Hospice Outcome Measures June 28, 2018

Current Florida Hospice Outcome Measures FAC 58A-2.005 (4) Outcome Measures. Hospices must annually report on outcome measures outlined on DOEA Form H-002, State of Florida Department of Elder Affairs Hospice Demographic and Outcome Measures Report. The reporting time frame is January 1 through December 31 The report must be submitted to DOEA no later than March 31 of the following year In addition to the outcome measure regarding pain management each hospice must conduct the National Hospice and Palliative Care Organization (NHPCO) Patient/Family Satisfaction Survey, or a similar survey, with its patients and families. *The form is currently incorporated by reference and may be obtained from the department’s Web site at: http://elderaffairs.state.fl.us/english/hospice/DOEAformH002.xls *The form DOEA H002 will need to be updated to accommodate change in outcome measures *The survey now must match the Federal HIS and CAHPS

Current Florida Hospice Measures DOEA Form H-002 OUTCOME MEASURE 1   Number 1) Total number of patients reporting pain on a 0-to-10 scale at time of admission to the hospice program. 2) Of the patients reporting pain, the number of patients who reported severe pain (7 or higher) at time of admission to the hospice program. 3) Of the number of patients reporting severe pain at admission, the number of patients who reported a reduction in pain level to 5 or less by the end of the 4th day of care in the hospice program. 4) Of the number of patients reporting severe pain at admission, the number of patients who continually reported pain level of 6 or higher by the end of the 4th day of care in the hospice program. 5) Of the number of patients reporting severe pain at admission, the number of patients who were unable to report pain level by the end of the 4th day due to death/discharge, transfer, or disease progression. OUTCOME MEASURE 2 Patient/Family Satisfaction Survey Question: Did the patient receive the right amount of medicine for his or her pain? Total number of surveys initiated during the reporting period. Total number of survey responses received during the reporting period. Number of survey responses received during reporting period indicating the patient received the right amount of medicine for his or her pain. Number of survey responses received during the reporting period indicating the patient did not receive the right amount of medicine for his or her pain. OUTCOME MEASURE 2A Patient/Family Satisfaction Survey Question: Based on the care the patient received, would the patient and/or responsible party recommend hospice services to others? Number of survey responses received during the reporting period answering “yes” to this survey question. Number of survey responses received during the reporting period answering “no” to this survey question. The form currently looks like this

Current Florida Hospice Measures (continued) The Affordable Care Act (ACA) requires that the Centers for Medicare and Medicaid Services (CMS) use nationally endorsed quality measures in the Hospice Quality Reporting Program (HQRP). Medicare certified hospices are currently required to use and submit patient-level data to CMS for the following seven measures endorsed by the National Quality Forum (NQF): NQF #1617 - Opioid/Bowel NQF #1634 - Pain Screening NQF #1637 - Pain Assessment NQF #1638 - Dyspnea Treatment NQF #1639 - Dyspnea Screening NQF #1641 - Treatment Preferences NQF #1647 - Beliefs and Values Addressed Hospice Quality Reporting Program (HQRP), mandated by the Affordable Care Act of 2010. Section 3004 of the Affordable Care Act directs the Secretary to establish quality reporting requirements for hospice programs. The Hospice Quality Reporting Program includes data submitted by hospices through the Hospice Item Set (HIS) data collection tool, and an experience of care survey, the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®).

New Hospice Measures 2018 Legislative Session Chapter 2017-119, Committee Substitute for Committee Substitute for Senate Bill No. 474 Be It Enacted by the Legislature of the State of Florida: Section 1. Section 400.60501, Florida Statutes, is amended to read: 400.60501 Outcome measures; adoption of federal quality measures; public reporting; annual report. No later than December 31, 2019, the department (Department of Elderly Affairs), in conjunction with the agency (Agency for Health Care Administration), shall adopt the national hospice outcome measures and survey data in 42 C.F.R. part 418 to determine the quality and effectiveness of hospice care for hospices licensed in the state. The department in conjunction with the agency, shall make available to the public the national hospice outcome measures and survey data in a format that is comprehensible by a layperson and that allows a consumer to compare such measures of one or more hospices.

Change in Survey and Outcome Reporting Florida must soon adopt its hospice quality reporting process to match all Federal outcomes gathered through the federal survey instrument. Pursuant to 42 CFR 418, the following are the current Federal hospice survey outcome measures that will be incorporated into Florida’s reporting process.

Federal Hospice Measures The federal Centers for Medicare and Medicaid Services (CMS) Hospice Quality Reporting Program (HQRP) currently consists of two reporting requirements: HIS - Hospice Item Set CAHPS® - Consumer Assessment of Healthcare Providers and Systems hospice survey Both HIS and CAHPS® data are currently used to calculate performance on hospice quality measures. *HIS data can be used to calculate eight National Quality Forum (NQF)-endorsed measures and one non-NQF-endorsed measure. *The CAHPS® Hospice Survey was considered as a single measure by NQF and endorsed as NQF #2651; CAHPS® data can be used to calculate eight patient experience measures.

9 Quality Measures Calculated Using the HIS (Hospice Item Set) NQF #1617 - Patients Treated with an Opioid who are Given a Bowel Regimen NQF #1634 - Pain Screening NQF #1637 - Pain Assessment NQF #1639 - Dyspnea Screening NQF #1638 - Dyspnea Treatment NQF measures and standards serve as a critically important foundation for initiatives to enhance healthcare value, make patient care safer, and achieve better outcomes. The federal government and many private sector entities use NQF-endorsed measures above all others because of the rigor and consensus process behind them *Patients are excluded from the survey if they are under 18 years of age. 1) Percentage of patient stays treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed. 2) Percentage of patient stays during which the patient was screened for pain during the initial nursing assessment. 3) Percentage of patient stays during which the patient screened positive for pain and received a comprehensive assessment of pain within 1 day of the screening. 4) Percentage of patient stays during which the patient was screened for dyspnea during the initial nursing assessment 5) Percentage of patient stays during which the patient screened positive for dyspnea and received treatment within 1 day of the screening.

9 Quality Measures Calculated using the HIS (Hospice Item Set) NQF #1641 - Treatment Preferences NQF #1647 - Beliefs/Values Addressed (if desired by the patient) Hospice Visits when Death is Imminent NQF #3235 - Hospice and Palliative Care Composite Process Measure /Comprehensive Assessment at Admission *Patients are excluded from the survey if they are under 18 years of age. 6) Percentage of patient stays with chart documentation that the hospice discussed (or attempted to discuss) preferences for life sustaining treatments. 7) Percentage of patient stays with documentation of a discussion of spiritual/religious concerns or documentation that the patient and/or caregiver did not want to discuss spiritual/religious concerns. 8) This measure is a measure pair assessing hospice staff visits to patients at the end of life. Measure 1: Percentage of patients receiving at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life. Measure 2: Percentage of patients receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides in the last 7 days. Exclusions Measure 1: Patients are excluded from the survey if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 3 days of life. Exclusions Measure 2: Patients are excluded from the survey if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 7 days of life, or had a length of stay of one day. 9) Percentage of patient stays during which the patient received all care processes captured by quality measures NQF #1617, NQF #1634, NQF #1637, NQF #1638, NQF #1639, NQF #1647, NQF #1641, as applicable

Hospice CAHPS® (Consumer Assessment of Healthcare Providers and Systems) The CAHPS® Hospice Survey is considered as a single measure by NQF and endorsed as NQF #2651. The Hospice CAHPS® is a customer satisfaction survey for hospice providers. It is a standardized survey that will be conducted with the family members or close friends of deceased recipients of hospice care. * It is also called the CAHPS® Hospice Survey. It was previously called the Hospice Experience of Care Survey. *The Hospice CAHPS® survey is part of a family of surveys that spans across many different levels of care. CAHPS® stands for Consumer Assessment of Healthcare Providers and Systems. This family of surveys belongs to the Agency for Healthcare Research and Quality (AHRQ) a branch of the US Department of Health & Human services.

Measures calculated from the CAHPS® Hospice Survey Communication with family Getting timely help Treating patient with respect Emotional and spiritual support Help for pain and symptoms Training family to care for patient Rating of this hospice Willing to recommend this hospice if adequate communication was received from the hospice to the family if hospice responded timely to questions and requests made by the family if family indicates the patient was treated with dignity and felt cared for by the hospice did family receive emotional counsel and were spiritual beliefs acknowledged by the hospice? was loved helped by the hospice with pain, breathing, constipation, anxiety? were side effects of pain meds, help with breathing, or how to address agitation discussed and addressed with family? From 1 to 10 (worst to best) Yes or no, if yes, how definitely; if no, why not.

Resources Medicare.gov: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/Current-Measures_121117.pdf Florida Department of Elder Affairs – Hospice Demographics and Outcome Measures http://elderaffairs.state.fl.us/doea/Evaluation/2017_Hospice_Report.pdf The Florida Legislature: http://www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=400.60501&URL=0400-0499/0400/Sections/0400.60501.html The Florida Administrative Code & Florida Administrative Register: https://www.flrules.org/gateway/ChapterHome.asp?Chapter=58A-2

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