CMS Hospice Quality Reporting Program: Challenges & Opportunities

Transcription

1 1 CMS Hospice Quality Reporting Program: Challenges & Opportunities Carol Spence, PhD, RN National Hospice and Palliative Care Organization TODAY WE WILL COVER: Changes to HIS data collection CMS quality measures for hospices Requirements for compliance with HQRP Public reporting (Hospice Compare) 2 1

2 HIS CHANGES 3 NEW ITEMS 4 2

3 HIS NEW ITEMS Patient Zip Code Admission Record Section A: A0550 Address where patient resides while receiving hospice services May not be permanent, usual or legal residence PATIENT ZIP CODE 3

4 HIS NEW ITEMS Patient Zip Code - Examples Patient usually lives in Miami. She has moved in with daughter in San Diego. Code for the daughter s home in San Diego. Patient s home is in Alexandria, VA. He is admitted to the hospice s inpatient unit in Aldie, VA. Code for the inpatient unit. HIS NEW ITEMS Admission Record Section A: A1400 Payor Information All current payment sources - regardless if will be paying for hospice care Do not include pending/applied for sources 4

5 HIS NEW ITEMS HIS NEW ITEMS Payor Information Self Pay Select if patient is paying for any of their own medications, supplies, services, etc. Examples may include, but are not limited to: medications the patient may pay for out of pocket, respite level of care beyond what is allowed under the Hospice Benefit, and room and board. 5

6 HIS NEW ITEMS Scenario: Mrs. Jones has Medicare A,B and D plus a Medicare supplemental plan. She pays for her over-counter medications herself. Question: What should you code for A1400? PAIN ACTIVE PROBLEM J0905 Pain Active Problem The pain active problem skip pattern replaces the prior pain screening skip pattern. Skip J0910 (Comp Pain Assess) based on whether pain is an active problem, not whether the patient has current pain at the time of the screening. 6

7 HIS NEW ITEMS PAIN ACTIVE PROBLEM Select YES for J0905 if patient denies pain when asked screening question, BUT Patient is taking medication to treat pain Reports recent symptoms Pain is present intermittently under specific circumstances Recent treatment other than medication (e.g., nerve block) 7

8 HIS NEW ITEMS J2030 Screening for Shortness of Breath C. Did the screening indicate the patient had shortness of breath? Can code yes for active problem for the patient even if shortness of breath not present during assessment Based on reports of recent symptoms, current treatment, and patient/family history SCREENING FOR SHORTNESS OF BREATH Example: Mr. Brown denies shortness of breath at assessment while sitting in a chair, but reports dyspnea with stair climbing. Code Yes for J2030C: Did the screening indicate the patient had shortness of breath? (and there is evidence that severity was rated) 8

9 SCREENING FOR SHORTNESS OF BREATH I Scenario: As documented in the initial nursing assessment, Ms. Scarlett denies shortness of breath on assessment, but uses O 2 at night and sleeps with two pillows. Question: How should you code J2030C? PAIN ACTIVE PROBLEM I Scenario: Mr. Smith denies pain but has a comfort kit in the home and has not yet taken any medication in the kit for pain. Question: How should you code J0905? 9

10 HIS NEW ITEMS Section O HIS NEW ITEMS 10

11 HIS NEW ITEMS Section O Service Utilization Discharge record Only for discharge due to death Only for RHC level of care Patient discharges on and after April 1, 2017 HIS NEW ITEMS Section O 4 additional items Level of Care Items O5000: LoC in final 3 days O5020: LoC in final 7 days Visit Items O5010: Visits in final 3 days O5030: Visits in 3 6 days before death 11

12 Visit Items HIS NEW ITEMS Section O O5010: Visits in final 3 days O5030: Visits in 3 6 days before death Both items ask about the same types of visits from the same disciplines (Registered Nurse, Physician, Nurse Practitioner, Physician Assistant, Medical Social Worker, Chaplain or Spiritual Counselor, Licensed Practical Nurse, and Aide). HIS NEW ITEMS Do Count visits to family Do NOT Count phone calls Count post mortem visits 12

13 HIS NEW ITEMS Section O Scenario: Patient A admitted 2/4/17 in nursing home on RHC. Died 4/15/17. Question: How should Section O be completed? HIS NEW ITEMS Section O Scenario: Patient B admitted 4/5/17 at home on RHC. Went to hospital 4/7/17 and revoked. Readmitted on 4/9/17 to hospice inpatient unit on GIP. Died there on 4/12/17. Question: How should Section O be completed? 13

14 HIS NEW ITEMS REMember HIS is a data collection tool HIS data are used to calculate quality measure scores HIS NEW ITEMS REMember Measure specifications (numerator and denominator) and HIS data elements may not be the same Do not confuse instructions for completing the HIS record with how the measure is calculated 14

15 HIS NEW ITEMS REMember More data are collected in HIS than are used in calculating the measures. 30 QUALITY MEASURES (QMs) 15

16 CURRENT HIS MEASURES CURRENT HIS MEASURES 16

17 HIS MEASURE EXCLUSIONS Measure scores are not calculated for patient stays if: Patient is under 18 years of age Discharge record but no admission record Admission record but no discharge record CURRENT HIS MEASURES REMember Patients with length of stay less than 7 days are no longer excluded from the measures. In other words, patients are included regardless of length of stay 17

18 PAIN ASSESSMENT MEASURE NQF #1637 Measure Specifications: Patients who screen positive for pain Received a comprehensive pain assessment within 1 day of the pain screening Pain assessment included at least 5 of the assessment elements PAIN ASSESSMENT MEASURE Comprehensive Assessment Definition Included at least five of the following characteristics: location, severity, character, duration, frequency, what relieves or worsens the pain, and the effect on function or quality of life. 18

19 PAIN ASSESSMENT MEASURE Keep in Mind Mark each characteristic for which the clinician documented an attempt to gather the information, even if no information was obtained Report can be from the patient, caregiver (informal or paid), or observation PAIN ASSESSMENT MEASURE Keep in Mind Mark Yes that Comprehensive Pain Assessment was done as long as o o at least 1 pain characteristic was assessed even if date of assessment was more than one day after positive pain screening (Example of data collection protocol not matching measure specifications) 19

20 NEW HIS MEASURES COMPOSITE MEASURE Percentage of patients who received care processes in 7 current HIS measures Admissions on and after April 1, 2017 No additional data collection needed 20

21 COMPOSITE MEASURE Denominator All discharged patients except: Admission record missing Active stays (still receiving care) Under 18 years old on admission date COMPOSITE MEASURE Numerator Patient stays in the denominator where the patient received all 7 care processes which are applicable to the patient at admission, as captured by the current HQRP quality measures 21

22 COMPOSITE MEASURE COMPOSITE MEASURE Numerator Criteria Pain Screening: The patient was screened for pain within 2 days of the admission date and the patient reported they had no pain, or pain severity was rated and a standardized pain tool was used. 22

23 COMPOSITE MEASURE Numerator Criteria Pain Assessment: Comprehensive pain assessment within 1 day of the initial nursing assessment during which the patient screened positive for pain and included at least 5 of 7 pain characteristics. COMPOSITE MEASURE Numerator Criteria Dyspnea Screening: The patient was screened for shortness of breath within 2 days of the admission date. 23

24 COMPOSITE MEASURE Numerator Criteria Dyspnea Treatment: Treatment for shortness was initiated within 1 day of the initial nursing assessment during which the patient screened positive for shortness of breath. COMPOSITE MEASURE Numerator Criteria Bowel Regimen: There is documentation that a bowel regimen was initiated or continued, or why a bowel regimen was not initiated, within 1 day of a scheduled opioid being initiated or continued. 24

25 COMPOSITE MEASURE Numerator Criteria Preferences and Beliefs/Values Addressed : No more than 7 days prior to or within 5 days of the admission date. COMPOSITE MEASURE Status Currently undergoing review for endorsement by NQF NQF #3235 Recommended by NQF Palliative/End-of-Life Care Standing Committee Expect to see Composite Measure in public reporting in

26 VISITS WHEN DEATH IS IMMINENT Measure Pair Measure 1 RN, MD, NP, PA Visits in last 3 days of life (at least 1) Measure 2 SW, Chaplain, LPN, hospice aide Visits in last 7 days of life (at least 2) Do VISITS WHEN DEATH IS IMMINENT Count visits to family as well as patient Clinical encounters with RHC patients in an inpatient hospice setting count any visit that requires documentation (up to 9 per discipline for each day) Count visits by two clinical staff occurring at the same time 26

27 VISITS WHEN DEATH IS IMMINENT Do Not Count phone calls Count post mortem visits If patient is still alive when the clinician arrives and dies during the visit, the visit counts If patient is dead when clinician arrives, do not count the visit VISITS WHEN DEATH IS IMMINENT Denominator All discharged patients except: Discharge other than death Received Continuous Care, GIP, Respite (in measure timeframe) Admission record missing LOS of 1 day Measure 2 only* 27

28 VISITS WHEN DEATH IS IMMINENT Numerator Measure 1: Patients in denominator who received at least one visit from RN, MD, NP, or PA in last 3 days of life Measure 2: Patients in denominator who received at least two visits from SW, Chaplain, LPN, hospice aide in last 7 days of life VISITS WHEN DEATH IS IMMINENT Status Data collection just started need 1 year for analysis NQF endorsement submission TBD Public reporting after NQF endorsement 28

29 VISITS WHEN DEATH IS IMMINENT Scenario: Colonel Mustard, a resident at Tudor Mansion Nursing Home, was admitted to hospice services under RHC on 3/31/17 and died on 4/4/17. He received the following visits: RN 3/31; 4/1; 4/3; 4/4 Hospice Aide: 4/2 Volunteer: 4/3/;4/4 Question: What is the hospice s performance on the Visit When Death is Imminent measure pair? HOSPICE CAHPS MEASURES 29

30 CAHPS SURVEYS CAHPS = Consumer Assessment of Healthcare Providers and Systems Family of standardized surveys (hospitals, home health care agencies, doctors, and health and drug plans, etc.) Rigorous development process Tested for validity and reliability Goal = survey results comparable across users. 59 CAHPS SURVEYS Focus: patient experience of care Content: What patients say is important to them For which patients are the best and/or only source of information

31 CAHPS SURVEYS Satisfaction survey deals with expectations for care Experience of care survey report on specific aspects of care 61 CAHPS SURVEYS Reports of Specific Experiences Ratings of Care 62 31

32 CAHPS SURVEYS Whether, or how often, specific events or behaviors that are indicators of health care quality occurred Reports about events and behaviors are more meaningful and actionable than general ratings 63 HOSPICE CAHPS SURVEY Consistent with externally validated aspects of hospice care (e.g., NQF preferred practices). Capture patient and/or caregiver experience, rather than care processes that may be measured by other sources of data. Be under the control of the hospice provider. 32

33 HOSPICE CAHPS SURVEY Use language that most respondents find easy to understand. Be clear about the time frames that respondents area asked to assess. Use screener questions to identify the denominator of respondents who can report on experiences that may not be universal HOSPICE CAHPS SURVEY 47 items long 3 modes of survey administration: Mail only Telephone only Mixed mode (mail with telephone follow-up) Up to 15 additional questions chose by hospice 33

34 HOSPICE CAHPS MEASURES Eight Measures using Hospice CAHPS survey as data source Six composite measures (combined score from 2 or more survey items) Two global measures (single items) Measures received NQF endorsement in 2016 HOSPICE CAHPS MEASURES Composite Measures Hospice Team Communication (6 items) Getting Timely Care (2 items) Treating Family Member with Respect (2 items) Getting Emotional and Religious Support (3 items) Getting Help for Symptoms (4 items) Getting Hospice Care Training (5 items) 34

35 HOSPICE CAHPS MEASURES Global Measures Rating of Hospice (1 item) Willingness to Recommend (1 item) HOSPICE CAHPS RESOURCES Measures with Items: CAHPS Hospice Survey Fact Sheet January 2017 Help: or (844)

36 CAHPS HOSPICE MEASURE RESULTS SCORING Top Box Scores proportion of best/positive response to a survey item Composite Measure scores average of top box scores for all items in the measure Global Measure scores proportion of 9-10 or Definitely Yes responses CAHPS HOSPICE MEASURE RESULTS Risk Adjustment SCORING Takes into account factors not in control of the hospice Patient Mix respondent characteristics Mode mode adjustment value added/subtracted for mail-only and mixed 36

37 CAHPS HOSPICE MEASURE RESULTS Provider Preview Reports in CASPER prior to Hospice CAHPS measure results inclusion in Hospice Compare Unadjusted scores (percentages) may differ from final risk adjusted scores CAHPS HOSPICE MEASURE RESULTS How to go about performance improvement? 37

38 CAHPS HOSPICE MEASURES Become familiar with all of the questions on the survey Consider what aspect of care and hospice practice each question reflects CAHPS HOSPICE MEASURES Look for opportunities for improvement using unadjusted results 38

39 CAHPS HOSPICE MEASURES Yes Definitely/Yes Somewhat/No Yes Definitely Yes Somewhat No N % N % N % Q 18 Side effects of pain medicine discussed 10 10% 15 15% 75 75% CAHPS HOSPICE MEASURES Determine which opportunities for improvement should be your focus based on your hospice s standard of care. 39

40 CAHPS HOSPICE MEASURES Yes Definitely/Yes Somewhat/No Yes Definitely Yes Somewh at No N % N % N % Q 16 As much help with pain as needed 70 70% % % If 3 in 10 persons responded with the less than best response for a question, is that the goal that you want to set for your hospice program? CAHPS HOSPICE MEASURES Examine your respondent population Compare respondent population to total population served 40

41 DON T Do not make evaluations based on too little data Results from a small number of surveys may not accurately reflect performance. Use a timeframe (e.g., calendar quarters) that will allow meaningful evaluation of trends in scores DON T Do not assume your vendor s comparison data are the same as national data Check CMS national results against vendor s Directory/National-CAHPS-Hospice-Surveydata/sj42-4yv4 41

42 CMS Support Web site: Telephone: COMPLIANCE 42

43 HQRP REQUIREMENTS Two current requirements for HQRP: Hospice Item Set (HIS). CAHPS Hospice Survey. All Medicare-certified hospice providers must comply with these two reporting requirements. HQRP REQUIREMENTS PAY FOR PARTICIPATION Submitting data determines compliance with HQRP requirements Failure to comply = market basket update (also known as the Annual Payment Update, or APU) reduced by 2 percentage points. 43

44 HQRP COMPLIANCE HIS Submission Through QIES ASAP system Must be successfully accepted by system within 30 calendar days of the event date 30 calendar days from the Admission Date (A0220) No later than 30 calendar days from the Discharge Date (A0270) HQRP COMPLIANCE HIS Submission SUBMITTED does not mean that the HIS Records are ACCEPTED Need to check final validation reports in CASPER 44

45 HQRP COMPLIANCE Final Validation Reports Review each one to determine the status of each submitted record. Fatal Error = Rejected status: Not saved into the system. Correct and resubmit Records with Warning messages are accepted and saved are saved into the QIES ASAP system, even if there are Warning messages associated with them. HQRP COMPLIANCE Final Validation Reports Evaluate warnings and take necessary corrective actions! An error identified in an accepted HIS record must be corrected. Modification Request Inactivation Request 45

46 HQRP COMPLIANCE RESOURCES Hospice User Guides and Training Hospice Quality Reporting Training Downloads April 2017 Data Submission and Reporting Webinar pdf Technical Help Desk or HQRP COMPLIANCE HIS Submission Timeliness % of HIS Records Submitted on Time = The number of HIS records in the numerator divided by the number of HIS records in the denominator, multiplied by 100 rounded to the nearest whole number. 46

47 HQRP COMPLIANCE HOSPICE CAHPS SURVEY Contract with an approved survey vendor to collect and submit data using the CAHPS Hospice Survey on an ongoing monthly basis. Hospice responsible to see that vendor is in compliance HQRP COMPLIANCE 47

48 HQRP COMPLIANCE The HIS reporting cycle spans three years. FY 2018 Reporting Year data collection and submission in calendar year 2016 Compliance determinations in 2017 Payment impact for the fiscal year 2018 APU. HQRP COMPLIANCE SUBMISSION THRESHOLDS APU Year Data Submission % Required FY 2018 (1/1/16 12/31/16) 70% FY 2019 (1/1/17 12/31/17) 80% FY 2020 (1/1/18 12/31/18) 90% 48

49 97 PUBLIC REPORTING HOSPICE COMPARE CMS HOSPICE COMPARE WEBSITE Search for Medicare certified hospice providers based on provider name and/or service area Provider quality information Launch late summer 2017 (website still under construction) 49

50 HOSPICE COMPARE INAUGURAL RELEASE Will include: 7 current HIS measures Individual scores National average scores Based on 12 months of data: Discharges Q (10/1/15) through Q (9/30/16) HOSPICE COMPARE INAUGURAL RELEASE HIS QMs on Hospice Compare 2017: Treatment Preferences (NQF #1641) Beliefs/Values Addressed (modified NQF #1647) Pain Screening (NQF #1634) Pain Assessment (NQF #1637) Dyspnea Screening (NQF #1639) Dyspnea Treatment (NQF #1638) Opioid and Bowel Regimen (NQF #1617) 50

51 HOSPICE COMPARE INAUGURAL RELEASE Will NOT include State level scores Star ratings Hospice CAHPS scores Composite Measure scores Visit When Death Imminent Measures HOSPICE COMPARE HOSPICE CAHPS First Refresh in 2018 scheduled to include CAHPS results Data from patient deaths 4/1/2015 3/31/2017 No scores if < 30 completed surveys during reporting period 51

52 Results suppressed for: HOSPICE COMPARE Hospices with a QM denominator size of fewer than 20 patient stays (based on 12 rolling months of data) Data not available (Medicare certified < 6mos or not submitted) Provider request (circumstances beyond control) HOSPICE COMPARE Refresh Quarterly Rolling 12 months of data Discharges Q through Q Discharges Q through Q Discharges Q through Q

53 HOSPICE COMPARE PROVIDER PREVIEW REPORTS Hospice providers must have opportunity to preview quality data that is to be made public prior to such data being made public (in ACA). Show quality measure performance results that will appear on Hospice Compare website HOSPICE COMPARE PROVIDER PREVIEW REPORTS 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 First reports available June 1,

54 HOSPICE COMPARE PROVIDER PREVIEW REPORTS HOSPICE COMPARE INITIAL PROVIDER PREVIEW REPORT Available for 60 days Download and save (same as other CASPER reports) 54

55 HOSPICE COMPARE INITIAL PROVIDER PREVIEW REPORT Hospice's Observed Percent (score) National Rate (national average percent) Scores calculated without the 7 day LOS exclusion Provider Reports and Hospice Compare website will NOT include percentiles! HOSPICE COMPARE PROVIDER PREVIEW REPORTS 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. 55

56 HOSPICE COMPARE PROVIDER PREVIEW REPORTS 30 days to review Provider Preview reports for accuracy. Review period begins the day the reports are issued in CASPER system folders. Initial reports 6/1/17 6/30/17 HOSPICE COMPARE PROVIDER PREVIEW REPORTS Once the Preview Reports are generated data are frozen. Cannot make corrections in results or underlying data in the Preview Report 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) 56

57 HOSPICE COMPARE CMS REVIEW REQUEST Submit request via Subject line: [Provider/Facility Name] Hospice Public Reporting Request for Review of Data followed by CCN Send to: HOSPICE COMPARE CMS REVIEW REQUEST Requirements for submitting request HQRP web site Hospice Quality Reporting section (left menu) 57

58 HOSPICE COMPARE PROVIDER PREVIEW REPORTS 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. NHPCO REGULATORY AND QUALITY TEAM us at: regulatory@nhpco.org or quality@nhpco.org

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