Connecting the Dots Between Hospice Quality Reporting and

2019 KHCHA Annual Conference Workshop H1

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Connecting the Dots Between Hospice QualityReporting and Patient CareP R E S E N T E D B Y :

J u d y M o r r i s , R N , B S N

R N C o n s u l t a n t

5 S t a r C o n s u l t a n t s , L L C

KHCHASeptember 2019

Objectives

o Understand why quality measures are needed

o Be familiar with what the HQRP requirements are and their impact on your agency

o Understand the changes with the FY2020 Hospice Wage Index Final Rule

o Learn how measures for both the Hospice Item Set (HIS) and the CAHPS Hospice Survey items correlate to clinical practice

o Be able to identify strategies to maximize customer service opportunities within your own agency targeting HIS and CAHPS questions

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What is HQRP?

Hospice Quality Reporting Programo Promotes the delivery of person-centered, high quality, and safe care by hospices

o CMS adopted measures that were recommended by multi-stakeholder organizations and developed with the input of providers, payers, and other stakeholders.


Why HQRP is Needed?

o Medicare CoPs• §418.58 – Quality Assessment and Performance Improvement

oAffordable Care Act• Section 3004 authorized the Health and Human Services Secretary to

establish a quality reporting program for Hospice

o Measure Value Based Care• Quality, safe and efficient care

o Revise payment models

o Monitor resource utilization

o Protect and detect fraud and abuse

o Performance monitoring



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HQRP Requirements

o Two requirements for HQRP• Hospice Item Set (HIS) data collection and submission• Consumer Assessment of Healthcare Providers and

Systems (CAHPS) Hospice Survey submission

o All Medicare-certified hospice providers must comply with these two reporting requirements


HIS CAHPS HQRP

Quality of Care

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Hospice Item Set (HIS)

o All Medicare-certified hospice providers are required to submit:• HIS Admission records• HIS Discharge records

o HIS data is collected and submitted on all patient admissions, regardless of the payer, patient’s age, or location of the receipt of hospice services• CMS will cut out patients under 18 and length of stay less than

7 days but data is still required to be collected and submitted

o Displayed publicly on Hospice Compare


Hospice Item Set (HIS)

o Not an assessment instrument; however, the questions can be incorporated into the nursing assessment process

o HIS Admission Records• Need to be completed within 14 days of admission

oHIS Discharge Records• Need to be completed within 7 days of discharge



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HIS MeasuresComposite Measure

o Patients who got an assessment of all 7 HIS quality measures at the beginning of hospice care to meet the HIS Comprehensive Assessment Measure requirements


HIS MeasuresThe seven measures that make up the HIS Comprehensive Assessment Measure

o NQF #1641 – Treatment preferences

o NQF #1647 – Beliefs / Values addressed

o NQF #1634 & NQF #1637 – Pain screening and pain assessment

o NQF #1639 & NQF #1638 – Dyspnea screening and dyspnea treatment

o NQF #1617 – Patients treated with an Opioid who are given a bowel regimen



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Visits When Death is Imminent

Pair Measure

oMeasure 1:• Percentage of patients receiving at least one visit from

RN, physician, NP, or PA in the last 3 days of lifeWas to be first reported August of 2019 (


Visits When Death is Imminent

Pair Measure

Measure 2:• Percentage of patients receiving at least two visits from

social worker, chaplains/spiritual counselor, LPN/LVN, or hospice aide in the last 7 days of lifeWill NOT be publicly reported at this time as it did not

meet readiness standards



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HIS Data: When to Submit Data?

o Hospice Admission HIS and Discharge HIS data must be submitted for all patients within 30 days of the event or target date

o Submission does not equal acceptance

o Recommend submitting data within 7 – 14 days to be sure of acceptance by the 30-day deadline


HIS Data Submission

oData collection year runs from January to December

oHIS data needs to be submitted and accepted within the acceptable threshold


HIS Records From Submission Threshold Reporting Year

CY 2018 and beyond 90% FY 2020 and beyond

CY 2019 90% FY 2021

CY 2020 90% FY 2022


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Family Experience of Care


Hospice CAHPS Surveyo The CAHPS Hospice Survey is to measure and assess the experience of patents who died while receiving hospice care, as well as the experiences of their informal primary caregivers

o Focuses on experiences of care

oConsists of 47 questions

o Incorporates questions for all patient locations:• Home• Facility / Hospital• Nursing Facility

o Administered via:• Mail only• Telephone only• Combination of mail with telephone follow-up



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Hospice CAHPS Surveyo Survey administration begins two months following the month of patient death

o Data collection process must be completed within 42 calendar days after initial contact

o All Medicare-certified hospice providers must participate

o Data collection year runs from January to December

o Displayed publicly on Hospice Compare• Need to have 30 completed and returned surveys in order for data to

be displayed


Hospice CAHPS Survey

o Hospices are allowed to do the following:• Inform caregivers about the survey• Perform quality improvement initiatives such as assessing

patient and family responses to questions asked to promote well-being

o Hospice are NOT allowed to:• Ask CAHPS Hospice Survey questions• Influence or direct caregivers on how to answer the questions• Offer incentives



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Hospice CAHPS Survey Exemptions

o Patients under 18 at the time death

o Patients who died within 48 hours of admission to hospice care

o Agency is unable to locate caregiver or not available

o Primary caregiver has a foreign address listed

o Caregiver requests to no be contacted• Ensure documentation in record of this request


CAHPS Quality Measureso Communication with family• The hospice team always listened carefully and kept the patient’s

family informed

o Getting timely help• The hospice team always gave patients and families help when they

needed it

o Treating patient with respect • The hospice team always treated the patient with dignity and

respect

o Emotional and spiritual support• The hospice team gave the right amount of emotional, spiritual, and

religious support



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CAHPS Quality Measureso Help for pain and symptoms• The hospice team always gave the patient as much help as needed

for pain and other symptoms

o Training family to care for patient• The hospice team always gave family members the training and

information they needed to care for the patient

o Rating of hospice• Family caregivers who gave the agency a total rating of 9 or 10

(where 10 is the best)

o Willing to recommend hospice• Family caregivers who would definitely recommend the hospice

agency to friends and family


CAHPS Hospice Survey Submission Requirementso Requires ongoing monthly participation through an approved vendor who submits data quarterly per CMS deadlines

o Submission of data does not equal successful submission of data• Submission of survey data needs to be to the CAHPS Hospice Data

Warehouse

o Apply for access to the Data Warehouse so you can get reports about your data submission

o Keep in touch with your vendor



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Agency Exemptions From CAHPS Hospice Survey

o Can request a size exemption from collection and reporting requirements for CAHPS ONLY --- NOT HIS• Fewer than 50 survey eligible decedents/caregivers in the

reference year (January 1 – December 31)◦ Only is good for one year

• Newness exemption◦ Only a one-time exemption◦ Recommend saving your letter with your new CCN and save the

envelope

oMore on exemptions later in presentation with 2020 Hospice Final Rule


Potential Penalties

o Must submit BOTH HIS and CAHPS for HQRP• Failure to comply will result in a 2% decrease in

reimbursement for providers

o Review CASPER reports timely and address all errors timely to avoid 2% penalties• Hospice Timeliness Compliance Threshold Report• Final Validation Report



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Quality and its Financial Impact

o A 2% reduction in annual payments if HQRP requirements not met

o Accuracy of HIS questions• Ensure documentation in clinical record to support all HIS responses

o Referral relationships• If outcomes are good, can show referral sources and providers how

your agency compares to others• If outcomes are poor, could result in few referrals

o Hospice will likely be included in Value Based Purchasing (VBP) in the future• Want to ensure you are establishing quality indicators now along

with committing to continued improvement


FY2020 Hospice Wage Index Final Rule



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Hospice Final Rule 2020

oFY 2020 Hospice per diem payment rates will be wage-adjusted by your geographic location—see 2020 wage index tables

oOnline FY2020 Hospice Wage Index Table at:

ohttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index.html


Hospice Final Rule 2020

oUpdated payment rates, cap amount, and rebased payment rates

oRoutine Home Care payment rates down 2.72% and they increased payment rates for Inpatient, Respite and Continuous Care.

oHospice base payment (for FY 2020) is 2.6% for hospices that report the required quality data BUT is only 0.6% (2% reduction) for hospices that fail to report required quality data. (Make sure to check after submission of HIS admission and discharge data for not only that it was successfully submitted but that the data was accepted!)

oNo changes to submission requirements for HIS or CAHPS -but there will be a new QIES (Quality Improvement and Evaluation System) internet upgrade coming soon (QRP submissions) that will be announced in CMS webinars/ updates in future



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Hospice Final Rule extrasoPayment rates effective 10/1/2019 (for federal FY 2020)oEnsure your hospice cost reports are complete and accurate so next year's rates will not be based on under-reported cost figuresoKnow that Medicare will continue monitoring for the appropriate use of the higher level of care (IE: continuous care, inpatient care).oNeed documentation to show the higher level of care meets the criteria for use (refer to State Operations Manual for hospice use of CC, Respite, and Inpatient levels of care) AND review your Medicare Benefit Manual regarding documentation/ billing for the higher levels of care.oDevelop your modified election statement to be implemented by 10/1/2020 so it will be in effect for 2021.


Final Rule Updates on CAHPSoContinue to give volume-based exemptions for CAHPS Hospice Survey Data Collection and Reporting in 2021 –use the data from 2018 (for CY 2019 )

oDue date for exemption to be submitted to CMS for FY 2021 is December 31,2019

oHospices that have fewer than 50 survey-eligible decedents or caregivers from the collection period for CY 2019- can submit application for size exemption from reporting CAHPS

oExemption for CAHPS continues to be issued for one year.

oIf given the one-time newness (brand new hospice) exemption, be sure to keep your letter granting this automatic exemption. Also keep your original letter granting you a CCN # on file for future proof of when it was issued.



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Exemption Applications

Exemption information and request form on the official CAHPS Hospice Survey website at:

http://www.hospiceCAHPSsurvey.org

Due date to submit exemption request is December 31, 2019 for FY2021.


What Should You Be Doing Now?



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Identify and Prioritize

o Identify how daily clinical practice and operations can impact responses and hospice outcomes

o Prioritize the areas that you are significantly below average first• What needs your attention the most?

o Develop a top priority list• Often this will branch off into other areas to work on

o Spend the majority of your time on the biggest challenges

o Assign task force for bigger areas


Educate…Educate…Educate

o Involve EVERYONE

o Educate staff on HIS and CAHPS and review the items/questions• Educate monthly in various ways: Staff meetingsPostersNewslettersGamesQuizzes

oDiscuss the impact of HIS and CAHPS and Hospice Quality Reporting has on agency outcomes

oAt admission, educate patient, families and/or caregivers



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Have a Meaningful QAPI Plan

o Ensure program is designed to help you

o Incorporate HIS items and Hospice CAHPS survey results into your QAPI program

o Collect data

o Trend

o Analyze• Root cause analysis

o Develop action plans

o Evaluate plan


Hospice Quality Reporting and

Patient Care



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Connecting the Dots o HIS and Hospice CAHPS Survey cross over areas:• Pain• Dyspnea / Breathing• Opioid Use / Bowel Regimen

o Be aware of areas where both direct and non-direct care employees could have impact• Dignity, respect and caringHome visits Patient / family / caregiver calls into office – during office hours

and after hours


Connecting the Dots o Be aware of areas that involve multiple disciplines• CommunicationTelephone calls to schedule visits

• Timeliness of visits / callsDuring business hoursAfter hours – evenings, weekends, holidays REMEMBER: When a patient/family member calls, they need assistance

• Timeliness of follow-up• Listening carefully• Team working well together and coordinating careAmong IDG membersInternal hospice staff and facility staff Coordinating visits on different days



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CAHPS Best PracticesoDid the hospice team give you the training you needed about what side effects to watch for from pain medicine?• Summarize visit before leaving using “key words” Example: Today I reviewed the side effects of your pain

medications; do you have any questions?• Communicate with caregiver, if not present at visit (They are the

ones who complete the survey)Example: Today I reviewed the side effects of pain medications

with your mother, which are……

o Use of teach-back can be effective with many of the questions• Educate staff on teach-back and role play


CAHPS Best PracticesoHow often did the hospice team listen carefully to you…..• Ask patient AND caregiver what his/her goals are and what is most

important to themIncorporate those into the plan of careAddress on future visits

o How often did your family member get the help he or she needed for trouble breathing?• Communicate with caregiver, if not present at visitExample: Today your father had some trouble with breathing,

which is under control now. Here is how we helped him……This example can be use with any of the symptom

management questions



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CAHPS Best Practiceso Incorporate quarterly follow-up calls to patients / families about service delivery into your QAPI Program

o Ask: • How has your care been with the team members?• Do the team members communicate with you about arrival time?• Have you been informed about the care that is being delivered?• Have you experienced any symptoms and if so, what were they and

were they resolved in a way that is satisfactory to you?• Have you had to use the after – hours number and if so, how was

your experience?• How has your Hospice experience been overall? • Is there anything we could do to improve?


The Key to Success – Exceptional Customer Serviceo Focus always needs to be on the patient and family

o First interactions impact patient and family experience significantly• By phone conversation or in person visit

o Quality starts when the phone rings• What does it sound like when the phone rings at your agency?Live voice within your officeIs the voice cheerful or does it sound annoyed?

Answering serviceVoicemail with number prompts



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Conclusion

o Educate staff on the importance of HIS and Hospice CAHPS

o Be aware of your agency specific results• Share results with staff

o Incorporate HIS and Hospice CAHPS items into your agency QAPI plan


References

CAHPS Hospice Survey

• https://www.hospicecahpssurvey.org/

HIS User Manual / HIS Forms and Guidance / Q & As

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html



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Judy Morris, RN, BSNRN Consultant

5 Star Consultants, [email protected]

Documents

Connecting the Dots Between Hospice Quality Reporting and