Hospice Quality Reporting Update: June 2014
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Transcript of Hospice Quality Reporting Update: June 2014
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Presented by:Anne Shelley, MBA, BSN, RN
Susan Wallace, MSW, LSW
Hospice Quality Reporting Update: June 2014
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Objective
Discuss the updates to hospice quality reporting requirements.
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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
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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
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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
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A NEW Alphabet Soup
QIES ASAP
RTI
NQF
HART
CASPER
QTSO
MAP
HQRP
HIS
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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)
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Preparation• Research• Staff Assignment• Medical Records Evaluation, Reconciliation with the
HIS• Organizational Communication Plan• Staff Education• Implementation
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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
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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
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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
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Organizational Communication Plan• Leadership
• Resource Allocation/Redistribution• Communication to Board
• Initial Education Plan for Staff
• Ongoing Education Plan for Staff• Orientation/Training• Annual Updates
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Staff Education
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Implementation
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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
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Hospice EOCS (CAHPS): Timeline• First quarter 2015: 1-month “trial run” for
submission
• April 1, 2015: Begin continuous usage
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Vendors
• Hospices must contract with CMS-approved vendor• Vendor applications: late 2014
• Home Health CAHPS Vendors:• https://homehealthcahps.org/GeneralInformation/ApprovedS
urveyVendors.aspx
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On the Horizon
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NQF Endorsement Process
• Call for Measures• Call for Nominations• Measure Review• Comment• Voting
• CSAC Decision• Board Ratification• Appeals
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Measures Application Partnership• Measure concepts:
pain goal attainment patient engagement care coordination depression caregiver’s role timely referral to hospice
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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).
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Questions?