Hospice Quality Reporting Program

Hospice Quality Reporting Program

 CMS Releases Final Rule on FY2014 Hospice Wage Index (con’t)
August 6, 2013

Summary of the Provisions of the Final Rule

B. Hospice Quality Reporting Program

Quality Measures for Data Submission in CY2013 for Payment Year FY2015

Hospice providers will continue to collect data on two quality measures in CY2013:

  1. Structural measure: participation in a quality assessment and performance improvement (QAPI) program that includes at least three quality indicators related to patient care.
  2. NQF #0209: pain management.

This data collection submission will be due no later than April 1, 2014 for CY2013. Hospices failing to report quality data before the specified deadline in 2013, will have their market basket update reduced by 2 percentage points in FY 2015. Hospice programs will be evaluated for purposes of the quality reporting program based on whether or not they submit data, and not based on their performance level on required measures.

Quality Measures for Data Submission in CY2014 for Payment Year FY2016 and Beyond

CMS is making changes in the data to be collected in calendar year 2014 (CY2014). The following hospice quality measures will be discontinued for data collection in CY2014:

  1. Structural measure: participation in a quality assessment and performance improvement (QAPI) program. CMS reminds providers that the requirements regarding QAPI in the Medicare Hospice Conditions of Participation remain intact.
  2. NQF #0209: pain management.

Hospices should continue to collect data for these two measures through December 31, 2013.

New Hospice Quality Reporting Requirements for CY2014

Seven new quality measures will be implemented in 2014. In order to support the standardized collection and calculation of these new measures collection of the data elements hospices will be required to use a standardized data collection instrument. For each patient admitted on or after July 1, 2014, completion of a standardized Hospice Item Set (HIS) will be required on admission and on discharge. Data will be collected on every patient, regardless of payer source.

The measures are:

Data Collection

Data
ubmission

Annual Payment Update Year (APU) Impact

Measure Name

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1634: Hospice and Palliative Care – Pain Screening

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1637: Hospice and Palliative Care – Pain Assessment

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1639: Hospice and Palliative Care – Dyspnea Screening

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1638: Hospice and Palliative Care – Dyspnea Treatment

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1617: Patients Treated with an Opioid who are Given a Bowel Regimen

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1641: Hospice and Palliative Care – Treatment Preferences

7/1/2014 –

12/31/2014

Rolling

FY 2016

(10/1/2015)

NQF #1647: Beliefs/Values Addressed (if desired by patient) modified

Rolling Data Submission: Data submission will be rolling, meaning that data will be submitted electronically on each patient admission or discharge using the approved submission methods as patients are admitted and discharged. All data will be submitted electronically; no other data submission option will be available.

HIS Use: The HIS is a set of data elements that can be used to calculate 7 NQF endorsed quality measures. The HIS is not a patient assessment and it will not be administered to the patient and/or family or caregivers during the initial assessment visit. The HIS is not intended to replace a hospice’s current initial and comprehensive patient assessment.

Use of Discharge HIS: The discharge HIS is needed to provide an end date for the episode of care, and to establish the length of stay exclusion for patients whose hospice stay was less than 7 days.

Mandatory Submission: Submission of the HIS on all patients admitted to hospice, regardless of payer, is expected. The data submission system will include validation and receipt processes that will serve as evidence of submission. Hospices failing to report quality data via the HIS in 2014 will have their market basket update reduced by 2 percentage points in FY 2016. Hospice programs will be evaluated for purposes of the quality reporting program based on whether or not they submit data, not on their performance level on required measures.

Software Available: CMS will provide free software for the HIS. A beta version of the software will be available in May 2014 for download to allow hospice staff to become familiar with the functionality of the tool. CMS will also provide training on the CMS HIS software and the submission process, sometime in the spring of 2014. In cases where a hospice has purchased vendor software and the product is not available by July 1, 2014, the hospice may download the CMS software and submit records to the Quality Improvement and Evaluation System (QIES) Assessment and Submission Processing (ASAP) system as required.

Performance Reports: CMS and its contractors will also provide reports to individual hospices on their performance on the measures calculated from data submitted via the HIS. The specifics of the reporting system and precisely when specific measures will be made available have not yet been determined.

More Information: CMS will be issuing guidance and training materials, including a detailed user guide, to hospices prior to implementation of the HIS. Watch for more information in postings on the Hospice Quality Reporting Program (HQRP) webpage, Open Door Forums, announcements in the CMS E-News, provider training and national provider calls.

Public Reporting

The Affordable Care Act (ACA) requires that hospice quality reporting be made public on a CMS website and that providers have an opportunity to review their data prior to public reporting. CMS states in this final rule that they will develop the infrastructure for public reporting and a mechanism for hospice review of data. Data that is collected during the first three quarters of CY2015 will be analyzed to determine whether some or all of the quality measures will be made publicly available. CMS anticipates that public reporting will not be implemented in FY2016.

CMS Hospice Experience of Care Survey

CMS has developed a Hospice Experience of Care Survey questionnaire, drawn heavily on questions in the Family Evaluation of Hospice Care (FEHC). The survey will include survey administration protocols that will allow comparisons across hospices, and will include topics important to hospice users and demographic characteristics of the patients and their caregivers. Field testing of the survey will be conducted in the fall of 2013 in both English and Spanish.

CAHPS: The Hospice Experience of Care Survey joins the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of surveys, which focuses on patient perspectives on the experience of care, rather than on patient satisfaction. Currently CAHPS surveys are available for hospitals and home health agencies. Hospices interested in viewing similar model websites are encouraged to visit the hospital HCAHPS website at www.hcahpsonline.org or the home health HHCAHPS website .

Mandatory survey: To meet the quality reporting requirements for the FY2017 annual payment update year, all hospices will be required to conduct a “dry run” of the survey for at least one month in January, February or March 2015. Beginning in April 2015, all hospices will be required to participate in the survey. Participation in he “dry run month” and the nine months from April through December 2015 will be required as a part of quality data submission requirements to receive the full annual payment update (APU) for FY2017.

Very small hospices: Hospices that have fewer than 50 unduplicated or unique deceased patients in the period from January 1, 2014 through December 31, 2014 will be exempt from the Hospice Experience of Care Survey data collection and reporting requirements for the FY 2017 payment determination. The hospices would be required to submit their patient counts for the period of January 1, 2014 through December 31, 2014 to CMS on a participation exemption form that will be detailed in the summer of 2014.