Hospice Quality Reporting
Update: June 2014
Presented by:
Anne Shelley, MBA, BSN, RN
Susan Wallace, MSW, LSW
Objective
Discuss the updates to hospice quality
reporting requirements.
Hospice Quality Reporting Program
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Structural Measure & Comfortable Dying Measure
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Hospice Item Set
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Concluded April 2014
July 2014
Hospice Experience of Care Instrument/CAHPS
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Early 2015
What is the HIS?
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“Item Set” vs. “Standardized Assessment”
Based on seven NQF-endorsed measures
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Treatment preferences (CPR, Hospitalization, Other lifesustaining treatments
Beliefs/values addressed
Pain screening and assessment (2)
Dyspnea screening and treatment (2)
Opioid and bowel regimen
What is the HIS?
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Admission & Discharge
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Completed for ALL patients
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Submitted on a rolling basis
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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
CASPER
RTI
HQRP
NQF
MAP
QTSO
HIS
HART
Measure
Development
Program
Design
Measure
Collection
• Measures Application Partnership (MAP)
• National Quality Forum (NQF)
• Centers for Medicare & Medicaid Services (CMS)
• RTI International
• 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
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Research
Staff Assignment
Medical Records Evaluation, Reconciliation with the
HIS
Organizational Communication Plan
Staff Education
Implementation
Research
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http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/Hospice-QualityReporting/Hospice-Item-Set-HIS.html
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https://www.qtso.com/hospice.html
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HIS Manual
Training Slides (2/4 & 2/5)
Fact Sheet
Registration announcement
Technical Training Modules
Other announcements
https://www.qtso.com/hart.html
Staff Assignment
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Who needs to be involved in planning?
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QAPI/Compliance
Executive Director
P&P Interdisciplinary Group
Care Managers
Administrative staff
Preliminary estimate of staff hours required
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Paper: 40 minutes per patient
EMR: 15-20 minutes per patient
Medical Records Evaluation,
Reconciliation with the HIS
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Contact EMR vendor
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Are assessments aligned with HIS items and language?
Will reporting mechanisms be fully functional by July?
Will reporting mechanisms match CMS expectations?
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Crosswalk the HIS to your records
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Time Study
Organizational Communication Plan
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Leadership
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Resource Allocation/Redistribution
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Communication to Board
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Initial Education Plan for Staff
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Ongoing Education Plan for Staff
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Orientation/Training
Annual Updates
Staff Education
Implementation
What is the Hospice Experience of
Care Instrument?
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Evaluation of the patient/family’s experience of care
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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
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Home, Inpatient, Nursing Facility
Hospice EOCS (CAHPS): Timeline
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First quarter 2015: 1-month “trial run” for
submission
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April 1, 2015: Begin continuous usage
Vendors
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Hospices must contract with CMS-approved vendor
Vendor applications: late 2014
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Home Health CAHPS Vendors:
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https://homehealthcahps.org/GeneralInformation/ApprovedS
urveyVendors.aspx
On the Horizon
NQF Endorsement Process
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Call for Measures
Call for Nominations
Measure Review
Comment
Voting
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CSAC Decision
Board Ratification
Appeals
Measures Application Partnership
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Measure concepts:
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pain
goal attainment
patient engagement
care coordination
depression
caregiver’s role
timely referral to hospice
April 2014: Call for TEP Nominations
Project Objectives Include:
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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?