hospice item set his - memberclicks · •a single hospice’s claims data report –ub-04 claims...

HOSPICE ITEM

SETHIS

INCORPORATING HIS INTO QAPI

PROGRAMS

Track and trend patients’ palliative care and

quality of care outcomes, not just on admission

but throughout hospice care

Results can be reported based on all teams as

well as individual teams. Drill down further to

team members

Provide measurable patient outcomes that show

strengths and PIP opportunities

PAIN AND DYSPNEA ASSESSMENTS

Patients screened for pain and dyspnea during

each nursing visit

Was a standardized pain tool used?

Was a comprehensive assessment performed?

TREATMENT FOR PAIN AND DYSPNEA

Patients who c/o pain and dyspnea that receive

treatment

Were new medications and interventions added

or adjusted?

REASSESSMENT WITHIN 24 AND 48 HOURS

Patients that receive a follow-up call or visit

within 24 hours of a change in symptom

management orders or interventions.

Patients who receive symptom management for

pain and dyspnea that achieve an acceptable

level within 24 to 48 hours

BOWEL REGIMEN WITH OPIOID USE

Patients who are treated with an opioid that are

prescribed a bowel regimen or if not, a reason is

documented

EMR and Pharmacy reports can provide lists of

patients who are prescribed opioids.

TREATMENT PREFERENCES

Patients whose preferences regarding CPR,

hospitalization, and life-sustaining treatments

other than CPR were documented on the plan of

care

Patients whose documented preferences were not

met or the reason for not following the

preferences were documented in the medical

record

HOSPICE-LEVEL QUALITY MEASURE

REPORT

View HIS data during a specific reporting period

Compare your data to other providers

Available as of December 2016

Log into QIES ASAP and retrieve from CASPER

reports

RESOURCES FOR THE HIS

www.cms.gov

www.nhpco.org

www.ghpco.org

CAHPS

Caregiver perception of your organization’s

performance

Aggregate data related to specific areas of

concern, ie: pain medication teaching

Positive feedback

Comparison of your organization to the

national/state average for each data point

DRILL DOWN!

Is there a specific department that

consistently has low scores?

Is there a specific team member whose patients’

caregivers consistently report negative feedback?

Is there a specific data point that is

consistently lower than the benchmark? (ie:

pain medication teaching)

Set your goals at or above the state average

What other quality measures are there that

can be compared against the CAHPS?

HIS! Pain/dyspnea on admission-HIS

VS.

Pain/dyspnea symptom management-CAHPS

PIP – able to show a surveyor that you’ve

identified an area for improvement and have

come up with a plan

Start a complaint/negative survey process for

follow up by management

This can also help drill down for negative trends

in specific staff or departments

EDUCATION, EDUCATION, EDUCATION!

Staff don’t always know/understand what

they’re being “judged” on

Lauren Ogilvie, PIS

VITAS Healthcare

404-843-6533

Lauren.Ogilvie@vitas.com

The Program for Evaluating

Payment Patterns Electronic

Report

PEPPER

Why PEPPER?

• Medicare designated as high risk for fraud and

abuse by Government Accountability Office

(GAO)

• Medicare Hospice Benefit identified as

vulnerable

• Office of Inspector General (OIG) encouraged

hospices to audit to ensure charges are correct.

PEPPER can help

What is PEPPER?

• A single hospice’s claims data report

– UB-04 claims submitted to Medicare Administrative

Contractor (MAC)

• Compares data to national, MAC jurisdiction,

and state statistics

• Centers for Medicare and Medicaid Services

(CMS) contracted TMF Health Quality Institute to

distribute

Who Gets PEPPER?

• Provider only gets their report

• TMF does not provide it to other contractors

• TMF DOES provide Access database (First-look

Analysis Tool for Hospital Outlier Monitoring

(FATHOM) to MACs and Recovery Auditors

– FATHOM can be used to produce a PEPPER

External PEPPER Request

• CMS direction:

– CMS can direct TMF to respond to external requests

– Provided PEPPERS to OIG, DOJ, State Attorneys General

• Department of Justice:

– Uses billing data to create and corroborate investigative

leads

– Emerging fraud trends:

• Medicare Part D Laboratory services

• Drug diversion Hospital-based services

• Hospice care

PEPPER Access

• Compares 3 years of data

• Identify trends reflecting possible fraud and

waste

– Priority areas to monitor/audit

• Go to www.PEPPERresources.org

– Available to CEO/Administrator and Compliance

Officer

TARGET AREAS

Live Discharges

• No Longer Terminally Ill

– Review admission process

– Meet eligibility criteria

• Revocations

– Initiated by patient

– High cost care

• Length of Stay (LOS) 61-179 days

– Financial incentives

2014 LOS Data

Target Areas

• Long LOS

– Review admission process

– Meet eligibility criteria

2014 LOS Data

Target Areas

• Continuous Home Care in Assisted

Living Facility

– Meet eligibility criteria

– Appropriate care in ALF

– Documentation supports care hours billed

Routine Home Care

IN:

• Assisted Living Facility

• Nursing Facility

• Skilled Nursing Facility

– Review admission process

– Meet eligibility criteria

Target Areas

• Single Diagnosis

– Related to terminal illness

– Substantiated with documentation

– Physician determines

• No General Inpatient or Continuous

Home Care

– Provide all levels of care

– Process to assess needs

Next Steps

• Review data

– Are data differences due to your area

• Identify priority areas to monitor/audit

– Determine audit frequency

– Develop improvement plan

• Compliance Officer role

– Stop issues before they become problems

Conclusion

The Program for Evaluating Payment Patterns

Electronic Report summarizes provider-

specific data for Medicare services that may

be at higher risk for improper Medicare

payments.

PEPPER can assist providers in identifying

areas for improvement

References

• Government Accountability Office. “Medicare Fraud, Waste and Abuse:

Challenges and Strategies for Preventing Improper Payments.” June 15,

2012. Available at: http://www.gao.gov/new.items/d10844t.pdf.

• Department of Health and Human Services/Office of Inspector General.

1999. “Publication of the OIG Compliance Program, Guidance for Hospices,

“Federal Register 64, no. 192, October 5, 1999, 54031-54049. Available at:

https://oig.hhs.gov/authorities/doc/hospicx.pdf.