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