cms’ hospice quality reporting program: challenges ...€¦ · cms’ hospice quality reporting...
TRANSCRIPT
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CMS’ Hospice Quality Reporting
Program:
Challenges & Opportunities
Carol Spence, PhD, RN
National Hospice and Palliative Care Organization
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TODAY WE WILL COVER:
• Changes to HIS data collection
• CMS’ quality measures for hospices
• Requirements for compliance with HQRP
• Public reporting (Hospice Compare)
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HIS CHANGES
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NEW ITEMS
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HIS NEW ITEMS
Patient Zip Code
• Admission Record
• Section A: A0550
• Address where patient resides while receiving hospice services
• May not be permanent, usual or legal residence
PATIENT ZIP CODE
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HIS NEW ITEMS
Patient Zip Code - Examples
• Patient usually lives in Miami. She has moved in
with daughter in San Diego. Code for the
daughter’s home in San Diego.
• Patient’s home is in Alexandria, VA. He is
admitted to the hospice’s inpatient unit in Aldie,
VA. Code for the inpatient unit.
HIS NEW ITEMS
Payor Information
• Admission Record
• Section A: A1400
• All current payment sources - regardless if will
be paying for hospice care
• Do not include pending/applied for sources
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HIS NEW ITEMS
HIS NEW ITEMS
Payor Information – Self Pay
Select if patient is paying for any of their own
medications, supplies, services, etc. Examples
may include, but are not limited to: medications
the patient may pay for out of pocket, respite
level of care beyond what is allowed under the
Hospice Benefit, and room and board.
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HIS NEW ITEMS
Scenario:
Mrs. Jones has Medicare
A,B and D plus a Medicare
supplemental plan. She
pays for her over-counter
medications herself.
Question:
What should you code for
A1400?
PAIN ACTIVE PROBLEM
J0905 Pain Active Problem
• The pain active problem skip pattern replaces the
prior pain screening skip pattern.
• Skip J0910 (Comp Pain Assess) based on
whether pain is an active problem, not whether
the patient has current pain at the time of the
screening.
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HIS NEW ITEMS
PAIN ACTIVE PROBLEM
Select YES for J0905 if patient denies pain when
asked screening question, BUT
• Patient is taking medication to treat pain
• Reports recent symptoms
• Pain is present intermittently under specific
circumstances
• Recent treatment other than medication (e.g.,
nerve block)
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HIS NEW ITEMS
J2030 Screening for Shortness of
Breath
C. Did the screening indicate the patient had
shortness of breath?
• Can code yes for active problem for the patient
even if shortness of breath not present during
assessment
• Based on reports of recent symptoms, current
treatment, and patient/family history
SCREENING FOR SHORTNESS OF BREATH
Example: Mr. Brown denies shortness of breath at
assessment while sitting in a chair, but reports
dyspnea with stair climbing.
Code ‘Yes” for J2030C: Did the screening
indicate the patient had shortness of breath? (and
there is evidence that severity was rated)
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SCREENING FOR SHORTNESS OF BREATH
IScenario:
As documented in the initial
nursing assessment, Ms.
Scarlett denies shortness of
breath on assessment, but
uses O2 at night and sleeps
with two pillows.
Question: How should you
code J2030C?
PAIN ACTIVE PROBLEM
IScenario:
Mr. Smith denies pain but
has a comfort kit in the
home and has not yet taken
any medication in the kit for
pain.
Question:
How should you code
J0905?
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HIS NEW ITEMS
Section O
HIS NEW ITEMS
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HIS NEW ITEMS
Section O
Service Utilization
• Discharge record
• Only for discharge due to death
• Only for RHC level of care
• Patient discharges on and after April 1, 2017
HIS NEW ITEMS
Section O
4 additional items
Level of Care Items
• O5000: LoC in final 3 days
• O5020: LoC in final 7 days
Visit Items
• O5010: Visits in final 3 days
• O5030: Visits in 3 – 6 days before death
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HIS NEW ITEMS
Section O
Visit Items
• O5010: Visits in final 3 days
• O5030: Visits in 3 – 6 days before death
Both items ask about the same types of visits from
the same disciplines (Registered Nurse, Physician,
Nurse Practitioner, Physician Assistant, Medical Social
Worker, Chaplain or Spiritual Counselor, Licensed Practical
Nurse, and Aide).
HIS NEW ITEMS
Do
• Count visits to family
Do NOT
• Count phone calls
• Count post mortem visits
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HIS NEW ITEMS
Section O
Scenario: Patient A admitted 2/4/17 in
nursing home on RHC. Died
4/15/17.
Question: How should Section O be
completed?
HIS NEW ITEMS
Section O
Scenario: Patient B admitted 4/5/17 at
home on RHC. Went to hospital
4/7/17 and revoked. Readmitted
on 4/9/17 to hospice inpatient
unit on GIP. Died there on
4/12/17.
Question:How should Section O be
completed?
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HIS NEW ITEMS
REMemberHIS is a data collection tool
HIS data are used to calculate
quality measure scores
HIS NEW ITEMS
REMemberMeasure specifications (numerator
and denominator) and HIS data
elements may not be the same
Do not confuse instructions for
completing the HIS record with how
the measure is calculated
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HIS NEW ITEMS
REMember
More data are collected in HIS than
are used in calculating the
measures.
QUALITY MEASURES
(QMs)
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CURRENT HIS MEASURES
CURRENT HIS MEASURES
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HIS MEASURE EXCLUSIONS
Measure scores are not calculated for patient
stays if:
• Patient is under 18 years of age
• Discharge record but no admission record
• Admission record but no discharge record
CURRENT HIS MEASURES
REMemberPatients with length of stay less than 7 days
are no longer excluded from the measures.
In other words, patients are included
regardless of length of stay
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PAIN ASSESSMENT MEASURE
NQF #1637
Measure Specifications:
• Patients who screen positive for pain
• Received a comprehensive pain assessment
within 1 day of the pain screening
• Pain assessment included at least 5 of the
assessment elements
PAIN ASSESSMENT MEASURE
Comprehensive Assessment Definition
Included at least five of the following
characteristics:
location, severity, character, duration,
frequency, what relieves or worsens the
pain, and the effect on function or quality of
life.
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PAIN ASSESSMENT MEASURE
Keep in Mind
• Mark each characteristic for which the clinician
documented an attempt to gather the
information, even if no information was obtained
• Report can be from the patient, caregiver
(informal or paid), or observation
PAIN ASSESSMENT MEASURE
Keep in Mind
Mark ‘Yes’ that Comprehensive Pain Assessment
was done as long as o at least 1 pain characteristic was assessed
o even if date of assessment was more than one day after positive pain screening
(Example of data collection protocol not matching measure specifications)
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NEW HIS MEASURES
COMPOSITE MEASURE
• Percentage of patients who received care
processes in 7 current HIS measures
• Admissions on and after April 1, 2017
• No additional data collection needed
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COMPOSITE MEASURE
Denominator
All discharged patients except:
• Admission record missing
• Active stays (still receiving care)
• Under 18 years old on admission date
COMPOSITE MEASURE
Numerator
Patient stays in the denominator where the patient
• received all 7 care processes which are
applicable to the patient at admission, as
captured by the current HQRP quality measures
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COMPOSITE MEASURE
COMPOSITE MEASURE
Numerator Criteria
Pain Screening:
The patient was screened for pain within 2 days
of the admission date and the patient reported
they had no pain, or pain severity was rated and a
standardized pain tool was used.
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COMPOSITE MEASURE
Numerator Criteria
Pain Assessment:
Comprehensive pain assessment within 1 day of
the initial nursing assessment during which the
patient screened positive for pain and included at
least 5 of 7 pain characteristics.
COMPOSITE MEASURE
Numerator Criteria
Dyspnea Screening:
The patient was screened for shortness of breath
within 2 days of the admission date.
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COMPOSITE MEASURE
Numerator Criteria
Dyspnea Treatment:
Treatment for shortness was initiated within 1 day
of the initial nursing assessment during which the
patient screened positive for shortness of breath.
COMPOSITE MEASURE
Numerator Criteria
Bowel Regimen:
There is documentation that a bowel regimen was
initiated or continued, or why a bowel regimen was
not initiated, within 1 day of a scheduled opioid
being initiated or continued.
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COMPOSITE MEASURE
Numerator Criteria
Preferences and Beliefs/Values Addressed :
• No more than 7 days prior to or within 5 days of
the admission date.
COMPOSITE MEASURE
Status
• Currently undergoing review for endorsement by
NQF
• NQF #3235
• Recommended by NQF Palliative/End-of-Life Care
Standing Committee
• Expect to see Composite Measure in public
reporting in 2018
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VISITS WHEN DEATH IS IMMINENT
Measure Pair
Measure 1
• RN, MD, NP, PA
• Visits in last 3 days of life (at least 1)
Measure 2
• SW, Chaplain, LPN, hospice aide
• Visits in last 7 days of life (at least 2)
VISITS WHEN DEATH IS IMMINENT
Do
• Count visits to family as well as patient
• Clinical encounters with RHC patients in an
inpatient hospice setting
• count any visit that requires documentation (up
to 9 per discipline for each day)
• Count visits by two clinical staff occurring at the
same time
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VISITS WHEN DEATH IS IMMINENT
Do Not
• Count phone calls
• Count post mortem visits
• If patient is still alive when the clinician arrives and dies
during the visit, the visit counts
• If patient is dead when clinician arrives, do not count the
visit
VISITS WHEN DEATH IS IMMINENT
Denominator
All discharged patients except:
• Discharge other than death
• Received Continuous Care, GIP, Respite (in
measure timeframe)
• Admission record missing
• LOS of 1 day – Measure 2 only*
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VISITS WHEN DEATH IS IMMINENT
Numerator
Measure 1: Patients in denominator who received
at least one visit from RN, MD, NP, or PA in last 3
days of life
Measure 2: Patients in denominator who
received at least two visits from SW, Chaplain,
LPN, hospice aide in last 7 days of life
VISITS WHEN DEATH IS IMMINENT
Status
•Data collection just started – need 1
year for analysis
•NQF endorsement – submission TBD
•Public reporting after NQF
endorsement
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VISITS WHEN DEATH IS IMMINENT
Scenario: Colonel Mustard, a resident at
Tudor Mansion Nursing Home, was
admitted to hospice services under RHC
on 3/31/17 and died on 4/4/17. He
received the following visits:
RN 3/31; 4/1; 4/3; 4/4
Hospice Aide: 4/2
Volunteer: 4/3/;4/4
Question: What is the hospice’s
performance on the Visit When Death is
Imminent measure pair?
HOSPICE CAHPS® MEASURES
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CAHPS® SURVEYS
CAHPS = Consumer Assessment of Healthcare Providers and Systems
• Family of standardized surveys (hospitals, home health care agencies, doctors, and health and drug plans, etc.)
• Rigorous development process
• Tested for validity and reliability
• Goal = survey results comparable across users.
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CAHPS® SURVEYS
Focus: patient experience of care
Content:
• What patients say is important to them
• For which patients are the best and/or only
source of information.
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CAHPS® SURVEYS
• Satisfaction survey
deals with expectations for care
• Experience of care survey
report on specific aspects of care
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CAHPS® SURVEYS
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Ratings of
Care
Reports of
Specific
Experiences
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CAHPS® SURVEYS
• Whether, or how often, specific events or
behaviors that are indicators of health care
quality occurred
• Reports about events and behaviors are more
meaningful and actionable than general ratings
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HOSPICE CAHPS® SURVEY
• Consistent with externally validated aspects of
hospice care (e.g., NQF preferred practices).
• Capture patient and/or caregiver experience, rather
than care processes that may be measured by
other sources of data.
• Be under the control of the hospice provider.
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HOSPICE CAHPS® SURVEY
• Use language that most respondents find easy
to understand.
• Be clear about the time frames that respondents
area asked to assess.
• Use screener questions to identify the
denominator of respondents who can report on
experiences that may not be universal
HOSPICE CAHPS® SURVEY
• 47 items long
• 3 modes of survey administration:
• Mail only
• Telephone only
• Mixed mode (mail with telephone follow-up)
• Up to 15 additional questions chose by hospice
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HOSPICE CAHPS® MEASURES
Eight Measures using Hospice CAHPS survey as
data source
• Six composite measures (combined score from 2
or more survey items)
• Two global measures (single items)
Measures received NQF endorsement in 2016
HOSPICE CAHPS® MEASURES
Composite Measures
• Hospice Team Communication (6 items)
• Getting Timely Care (2 items)
• Treating Family Member with Respect (2 items)
• Getting Emotional and Religious Support (3
items)
• Getting Help for Symptoms (4 items)
• Getting Hospice Care Training (5 items)
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HOSPICE CAHPS® MEASURES
Global Measures
• Rating of Hospice (1 item)
• Willingness to Recommend (1 item)
HOSPICE CAHPS® RESOURCES
www.HospiceCAHPSSurvey.org
• Measures with Items:
CAHPS Hospice Survey Fact Sheet January 2017
• Help: [email protected] or
(844) 472-4621
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CAHPS® HOSPICE MEASURE RESULTS
SCORING
• Top Box Scores – proportion of best/positive
response to a survey item
• Composite Measure scores – average of top box
scores for all items in the measure
• Global Measure scores – proportion of 9-10 or
Definitely Yes responses
CAHPS® HOSPICE MEASURE RESULTS
SCORING
Risk Adjustment
Takes into account factors not in control of the
hospice
• Patient Mix – respondent characteristics
• Mode – mode adjustment value
added/subtracted for mail-only and mixed
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CAHPS® HOSPICE MEASURE RESULTS
• Provider Preview Reports in CASPER – prior to
Hospice CAHPS measure results inclusion in
Hospice Compare
• Unadjusted scores (percentages) may differ
from final risk adjusted scores
CAHPS® HOSPICE MEASURE
RESULTS
How to go about performance
improvement?
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CAHPS® HOSPICE MEASURES
Become familiar with all of the questions on
the survey
Consider what aspect of care and hospice
practice each question reflects
CAHPS® HOSPICE MEASURES
Look for opportunities for improvement using
unadjusted results
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CAHPS® HOSPICE MEASURES
Yes Definitely/Yes Somewhat/No
Yes
Definitely
Yes
Somewhat No
N % N % N %
Q 18 Side effects of pain medicine discussed 10 10% 15 15% 75 75%
CAHPS® HOSPICE MEASURES
Determine which opportunities for
improvement should be your focus
based on your hospice’s standard of
care.
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CAHPS® HOSPICE MEASURES
If 3 in 10 persons responded with the less than best response for a question, is that the goal that you want to set for your hospice program?
Yes Definitely/Yes
Somewhat/No
Yes
Definitely
Yes
Somewh
at No
N % N % N %
Q 16
As much help with pain
as needed 70 70% 20
20
% 10
10
%
CAHPS® HOSPICE MEASURES
Examine your respondent
population
Compare respondent population to
total population served
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DON’T
Do not make evaluations based
on too little data
• Results from a small number of surveys may not
accurately reflect performance.
• Use a timeframe (e.g., calendar quarters) that will
allow meaningful evaluation of trends in scores
DON’T
Do not assume your vendor’s comparison data are the same as national data
• Check CMS national results against vendor’s
https://data.medicare.gov/Hospice-Data-Directory/National-CAHPS-Hospice-Survey-data/sj42-4yv4
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CMS Support
• Web site: www.hospicecahpssurvey.org
• Email: [email protected]
• Telephone: 1-844-472-4621
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COMPLIANCE
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HQRP REQUIREMENTS
Two current requirements for HQRP:
• Hospice Item Set (HIS).
• CAHPS® Hospice Survey.
All Medicare-certified hospice providers must
comply with these two reporting requirements.
HQRP REQUIREMENTS
PAY FOR PARTICIPATION
• Submitting data determines compliance with
HQRP requirements
• Failure to comply = market basket update (also
known as the Annual Payment Update, or APU)
reduced by 2 percentage points.
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HQRP COMPLIANCE
HIS Submission
• Through QIES ASAP system
• Must be successfully accepted by system within
30 calendar days of the event date
• 30 calendar days from the Admission Date (A0220)
• No later than 30 calendar days from the Discharge Date
(A0270)
HQRP COMPLIANCE
HIS Submission
• SUBMITTED does not mean that the HIS
Records are ACCEPTED
• Need to check – final validation reports in
CASPER
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HQRP COMPLIANCE
Final Validation Reports
Review each one to determine the status of each submitted record.
• Fatal Error = Rejected status:
–Not saved into the system.
–Correct and resubmit
• Records with Warning messages are accepted and saved are saved into the QIES ASAP system, even if there are Warning messages associated with them.
HQRP COMPLIANCE
Final Validation Reports
• Evaluate warnings and take necessary corrective
actions!
• An error identified in an accepted HIS record
must be corrected.
• Modification Request
– Inactivation Request
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HQRP COMPLIANCE
RESOURCES
• Hospice User Guides and Training
https://www.qtso.com/hospicetrain.html
• Hospice Quality Reporting Training – Downloads
April 2017 Data Submission and Reporting
Webinar pdf
• Technical Help Desk
[email protected] or 1-877-201-4721
HQRP COMPLIANCE
HIS Submission Timeliness
% of HIS Records Submitted on Time =
The number of HIS records in the numerator
divided by the number of HIS records in the
denominator, multiplied by 100 rounded to the
nearest whole number.
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HQRP COMPLIANCE
HOSPICE CAHPS SURVEY
• Contract with an approved survey vendor to
collect and submit data using the CAHPS
Hospice Survey on an ongoing monthly basis.
• Hospice responsible to see that vendor is in
compliance
HQRP COMPLIANCE
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HQRP COMPLIANCE
The HIS reporting cycle spans three years.
• FY 2018 Reporting Year data collection and
submission in calendar year 2016
• Compliance determinations in 2017
• Payment impact for the fiscal year 2018 APU.
HQRP COMPLIANCE
SUBMISSION THRESHOLDS
APU Year Data Submission % Required
• FY 2018 (1/1/16 – 12/31/16) 70%
• FY 2019 (1/1/17 – 12/31/17) 80%
• FY 2020 (1/1/18 – 12/31/18) 90%
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PUBLIC REPORTING
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HOSPICE COMPARE
CMS HOSPICE COMPARE WEBSITE
• Search for Medicare certified hospice providers
based on provider name and/or service area
• Provider quality information
• Launch late summer 2017 (website still under
construction)
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HOSPICE COMPARE
INAUGURAL RELEASE
Will include:
• 7 current HIS measures
• Individual scores
• National average scores
• Based on 12 months of data:
Discharges Q4 2015 (10/1/15) through
Q3 2016 (9/30/16)
HOSPICE COMPARE
INAUGURAL RELEASE
HIS QMs on Hospice Compare 2017:
• Treatment Preferences (NQF #1641)
• Beliefs/Values Addressed (modified NQF #1647)
• Pain Screening (NQF #1634)
• Pain Assessment (NQF #1637)
• Dyspnea Screening (NQF #1639)
• Dyspnea Treatment (NQF #1638)
• Opioid and Bowel Regimen (NQF #1617)
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HOSPICE COMPARE
INAUGURAL RELEASE
Will NOT include
• State level scores
• Star ratings
• Hospice CAHPS scores
• Composite Measure scores
• Visit When Death Imminent Measures
HOSPICE COMPARE
HOSPICE CAHPS
• First Refresh in 2018 scheduled to include
CAHPS results
• Data from patient deaths 4/1/2015 – 3/31/2017
• No scores if < 30 completed surveys during
reporting period
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HOSPICE COMPARE
Results suppressed for:
• Hospices with a QM denominator size of fewer
than 20 patient stays (based on 12 rolling months
of data)
• Data not available (Medicare certified < 6mos or not
submitted)
• Provider request (circumstances beyond control)
HOSPICE COMPARE
“Refresh”
• Quarterly
• Rolling 12 months of data
• Discharges Q4 2015 through Q3 2016
• Discharges Q1 2016 through Q4 2016
• Discharges Q2 2016 through Q1 2017
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HOSPICE COMPARE
PROVIDER PREVIEW REPORTS
• Hospice providers must have opportunity to preview quality data that is to be made public prior to such data being made public (in ACA).
• Show quality measure performance results that will appear on Hospice Compare website
HOSPICE COMPARE
PROVIDER PREVIEW REPORTS
• Accessed through CASPER
• Automatically generated and saved
• Available approximately 8 months after the end of each data collection period
• CMS will announce when reports are available
• First reports available June 1, 2017
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HOSPICE COMPARE
PROVIDER PREVIEW REPORTS
HOSPICE COMPARE
INITIAL PROVIDER PREVIEW REPORT
• Available for 60 days
• Download and save (same as other CASPER reports)
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HOSPICE COMPARE
INITIAL PROVIDER PREVIEW REPORT
• Hospice's Observed Percent (score)
• National Rate (national average percent)
• Scores calculated without the 7 day LOS exclusion
Provider Reports and Hospice Compare website will NOT include percentiles!
HOSPICE COMPAREPROVIDER PREVIEW REPORTS
• Can still submit HIS modification and inactivation records up to 36 months after the target date.
(Target dates: Admission Record = admit date
Discharge Record = discharge date)
• Corrected data will be reflected in future Preview reports and Hospice Compare refreshes.
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HOSPICE COMPARE
PROVIDER PREVIEW REPORTS
• 30 days to review Provider Preview reports for accuracy.
• Review period begins the day the reports are issued in CASPER system folders.
• Initial reports 6/1/17 – 6/30/17
HOSPICE COMPARE
PROVIDER PREVIEW REPORTS
• Once the Preview Reports are generated data are frozen.
• Cannot make corrections in results or underlying data in the Preview Report
• If disagree with performance data (denominator, or quality measure score) in Preview Report, can request review by CMS.
• Requests for review must be made during 30-day preview period (30 days starting with posting date)
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HOSPICE COMPARE
CMS REVIEW REQUEST
• Submit request via email
• Subject line: “[Provider/Facility Name] Hospice Public Reporting Request for Review of Data” followed by CCN
• Send to: [email protected].
HOSPICE COMPARE
CMS REVIEW REQUEST
Requirements for submitting request”
• HQRP web site
• Hospice Quality Reporting section (left menu)
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HOSPICE COMPARE
PROVIDER PREVIEW REPORTS
• CMS will review all requests and provide a response with a decision via email.
• Data that CMS agrees is incorrect will be suppressed for one quarter, and corrected data will be reflected in the subsequent quarterly release (refresh) of quality data on Hospice Compare.
NHPCO REGULATORY AND QUALITY TEAM
Email us at:
or
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