Hospice Quality Reporting Update: June 2014 Presented by: Anne Shelley, MBA, BSN, RN Susan Wallace, MSW, LSW Objective Discuss the updates to hospice quality reporting requirements. Hospice Quality Reporting Program • Structural Measure & Comfortable Dying Measure • • Hospice Item Set • • Concluded April 2014 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 lifesustaining 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 CASPER RTI HQRP NQF MAP QTSO HIS HART Measure Development Program Design Measure Collection • Measures Application Partnership (MAP) • National Quality Forum (NQF) • Centers for Medicare & Medicaid Services (CMS) • RTI International • 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-InitiativesPatient-Assessment-Instruments/Hospice-QualityReporting/Hospice-Item-Set-HIS.html • • • • https://www.qtso.com/hospice.html • • • • HIS Manual Training Slides (2/4 & 2/5) Fact Sheet 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?