©copyright deyta, llc, all rights reserved the path to hospice public reporting rebecca van vorst,...

©Copyright Deyta, LLC, All Rights Reserved

The Path to Hospice Public Reporting

Rebecca Van Vorst, MSPHPennsylvania Homecare Association

2012 Annual ConferenceState College, PA

May 16, 2012

The Path to Hospice Public Reporting

Rebecca Van Vorst, MSPHPennsylvania Homecare Association

2012 Annual ConferenceState College, PA

May 16, 2012


ObjectivesObjectives

• Describe the current regulatory requirements of the hospice quality reporting program.

• Identify the hospice quality measures endorsed by the National Quality Forum.

• Discuss three ways hospices can prepare now for future reporting requirements.

• Describe the current regulatory requirements of the hospice quality reporting program.

• Identify the hospice quality measures endorsed by the National Quality Forum.

• Discuss three ways hospices can prepare now for future reporting requirements.


Knowledge is the key to survivalKnowledge is the key to survival

3


The Hospice RoadmapThe Hospice Roadmap2005

Hospice COPs

Written

2008

COPs Become

Effective

Feb 2008

CMS PEACE Project

Report Released

March 2010

Affordable Care Act

Nov 2010

CMS Hospice AIM

Project Report Released

Jan 2011

CMS Quality Measures

TEP Convened

August 2011

Hospice Wage

Index Final Rule

Nov 2011

MedPAC Hosts Quality

Advisory Group

Jan 2012

Structural Measure

Voluntary Submission

Feb 2012

NQF Endorses EOL

Measures

Oct 1, 2012

Comfortable Dying

Measure Data Collection

Begins

Oct 1, 2012

QAPI Indicators in

Use are Reportable

Dec 31, 2012 Comfortable

Dying Measure Data

Collection and Structural

Measure Both End

Jan 1, 2013

Data Collection for April

2014 Reporting Begins

Jan 1, 2013

Structural Measure

Reporting Begins

Jan 31, 2013

Structural Measure

Reporting Ends

April 1, 2013 Comfortable

Dying Measure Reporting

Begins

Oct 2013 (FY 2014)

Hospices Not Reporting

Face Payment Reduction

?Public

Reporting


5


CMS Roadmap for QualityCMS Roadmap for Quality

Vision: The right care for the every person every time.

Aims: Make care safe, effective, efficient, patient-centered, timely, equitable.

Vision: The right care for the every person every time.

Aims: Make care safe, effective, efficient, patient-centered, timely, equitable.


CMS Quality InitiativesCMS Quality Initiatives

• Industry encouraged to develop measures and collect data

• Standard measures identified

• Required reporting to CMS

• “Public” reporting for consumers – accountability

• Pay for performance = Value-based purchasing







CMS Quality InitiativesCMS Quality Initiatives











Hospice


Why Hospice NOW?Why Hospice NOW?

• CMS commitment to increasing availability and use of healthcare information

– Informed decision making– Quality improvement

• Legislative mandate– Section 3004: Affordable Care Act

• CMS commitment to increasing availability and use of healthcare information

– Informed decision making– Quality improvement

• Legislative mandate– Section 3004: Affordable Care Act


• Requires quality reporting for hospice and other post-acute settings

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

• Requires hospices to submit data – or lose reimbursement – for FY 2014 (10/1/13) and subsequent fiscal years

• Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions

• Aims to make quality data available to the public (no timeline given)


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

• Requires hospices to submit data – or lose reimbursement – for FY 2014 (10/1/13) and subsequent fiscal years


• Aims to make quality data available to the public (no timeline given)

10

Section 3004 of the Patient Protection and Affordable Care Act

March 23, 2010

Section 3004 of the Patient Protection and Affordable Care Act

March 23, 2010


• Hospice wage index for fiscal year 2012– Continue the phase-out of the wage index

budget neutrality adjustment factor (BNAF)

• Change the hospice aggregate cap calculation methodology

• Revise the time frame for the face-to-face encounter

• Begin implementation of a hospice quality reporting program.

• Hospice wage index for fiscal year 2012– Continue the phase-out of the wage index

budget neutrality adjustment factor (BNAF)

• Change the hospice aggregate cap calculation methodology

• Revise the time frame for the face-to-face encounter

• Begin implementation of a hospice quality reporting program.

11

Final Rule

August 4, 2011

Final Rule

August 4, 2011


Hospice Public Reporting “Influencers”Hospice Public Reporting “Influencers”

• NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001

– Source of required comfortable dying measure

• Brown/NHPCO FEHC, introduced 2003• QAPI CoP, published 2005, effective Dec 2008

– Driver of required structural measure

• CMS-funded PEACE project, reported Feb 2008• CMS-funded AIM project, reported Nov 2010• MedPAC quality TEP meeting Nov 11

– Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges

• NQF endorsement of hospice measures Feb 2012









Quality ReportingQuality ReportingThe First YearThe First Year

13


Two Measures Required NowTwo Measures Required Now

• Comfortable Dying Measure (NQF #0209)– Comfort within 48 hours of admission

SPECIFIC DEFINITION (NQF #0209)

• Structural Measure– Yes/No: Does your QAPI program include 3 or

more quality indicators related to patient care?

• Comfortable Dying Measure (NQF #0209)– Comfort within 48 hours of admission

SPECIFIC DEFINITION (NQF #0209)

• Structural Measure– Yes/No: Does your QAPI program include 3 or

more quality indicators related to patient care?


The Comfortable Dying MeasureThe Comfortable Dying MeasureThe first hospice reportable outcome measureThe first hospice reportable outcome measure


NQF #0209 Comfortable Dying - Pain Brought to a Comfortable Level Within 48 Hours of

Initial Assessment

NQF #0209 Comfortable Dying - Pain Brought to a Comfortable Level Within 48 Hours of

Initial Assessment

Percentage of patients who reported being uncomfortable because of pain at the initial

assessment after admission to hospice services whose pain was brought to a comfortable level,

as defined/reported by the patient, within 48 hours of the initial assessment

Percentage of patients who reported being uncomfortable because of pain at the initial

assessment after admission to hospice services whose pain was brought to a comfortable level,

as defined/reported by the patient, within 48 hours of the initial assessment


Comfortable Dying MeasureComfortable Dying Measure

• One of the EROM – End Result Outcome Measures– Safe and comfortable dying– Self-determined life closure– Effective grieving

• Developed as the “Comfortable Dying” measure by NHWG and NHPCO task force in 2001

– Two rounds of pilot testing

• Assure as many patients as possible are comfortable within 2 days of the start of hospice care

• One of the EROM – End Result Outcome Measures– Safe and comfortable dying– Self-determined life closure– Effective grieving

• Developed as the “Comfortable Dying” measure by NHWG and NHPCO task force in 2001

– Two rounds of pilot testing

• Assure as many patients as possible are comfortable within 2 days of the start of hospice care

Designed to support good care management


Key Concept:Comfortable Dying Measure

Key Concept:Comfortable Dying Measure

• Relies on patient report of “comfort”

• Two questions– “Are you uncomfortable because of pain?”– “Was your pain brought to a comfortable level

within 48 hours of the initial assessment?”

• NOT on a numerical pain severity score– Can and should use numerical ratings in

addition

• Relies on patient report of “comfort”

• Two questions– “Are you uncomfortable because of pain?”– “Was your pain brought to a comfortable level

within 48 hours of the initial assessment?”

• NOT on a numerical pain severity score– Can and should use numerical ratings in

addition


The Comfortable Dying MeasureThe Comfortable Dying Measure• Are you uncomfortable because of pain?

– Asked during the Initial Assessment– Asked BEFORE any pain assessments are done– Must be answered by the patient

• Was your pain brought to a comfortable level within 48 hours of your Initial Assessment ?

– Only asked of those patients who said “Yes” to the first question

– Asked between 48 and 72 hours after the Initial Assessment

– Must be answered by the patient

• Are you uncomfortable because of pain?– Asked during the Initial Assessment– Asked BEFORE any pain assessments are done– Must be answered by the patient

• Was your pain brought to a comfortable level within 48 hours of your Initial Assessment ?

– Only asked of those patients who said “Yes” to the first question

– Asked between 48 and 72 hours after the Initial Assessment

– Must be answered by the patient19


Measure DefinitionsMeasure Definitions

• Includes all eligible patients:– Able to communicate and understand the language of the

person asking the question; – Able to self-report an answer to first question; and – At least 18 years of age or older.

• Denominator: Number of patients who relied “yes” when asked if they were uncomfortable because of pain at the initial assessment (after admission to hospice services)

• Numerator: Number of patients whose pain was brought to a comfortable level (as defined by the patient) within 48 hours of initial assessment (after admission to hospice services)

• Includes all eligible patients:– Able to communicate and understand the language of the

person asking the question; – Able to self-report an answer to first question; and – At least 18 years of age or older.

• Denominator: Number of patients who relied “yes” when asked if they were uncomfortable because of pain at the initial assessment (after admission to hospice services)

• Numerator: Number of patients whose pain was brought to a comfortable level (as defined by the patient) within 48 hours of initial assessment (after admission to hospice services)


The Comfortable Dying MeasureThe Comfortable Dying Measure

21

Numerator = Only those patients from the denominator who:• Answer “YES” to the second question

Denominator = All patients who:• Are at least 18 years of age or older;• Are able to communicate and

understand the language of the person asking the question;

• Are able to self-report on admission; and

• Answer “YES” to the first question



22

Data Collection & Reporting Path



23

• NO expectation that the measure score will be 100%

• Allows for the fact that some patients will not achieve a comfortable level

• Encourages hospices to make the effort to collect data for the second question

• Reflects expert opinion that most patients can and should have pain brought to a comfortable level within 2 days of the start of hospice care

• NO expectation that the measure score will be 100%

• Allows for the fact that some patients will not achieve a comfortable level

• Encourages hospices to make the effort to collect data for the second question

• Reflects expert opinion that most patients can and should have pain brought to a comfortable level within 2 days of the start of hospice care


The Comfortable Dying Measure - TimelineThe Comfortable Dying Measure - Timeline

24

Mandatory Data Collection Period

October 1 – December 31, 2012

Mandatory Data Submission Deadline

April 1, 2013


The Structural MeasureThe Structural MeasureInforming the future Informing the future


Two-part measure:

• Participation in a QAPI Program that includes at least 3 quality indicators related to patient care

– This is a YES or NO question

• If yes, submit a description of the quality indicators being used that relate to patient care

– Submission of a list of indicators, NOT the results

Two-part measure:

• Participation in a QAPI Program that includes at least 3 quality indicators related to patient care

– This is a YES or NO question

• If yes, submit a description of the quality indicators being used that relate to patient care

– Submission of a list of indicators, NOT the results

The Structural MeasureThe Structural Measure


Indicators Related to Patient Care Domains:

• Providing care in accordance with documented patient/family goals

• Effective and timely symptom management• Care coordination• Patient safety

Indicators Related to Patient Care Domains:

• Providing care in accordance with documented patient/family goals

• Effective and timely symptom management• Care coordination• Patient safety



Data Collection Requirements:

• Indicator Topic – selected from a dropdown list• Indicator Name – full name of the indicator• Brief Description – complete description of the

indicator including any information that will help CMS understand what the indicator measures

• Numerator – variable that is on the top part of the fraction that describes the process, condition, event or outcome that satisfies the measure

• Denominator – variable that is on the bottom part of the fraction that describes the population evaluated

• Data Source – data source such as survey or EMR

Data Collection Requirements:

• Indicator Topic – selected from a dropdown list• Indicator Name – full name of the indicator• Brief Description – complete description of the

indicator including any information that will help CMS understand what the indicator measures

• Numerator – variable that is on the top part of the fraction that describes the process, condition, event or outcome that satisfies the measure

• Denominator – variable that is on the bottom part of the fraction that describes the population evaluated

• Data Source – data source such as survey or EMR



• Indicator Topic:

36 Categories + “Other”Examples:

– Pain assessment or management– Anxiety assessment or management– Communication with patient/family– Culturally sensitive caregiving– Emotional care before and/or at time of death– Bereavement care– Infection reporting and control– and many more… !

• Indicator Topic:

36 Categories + “Other”Examples:

– Pain assessment or management– Anxiety assessment or management– Communication with patient/family– Culturally sensitive caregiving– Emotional care before and/or at time of death– Bereavement care– Infection reporting and control– and many more… !



The Structural Measure - ExampleThe Structural Measure - ExampleIndicator Topic (dropdown menu)

Communication with patient/family

Indicator Name Percentage of respondents who had enough instruction to do what was needed to care for the patient.

Brief Description Question D2 on the FEHC survey. Calculated from all who respond

Numerator Total number of respondents reporting family participated in the patient's care while in hospice and who answered Yes

Denominator Total number of respondents reporting family participated in the patient's care while in hospice and answered this question

Data Source (dropdown menu)

Family Survey/Questionnaire


The Structural Measure - TimelineThe Structural Measure - Timeline

Voluntary Data Collection Period


Voluntary Data Submission Deadline

January 31, 2012

Mandatory Data Collection Period


Mandatory Data Submission Deadline

January 31, 2013


• More than 900 hospices submitted a total of 6721 indicators to CMS

• Deyta’s Voluntary Reporting Program:– 269 hospices took advantage of this program– 532 different indicators were submitted – 3 out of 4 hospices used indicators from the

FEHC survey– 60% of hospices used indicators focused on

patient’s comfort from pain– 41% of hospices tracked patient falls

• More than 900 hospices submitted a total of 6721 indicators to CMS

• Deyta’s Voluntary Reporting Program:– 269 hospices took advantage of this program– 532 different indicators were submitted – 3 out of 4 hospices used indicators from the

FEHC survey– 60% of hospices used indicators focused on

patient’s comfort from pain– 41% of hospices tracked patient falls

The Structural MeasureWhat we learned from voluntary reporting

The Structural MeasureWhat we learned from voluntary reporting


Quality ReportingQuality ReportingBeyond 2013Beyond 2013


Remember the “Influencers”Remember the “Influencers”

















• Requires hospices to submit data to CMS – or lose partial reimbursement in FY 2014


Potential pool for additional required measures


• Requires hospices to submit data to CMS – or lose partial reimbursement in FY 2014


Potential pool for additional required measures

35

Remember the RegsRemember the Regs


Palliative and End-of-Life ProjectPalliative and End-of-Life Project• Identify and endorse measures for public reporting

and quality improvement• Sought to endorse performance measures on:

– Assessment, management and relief of symptoms at EOL and for acutely ill patients pain, dyspnea, weight loss, weakness, nausea, serious

bowel problems, delirium, and depression

– Patient- and family-centered palliative and hospice care that address psychosocial needs and care transitions

– Patient, caregiver, and family experiences of care

• Maintenance review of nine palliative consensus standards

• April 4, 2011• Project funded by DHHS

• Identify and endorse measures for public reporting and quality improvement

• Sought to endorse performance measures on: – Assessment, management and relief of symptoms at EOL

and for acutely ill patients pain, dyspnea, weight loss, weakness, nausea, serious

bowel problems, delirium, and depression

– Patient- and family-centered palliative and hospice care that address psychosocial needs and care transitions

– Patient, caregiver, and family experiences of care

• Maintenance review of nine palliative consensus standards

• April 4, 2011• Project funded by DHHS

36


NQF’s Consensus Development Process NQF’s Consensus Development Process

• 22 measures considered• Comment period: 121 comments - 33 organizations• 14 measures recommended for endorsement

– Voluntary consensus standards suitable for accountability and performance improvement

• 9 measures appropriate for hospice

• 22 measures considered• Comment period: 121 comments - 33 organizations• 14 measures recommended for endorsement

– Voluntary consensus standards suitable for accountability and performance improvement

• 9 measures appropriate for hospice

37


Hospice Measures by TopicHospice Measures by Topic

• Pain ManagementPercentage of hospice or palliative care patients who

were screened for pain during the hospice admission evaluation

Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.

Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed.

• Pain ManagementPercentage of hospice or palliative care patients who

were screened for pain during the hospice admission evaluation

Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.

Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed.

38


Hospice Measures by TopicHospice Measures by Topic

• Dyspnea ManagementPercentage of hospice or palliative care patients who

were screened for dyspnea during the hospice admission evaluation.

Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.

• Dyspnea ManagementPercentage of hospice or palliative care patients who

were screened for dyspnea during the hospice admission evaluation.

Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.

39


Measures by TopicMeasures by Topic• Quality of Care at the End of LifeComposite Score: Derived from responses to 17 items on

the Family Evaluation of Hospice Care (FEHC) survey presented as a single score ranging from 0 to 100.

and Global Score: Percentage of best possible response

(Excellent) to the overall rating question on the FEHC survey. (maintenance)

• Quality of Care at the End of LifeComposite Score: Derived from responses to 17 items on

the Family Evaluation of Hospice Care (FEHC) survey presented as a single score ranging from 0 to 100.

and Global Score: Percentage of best possible response

(Excellent) to the overall rating question on the FEHC survey. (maintenance)

40


Measures by TopicMeasures by Topic• Care Preference MeasuresPercentage of patients with chart documentation of

preferences for life sustaining treatments.Percentage of hospice patients with documentation in the

clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss

Number of patients who report being uncomfortable because of pain at the initial assessment who report pain was brought to a comfortable level within 48 hours. (maintenance)

• Care Preference MeasuresPercentage of patients with chart documentation of

preferences for life sustaining treatments.Percentage of hospice patients with documentation in the

clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss

Number of patients who report being uncomfortable because of pain at the initial assessment who report pain was brought to a comfortable level within 48 hours. (maintenance)

41


PREPARING for required reportingPREPARING for required reporting

42 February 2012

“The great aim of education is

not knowledge, but action.”

- Herbert Spencer


PreparationsPreparations

1. Read the Final Rulehttp://www.gpo.gov/fdsys/pkg/FR-2011-08-04/html/2011-19488.htm

2. Download the NHPCO instructions for using the Comfortable Dying measure (EROM Manual) http://www.nhpco.org/i4a/pages/Index.cfm?pageID=3376

1. Read the Final Rulehttp://www.gpo.gov/fdsys/pkg/FR-2011-08-04/html/2011-19488.htm

2. Download the NHPCO instructions for using the Comfortable Dying measure (EROM Manual) http://www.nhpco.org/i4a/pages/Index.cfm?pageID=3376

43 February 2012

http://www.gpo.gov/fdsys/pkg/FR-2011-08-04/html/2011-19488.htm


http://www.nhpco.org/i4a/pages/Index.cfm?pageID=3376










3. Start using the “Comfortable Dying” measure as soon as possible

MUST collect data as of 10/1/2012– Integrate into your more comprehensive pain

assessment and pain management procedures– Train and retrain - Assure that staff understand

The purpose of the measure Data collection and data recording procedures How to use the data to achieve optimal pain

management outcomes

– Think of the medical record as a data source AND a tool for optimizing outcomes

3. Start using the “Comfortable Dying” measure as soon as possible

MUST collect data as of 10/1/2012– Integrate into your more comprehensive pain

assessment and pain management procedures– Train and retrain - Assure that staff understand

The purpose of the measure Data collection and data recording procedures How to use the data to achieve optimal pain

management outcomes

– Think of the medical record as a data source AND a tool for optimizing outcomes



4. Consider participating in a performance measurement system to obtain comparative data

– NHPCO DART system (NHPCO members only) – Quality Navigator – Deyta, LLC– Others

5. Monitor your results and conduct a PIP if necessary

4. Consider participating in a performance measurement system to obtain comparative data

– NHPCO DART system (NHPCO members only) – Quality Navigator – Deyta, LLC– Others

5. Monitor your results and conduct a PIP if necessary



6. Check out the NQF endorsed measureshttp://www.qualityforum.org/Measures_List.aspx

7. Structural Measure– Define your list of measures– Confirm current measures and definitions

6. Check out the NQF endorsed measureshttp://www.qualityforum.org/Measures_List.aspx

7. Structural Measure– Define your list of measures– Confirm current measures and definitions

http://www.qualityforum.org/Measures_List.aspx





Becky VanVorst, MSPH

Director of Education and Data Analytics

Deyta, LLC

[email protected]

518.753.8003 direct

518.956.3531 cell

Becky VanVorst, MSPH

Director of Education and Data Analytics

Deyta, LLC

[email protected]

518.753.8003 direct

518.956.3531 cell

©copyright deyta, llc, all rights reserved the path to hospice public reporting rebecca van vorst,...

Documents

hospice quality measures

cms public reporting

required reporting

copyright deyta

quality vision

hospice roadmap slide

quality data available

future reporting requirements