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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
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.