Presented by: Kim Kranz, RN, MS

Sr. VP Hospice and Palliative Care

May 19, 2011

35 diverse, non-profit programs providing home and community based servicesCHAP accredited, Medicare certified Home Health CHAP accredited, Medicare certified HospiceNamed to the Best Place to Work in Pennsylvania since 2004Earned the distinction of “Best Practices in Homecare and Hospice” by Pennsylvania Homecare AssociationRecognized from Modern Healthcare as one of the Top 100 Best Places to Work in Healthcare in the nationRecognized for implementing Best Practices in Operations ManagementServing Central Pennsylvania for 41 years1,000 employees in thirteen counties32% employee growth in six years

Over 23,000 patients served in 2010

Birth 2 3 5 6 13 16 18 21 100+

Birth 2 3 5 6 13 16 18 21 100+

kb 7/09

Early Intervention

Children's Behavioral Health

Services:

* Behavioral Health

Rehabilitation Services

* Center for Counseling

* Children's Partial

Hospitalization

* Blended Case Management

* Drug & Alcohol CounselingBehavioral Health Services for Adults:

* Adult Partial Hospitalization

* Center for Counseling

* Drug & Alcohol Counseling

* Family Support Services

* Housing Assistance and Rental Program (HARP)

* Blended Case Management

* Co-occurring Disorder Treatment

* Mobile Psychiatric Rehabilitation

* Projects for the Assistance from Homelessness (PATH)

Housing:* Blair House Transitional* Blair House Apartments* Juniata House* Tartaglio Personal Care Home

AIDS Intervention Project (AIP)Bereavement Services

Home Health

Hospice & Palliative Care

Nurse Family

Partnership

Women, Infants and Children (WIC)

Pediatric Private Duty

Adult Center for Exceptional Learning (ACEL)

Adult Day Services

A brief overview of the QAPI requirementsThe background of the AIM ProjectThe quality measures and data of the AIM ProjectLessons learned from the AIM ProjectWays that you can implement the AIM Project measures and dataWhat is on the horizon in hospice quality measurement

Core of patient-focused and outcome oriented Conditions of Participation (CoP)Goal is to monitor quality/performance, find opportunities for improvement, and improveFocus is on achieving desired outcomes

QAPI operates on two levelsPatient-level and hospice-level

At both levels, hospices must:Collect data to assess qualityUse the date to identify opportunities for improvementDemonstrate performance improvement in one or more areas

Collect data on what happened for an individual patientAssess/reassessmentIDG plan of care/ update plan of careImplement and document care

Use the data to improve quality of care and outcomes for that patient

ClinicalAggregate patient-level dataCollect satisfaction data

Non-ClinicalAdministrative dataMarketing – Referral source contactOutreach to communityProfitabilityFundraising

Use the data to improve clinical operations andNon-clinical operations

The hospice must develop, implement, and maintain an effective, ongoing, hospice-wide, data-driven QAPI program

The hospice must ensure that the program:Reflects the complexity of its organization and servicesInvolves all hospice services (including those services furnished under contract or arrangement)Focuses on indicators related to palliative outcomesTakes actions to demonstrate improvement in hospice performance

The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS

PEACE Project (Prepare, Embrace, Attend, Communicate, Empower)

Completed in February 2008Listed 34 suggested measures along with data definitions and a tool for data collectionAvailable at www.qualitynet.orgCompleted by the Carolinas Center for Medical Excellence, the North Carolina QIO

AIM Project (Assessment, Intervention, Measurement)

August 2009 – November 2010Conducted by IPRO, the New York State QIOImplemented in 7 hospices and 1 palliative care site within the state of New York that volunteered to participate in the project. The participating sites were representative of hospices nationwide.

PROJECT GOALS

Use the PEACE quality measures and a modified version of the PEACE data collection tool to assess

the quality of care in participating hospice sites, identify areas for performance improvement and

measure quality of care improvements after performance improvement projects are

implemented.

PROJECT GOALS

Examine various factors related to the quality of the data collection tool and quality measures in

accordance with NQF standards.

Identify factors contributing to disparate and inequitable access to and use of hospice services.

The AIM Project was divided into 8 tasks and resulted in 4 major products:

1) A comprehensive literature review of existing research related to disparities in end-of-life care

2) An intervention package which hospices and QIOs can use to measure and improve the quality of care provided to hospice patients• http://www.ipro.org/index/hospice-aim

3) A report on each quality measure to be used in the NQF endorsement process, as appropriate

4) A final report on the project

M1: Percent of patients who were assessed for physical symptoms and screened for psychological symptoms during the admission visit.M2: Percent of patients with comprehensive assessment completed within 5 days of admission.M3: For patients who assessed positive for pain, the percent whose pain was at a rating of non or mild at the second pain assessment.M4: For patients who assessed positive for dyspnea at rest, the percent of patients who improved within 1 day of assessment.M5: For the patients who assessed positive for nausea, the percent who received treatment within 1 day of assessment.M6: Percent of patients on opioids who had a bowel regimen initiated within 1 day of opioid initiation.

M7: For patients who screened positive for anxiety, the percent who received treatment within two weeks of screening.M8: Percent of families reporting the hospice attended to family needs for information about medication, treatment and symptoms.M9: Provision of an interpreter or translator for non-English speaking or deaf patients.M10: Percent of patients who had moderate to severe pain on a standard rating at any time in the last week of life.M11: Percent of patients with documentation in the clinical record

of an advance directive or discussion that there is no advance directive.

M12: Number of adverse events per 1000 patient-days; falls, medication errors, DME issues, and patient/family complaints.

Percent of patients who were assessed for physical symptoms and screened for psychological symptoms during the admission visit.

PainDyspneaNauseaConstipationDepressionAnxiety

Performance = Credit

All data collected retrospectively Data collected for one yearManual record reviews5% - 10% of discharges per month (total: 63 – 225)Eligibility criteria

18 and olderOn service >7 days

Data entered in toolSent to IPRO monthly

Purpose1. Means of Communication2. Quality data productionConstruct

AccurateComplete picture of patient’s stay on service

Patient and family’s needsSeverity of symptomsManagement strategiesPatient preferences and outcomes

Must be a well developed and operational system

Generate Record Retrieve

Missing information due to oversight or error √ √ √

Lack of information obtained from patient/family √ √ √

Qualitative vs. quantitative documentation √ √ √

Vagueness/Lack of clarity √ √ √

Inability to document in a manner useful for data collection √ √

Negative charting √ √

For patients who assessed positive for dyspnea at rest, the percentage of patients who improved within 1 day of assessment.

•Standardize method to score severity not used•Symptoms not

quantified• Inconsistent

documentation of symptom severity•Abstraction tools

difficult to use

• Care issues not addressed • Documentation on

symptom assessments missing in record• Patient goals not

documented

• Diagnosis, co-morbidities• Data missing/difficult to

find• Definitions not clear

For patients who assessed positive for pain, the percent whose pain was at a rating of none or mild at the second pain assessment.

√ Aware of missing data√ Quantified symptom severity ratings√ Use of PAINAD/FLACC

For the patients who assessed positive for nausea, the percent who received treatment within 1 day of assessment

√ Aware of missing data√ Instituted symptom review forms√ Use of Edmonton Scale

For patients who screened positive for anxiety, the percent who receive treatment within two weeks of screening.

√ Use of standardized screening instrument

√ Consistency in word documentation

√ Process implemented

Conceptualize clinical records as data source

Optimize documentation methods

Review organizational structure

Establish teams

Review current documentation processesLocate the variables of interest in clinical recordUnderstand what your data area telling youDocumenting multiple assessment in same visit

Know what your EMR is capable ofAre scales built in?Can programming be done to “force” a response?If making programming changes, do early!

If using paper records, how are they organized?Checklists/text

Document consistently!Establish policies for data element locations

Utilize rating scales for assessmentsBe aware of the limitations of current clinical instruments.May not be instruments available that fit your clinical needs.

Document “something” to avoid missing data

Look at your systems/practices supporting the quality processChampion/supporterReview past organization changes

Identify areas of strength and weaknessStaff processes

Staff training timeKey personnelPriorities/Empowerment

Complete an Organizational Self-AssessmentNCP 8 essential domains of quality care

Structure and processCulturally appropriate carePhysical symptomsPsychological symptomsSocial aspects of careSpiritual assessmentImminently dyingEthical and legal aspects of care

Team MembersInclude 3 – 8 people from all disciplines

LeadershipNursingPhysicianSocial WorkSpiritualBereavementQI and EducationAdministrative support/medical records

Agency SponsorSupport quality team at agency level

Project LeaderStaff goes to this person with questions or for resolutions

Section 3004 of the Patient Protection and Affordable Care Act (aka the Affordable Care Act).

By October 1, 2012 the Secretary must publish hospice quality measures.

The published quality measures must receive endorsement from a consensus body (e.g. NQF), with exceptions.

CMS must take steps to make hospice quality measure data available to the public (no timeline given).

Beginning of FY 2014, hospices that do not submit required quality measure data will have their market basket rate reduced by 2% for that FY.

CMS has a contract with RTI International to develop the hospice quality reporting program.

This contract also focuses on the other providers that area affected by section 3004 (e.g. long-term care hospitals).

RTI has convened technical expert panels for each affected provider type. These panels will help guide the process and outcomes.

Dialogue with Stakeholders CMS held a listening session with industry leaders in

November 2010 and a special Open Door Forum in December 2010

There will be future Open Door Forums on this subject, as needed

(Information about future CMS Open Door Forums can be found at:

http://www.cms.gov/OpenDoorForums/17_ODF_HHHDME.asp)

Regulatory Process There will be a series of regulations to implement

the quality reporting requirements The first NPRM is scheduled to be published in

Spring 2011 60 day public comment period

NQF Upcoming call for measures (Spring 2011????) RTI will assist CMS in stewarding select measures

through the endorsement process CMS has no influence over which measures will be

endorsed