Presented by:Anne Shelley, MBA, BSN, RN

Susan Wallace, MSW, LSW

Hospice Quality Reporting Update: June 2014

Objective

Discuss the updates to hospice quality reporting requirements.

Hospice Quality Reporting Program

• Structural Measure & Comfortable Dying Measure• Concluded April 2014

• Hospice Item Set• July 2014

• Hospice Experience of Care Instrument/CAHPS• Early 2015

What is the HIS?

• “Item Set” vs. “Standardized Assessment”• Based on seven NQF-endorsed measures

• Treatment preferences (CPR, Hospitalization, Other life-sustaining treatments

• Beliefs/values addressed• Pain screening and assessment (2)• Dyspnea screening and treatment (2)• Opioid and bowel regimen

What is the HIS?• Admission & Discharge

• Completed for ALL patients

• Submitted on a rolling basis• Completed: 14 days from admission, 7 days from discharge• Submitted: 30 days from admission/discharge

• Linked to 2% market basket reduction

A NEW Alphabet Soup

QIES ASAP

RTI

NQF

HART

CASPER

QTSO

MAP

HQRP

HIS

Measure Developme

nt

• Measures Application Partnership (MAP)• National Quality Forum (NQF)

Program Design

• Centers for Medicare & Medicaid Services (CMS)

• RTI International

Measure Collection

• QIES Technical Support Office (QTSO)• Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP)

• Hospice Abstraction Reporting Tool (HART)• Certification and Survey Provider Enhanced Reports (CASPER)

Preparation• Research• Staff Assignment• Medical Records Evaluation, Reconciliation with the

HIS• Organizational Communication Plan• Staff Education• Implementation

Research• http://

www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html• HIS Manual• Training Slides (2/4 & 2/5)• Fact Sheet

• https://www.qtso.com/hospice.html • Registration announcement• Technical Training Modules• Other announcements

• https://www.qtso.com/hart.html

Staff Assignment

• Who needs to be involved in planning?• QAPI/Compliance• Executive Director• P&P Interdisciplinary Group• Care Managers• Administrative staff

• Preliminary estimate of staff hours required • Paper: 40 minutes per patient• EMR: 15-20 minutes per patient

Medical Records Evaluation, Reconciliation with the HIS• Contact EMR vendor

• Are assessments aligned with HIS items and language?• Will reporting mechanisms be fully functional by July?• Will reporting mechanisms match CMS expectations?

• Crosswalk the HIS to your records

• Time Study

Organizational Communication Plan• Leadership

• Resource Allocation/Redistribution• Communication to Board

• Initial Education Plan for Staff

• Ongoing Education Plan for Staff• Orientation/Training• Annual Updates

Staff Education

Implementation

What is the Hospice Experience of Care Instrument?• Evaluation of the patient/family’s experience of care

• Caregiver as proxy• Post-death

• Similar to CAHPS surveys• Similar to the Family Evaluation of Hospice Care

(FEHC)• Developed by Rand Corporation• Three versions based on place of death

• Home, Inpatient, Nursing Facility

Hospice EOCS (CAHPS): Timeline• First quarter 2015: 1-month “trial run” for

submission

• April 1, 2015: Begin continuous usage

Vendors

• Hospices must contract with CMS-approved vendor• Vendor applications: late 2014

• Home Health CAHPS Vendors:• https://homehealthcahps.org/GeneralInformation/ApprovedS

urveyVendors.aspx

On the Horizon

NQF Endorsement Process

• Call for Measures• Call for Nominations• Measure Review• Comment• Voting

• CSAC Decision• Board Ratification• Appeals

Measures Application Partnership• Measure concepts:

pain goal attainment patient engagement care coordination depression caregiver’s role timely referral to hospice

April 2014: Call for TEP Nominations

Project Objectives Include:

• Investigate the potential for expanding existing quality measures or measure concepts to the Hospice QRP.

• Generate measure ideas/concepts that address gaps in the current Hospice QRP identified by stakeholders such as the Measures Application Partnership (MAP).

Questions?