Program Objectives Hospice Compare

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1 Program Objectives Hospice Compare March 27, 2018 Jennifer Kennedy, EdD, MA, BSN, RN, CHC, NHPCO Kristi Dudash, MS, NHPCO National Hospice and Palliative Care Organization Describe the CASPER reports available for hospice providers and how to access and interpret them Identify the relationship between selected CASPER reports and organizational practices Determine effective approaches to using CASPER reports to improve performance in Hospice Compare The CASPER Reporting Application Certification and Survey Provider Enhanced Reporting (CASPER) The CASPER Reporting application enables you to connect electronically to the National Reporting Database. It contains a variety of useful reports for hospice providers. Accessing CASPER Reports The link to the CASPER Reporting application is available on the Welcome to the CMS QIES Systems for Providers web page. Provider should monitor the webpage frequently. Updates posted on a regular basis Note: NHPCO does not have access to the QIES system or CASPER reports. Hospice Reports in CASPER Hospice Provider Report Category NOTE: Hospice Provider reports are automatically purged after 60 days. COMPLIANCE Hospice CASPER Reports Examples: Provider Final Validation Reports Provide Threshold Reports PERFORMANCE Examples Quality Measure Reports (Hospice Compare) 1

2 Hospice Item Set Print CASPER REPORTS Hospice Item Set Submission Statistics by Provider Hospice Item Sets Submitted Hospice Roster Hospice Submitter Final Validation Report CASPER REPORTS HIS Record Error Detail by Provider HIS Record Errors by Field by Provider HIS Records with Error Number XXXXX Hospice Admissions Hospice Discharges Hospice Error Number Summary by Provider by Vendor The HIS Record Error Detail by Provider Reports for Compliance Monitoring This report lists the fatal errors and warning messages received by all HIS records that were successfully processed during a specified period. Essential for compliance monitoring. Hospice Final Validation Provides detailed information about the status of the select submission files. The report indicates whether the records submitted in each were accepted or rejected and details the warning messages and fatal errors encountered. Admissions Report The Hospice Admissions report is one that can be used to quickly do a check to determine if the admission records submitted to CMS closely match the number of hospice admissions during the specified time frame. 2

3 Discharge Report The Hospice Discharges report is one that can be used to quickly do a check to determine if the discharge records submitted to CMS closely match the number of hospice discharges during the specified time frame. Hospice Item Set Submission Statistics by Provider Tracks the number of Records processed, rejected and accepted for the agency. Easy way to track the overall for a specific date range. Patient Stay Level Report Provides the ability to see what patients who have been discharged are missing an Admission record Hospice Submitter Final Validation Report Provides detailed information about the status of a select submission file. Indicates whether the records submitted were accepted or rejected and details the warning messages and fatal errors encountered. Hospice Timeliness Compliance Threshold Report Run by Fiscal Year This one allows you to see if the agency is meeting submission requirements for the year. Reports for Performance Monitoring Important to track since this is currently how market basket payments may be reduced. 3

4 Hospice Level Quality Measure Report User requested, on demand report in CASPER Hospice Quality Reporting Program report category. Hospice Level Quality Measure Report Provides the hospice level quality measure values for the HIS based measures for the requested report period. Includes, per measure, the Numerator, Denominator, Hospice Observed Percent, Comparison Group National Average, and Comparison Group National Percentile. Source: Certification And Survey Provider Enhanced Reports HOSPICE 3 1 CASPER Reporting Hospice Provider User s Guide, 3/20/18 Reported Measures Quality Measures Reported on CASPER QM Reports Hospices are required to submit the appropriate HIS record for each patient admission and discharge, regardless of the patient s payer source, age, or location where the patient receives hospice services. Patients are excluded from the measure if they are under 18 years of age Hospices submit HIS data to CMS through the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Hospice Level Quality Measure Report Enables hospice providers to review their quality measure scores at the hospice level and compare their organization s overall performance to the national average scores. Can assist hospice providers in their quality improvement processes. Identifies which quality measures performed well which quality measures require interventions to improve performance Hospice Level Quality Measure Report Providers can trend their quality measure results by comparing their quality measure scores and percentiles across multiple reporting periods. Trending the quality measure scores enables hospice providers to monitor the progress of the quality improvement interventions. 4

5 Breakdown of Hospice Level Quality Measure Report Hospice Patient Stay Level Quality Measure Report Report is a companion to the Hospice Level Quality Measure Report and drills down to patient stay level information for each quality measure. Report enables hospice providers to review the quality measure outcomes for all patient stays during the reporting period. Source: CMS, Getting Started with Hospice CASPER Quality, Measure Reports: December 2016 Hospice Patient Stay Level Quality Measure Report Should quality measure scores on the Hospice Level Quality Measure Report be less favorable than anticipated, this report can assist a hospice to quickly assess which patient stays contributed to the unfavorable results and then implement care processes to address the issues identified. Hospice Patient Stay Level Quality Measure Report Report can be used to assess quality of care concerns for specific patient populations based upon length of stay. Example use a hospice provider could review cases in which the admission and discharge date were within the same month and year Identify patients in a reporting timeframe did not achieve three or more of the quality measures Determine if there are general quality of care concerns for patients with this length of stay Hospice Patient Stay Level Quality Measure Report This report also indicates when an admission record was not submitted with an HIS discharge record. This information can assist a hospice in identifying when a missing admission record should be submitted to the QIES ASAP system. Penalties for Failure to Report Failure to submit required quality data shall result in a 2 percentage point reduction to the market basket percentage increase for that fiscal year. The HQRP is currently pay for reporting, meaning it is the act of submitting timely and complete data that determines compliance with HQRP requirements. Reporting compliance is determined by successfully fulfilling both the Hospice CAHPS Survey requirements and the HIS data submission requirements. 5

6 Accessed through CASPER Automatically generated and saved Available approximately 8 months after the end of each data collection period CMS will announce when reports are available Current Contents: The seven (7) National Quality Forum (NQF) endorsed Hospice Item Set (HIS) quality measures. The Consumer Assessment of Healthcare Providers & Systems (CAHPS ) Hospice survey information. 30 days to review Provider Preview reports for accuracy. Review period begins the day the reports are issued in CASPER system folders. Last preview report release was 3/1/18 Next preview report release is 6/1/18 HIS Data Freeze Date = 5/15/18 Differences between Provider Reports and Hospice Compare website: The order of the measures may not be the same. The titles of the measure) are not the consumer language titles used for the Hospice Compare website. The numbering of the footnotes on preview report is different. Can still submit HIS modification and inactivation records up to 36 months after the target date. (Target dates: Admission Record = admit date Discharge Record = discharge date) Corrected data will be reflected in future Preview reports and Hospice Compare refreshes. Once the Preview Reports are generated data are frozen. Cannot make corrections in results or underlying data in the Preview Report 6

7 If disagree with performance data (denominator, or quality measure score) in Preview Report, can request review by CMS. Requests for review must be made during 30 day preview period (30 days starting with posting date) CMS will review all requests and provide a response with a decision via . Data that CMS agrees is incorrect will be suppressed for one quarter, and corrected data will be reflected in the subsequent quarterly release (refresh) of quality data on Hospice Compare. CASPER REPORTS What Went Wrong? Were best practice processes followed? Is practice accurately documented? Did data extraction capture everything needed? Were data submitted correctly to CMS? Performance and Hospice Compare HIS data currently reported CAHPS data currently reported Composite measure soon to be reported Visits at the end of life to be reported after NQF approval New measure TBD Using CASPER Reports for Compliance Improvement Assess current processes start to finish Are your processes defined and documented? Did data extraction capture everything needed? Were data submitted correctly to CMS? Are you proactively reviewing CASPER reports to monitor status? Do you understand how the measures are calculated? Using CASPER Reports for Performance Improvement Measure data is an expression of current clinical practice and should not drive clinical practice I.e.: increasing visits at the end of life to influence measure data Look at measure data as one information source for self assessing current performance. Are your staff documenting the assessment comprehensively? Are your staff assessing the patient/family comprehensively? 7

8 Quality Measures Moving Forward There will be more measures added for hospice data collection More measures will appear in Hospice Compare in the future Understand and use all applicable tools/ reports available to you proactively to detect and solve problems before you find them on your Provider Preview Report and eventually Hospice compare NHPCO members enjoy unlimited access to Quality Assistance Feel free to questions to National Hospice and Palliative Care Organization, Quality Questions Send your quality questions to Information Sources CMS Hospice Quality Reporting webpage Hospice Reports for Hospice Providers CMS, September 2015 Getting Started with Hospice CASPER Quality Measure Reports CMS, December 2016 Hospice Provider Reports CMS, March 2018 National Hospice and Palliative Care Organization,