREfirst HHCAHPS program data)

  • By Region:
    • South = 32.9%
    • West = 34.1%
    • Northeast = 35.3%
    • Midwest = 39.0%
  • By Survey Language:
    • Spanish = 20.4%
    • Chinese = 27.1%
    • English = 35.8%
    • Russian = 44.6%
  • By Length of Stay:
    • 91-180 days = 31.8%
    • 31-90 days = 33.5%
    • >180 days = 36.4%
    • 1-30 days = 38.4%
  • By Race:
    • Native HI/Other Pacific Islander = 0.2%
    • Asian = 1.3%
    • American Indian = 1.6%
    • No Answer = 5.0%
    • Black/African American = 8.9%
    • White = 82.9%
  • By Patient Age:
    • <18 years = 0.0%
    • 18-24 years = 0.2%
    • 25-34 years = 0.5%
    • 35-44 years = 0.9%
    • 45-54 years = 3.1%
    • 55-64 years = 8.6%
    • 65-74 years = 25.9%
    • 85+ years = 28.0%
    • 75-84 years = 32.7%
  • By Gender:
    • Male = 37.5%
    • Female = 62.5%
  • By Patient’s Highest Level of Education:
    • No Answer = 7.4%
    • 4-Year College Graduate = 8.0%
    • 8th Grade or Less = 8.1%
    • >4 Year College = 9.6%
    • Some High School = 10.4%
    • Some College = 22.1%
    • High School Graduate = 34.4%

The above information is good to know about your own patient population, as well as how that population mix may impact your actual performance scores. CMS includes these factors in case mix adjustment calculations performed before results are publicly reported to help level the playing field when comparing scores between agencies that are serving different areas with different attributes across the country.

What Can Influence HHCAHPS Survey Response Rate?

HHCAHPS Survey Awareness

In general, awareness of the HHCAHPS survey is a positive thing.  If your patients expect a survey, or at least the possibility of it, it’s not a surprise, they will know the reason for the survey and may be more likely to complete it. People may also be more apt to respond if they understand how the data will and will not be used. This is definitely a challenge for HHCAHPS given the regulations and restrictions CMS has outlined regarding communicating with patients about the HHCAHPS survey.

Survey & Cover Letter Design

A lot of research and field testing went into the overall design of the HHCAHPS survey, cover letter, and overall survey administration processes to ensure that the data captured is consistent, would allow for accurate comparisons, and would encourage patient participation. All of that work contributed to the standard layout, content, and administration protocols that are currently used and outlined by CMS in the HHCAHPS Protocols & Guidelines Manual.

While there is very little ability to “customize” what is sent to patients, HEALTHCAREfirst includes the agency’s logo on the cover letter for our HHCAHPS survey customers. This promotes agency recognition and increases the likelihood of survey completion.

Mode of Survey Administration

CMS conducted a mode experiment in 2009 to test the effect of survey administration mode on survey responses. The study was repeated in 2010 and 2011. While response rates were shown to be higher with phone and mixed mode, the actual impact to data results was not different from mail only, a more economical method for agencies.

Sampling Rate

Sampling rate is determined to ensure an even distribution of patients sampled over the 12 month period. Determination of the sampling rate can depend on the number patients served, the mix of short and long-stay patients, and the rate at which the sample exclusions apply to an agency’s patient population. Sampling rates adjust periodically based on data from the preceding 3-6 months.

At a minimum, home health agencies must submit 300 completed surveys for the 12 month period (25 surveys per month on average). To determine the sample size needed to meet the minimum compliance, agencies should take the number of responses needed divided by the HHCAHPS survey response rate.

Survey Administration Timing

Survey administration timing is important to consider as both administration and data collection timing can have an impact on results. If the survey is sent too soon, responses may be biased by emotions. If the survey is sent too late, the patient’s memories of the event may change or not be quite as accurate.

For HHCAHPS, initial contact must be made within 21 days after the sample month end. The second wave mailing or telephone follow-up is initiated approximately three weeks after initial contact. The collection period ends 42 days from initial contact. Some vendors, such as HEALTHCAREfirst, will still process returned surveys and report the results after the collection period has ended. While these results are not included in publicly reported data, the information can still be used by the agency for performance improvement.

Inaccurate or Incomplete Patient Data

This is the one component of response rate influencers that you have the most control over! Missing or incomplete patient data can have an impact on your response rate. Bad data decreases the chance of receiving responses, and it negatively impacts your return rate. Those records still count towards your response rate denominator.

Avoid using placeholders or “notes” entered into address fields. Don’t use terms like “Unknown,” “None known,” type of relationship, nickname, etc. This type of “junk” text may be included in the cover letter and within the mailing address when survey is mailed, which can be a turn off to your patients and could decrease the likelihood the survey will be received by the patient.

If new or updated information is collected (mailing information, survey language, etc.) a survey can be resent if it is received before the wave 2 mailing is generated. The 42-day data collection period does NOT reset if new or updated information is provided.

HHCAHPS Survey Response Rate Best Practices


It is important to educate staff about what they can and cannot say to patients about the HHCAHPS survey. Additionally, agencies should inform patients during their next scheduled assessment that they may receive a survey. However, if you tell one, you must tell all. Agencies cannot communicate in any way that would introduce bias into survey results or attempt to influence patient responses. Refer to the HHCAHPS Protocols & Guidelines Manual for more detailed regulations surrounding communication.

Supplemental Questions & Additional Surveys

Be mindful of your supplemental survey questions. Not only can they add length to the survey, the types of questions themselves may decrease your HHCAHPS survey response rate. Using additional surveys outside of HHCAHPS may inhibit patients from responding to the HHCAHPS survey. Carefully consider whether or not those surveys are important enough to potentially reduce your sample size.

Sampling Percentage

If your patient volume is high and you are sampling for minimum compliance, consider your sampling percentage. If you increase your sample, you will have a larger dataset, which will allow for more accurate analysis of your agency performance.

Accurate Patient Data

Ensure that your patient monthly file has complete and accurate information prior to sending the file to your HHCAHPS vendor. Missing data will not prevent patients from being sampled, but will very likely prevent them from responding.

The HEALTHCAREfirst Difference

HEALTHCAREfirst mails millions of CAHPS surveys for home health and hospice agencies nationwide. More agencies use us as their HHCAHPS survey vendor than any other because of our combination of value, service, and price. We offer a comprehensive HHCAHPS survey program that streamlines compliance, accelerates improvement, and facilitates a higher HHCAHPS survey response rate. Switching to HEALTHCAREfirst is easy! We would love to show you how.

Contact us to learn more!