South Carolina Association for Healthcare Quality July 13, 2007 Tamra N. West Director of SC Programs The Carolinas Center for Hospice and End of Life Care

Two State Association Technical Assistance and Support for hospice and end of life care coalitions End of Life Care Initiatives “Helping every community live & die well”

Advance care planning Palliative care Hospice care Bereavement care

Hospice Care in the Carolinas

Hospice 101 Goal is palliative rather than curative Not necessarily a “place” Unit of Care is the patient/family Interdisciplinary Team –RN, SW, CNA, MD, Chaplain, Therapists, Volunteer, Bereavement Counselors Six months or less if disease runs its normal course Wide range of diagnoses – not just cancer Is available in every county in SC Care provided at “home” and in other settings as needed

Hospice 101 (continued) Four levels of Care – routine, general inpatient, inpatient respite and continuous care Paid per diem for all except continuous care Per diem covers staff, related drugs, supplies and equipment, therapists and bereavement services after death Beneficiaries ELECT the hospice benefit and waive other services for the terminal illness – only the beneficiary can revoke and discharges should be minimal Paid for by Medicare, Medicaid, private insurance Hospice must serve without regard for pay source (or lack of)

SC Hospice Data (2006) 81 licensed sites; 61 different providers 8 hospice facilities, 132 beds Available in all counties – avg. 7 per county CON for facility only 64% for-profit, 46% not-for-profit 75% freestanding, 16% hospital based Approx. 50% are accredited, all are licensed, all but 1 are certified

In 2006, SC Hospices : Served over 120,000 patients Served approx. 250,000 family members Provided almost 1.5 million days of care –an increase of almost 400,000 days from 2005 Provided 23,000 days of care in hospice facilities Provided care to over *4,700 residents of nursing homes (*2005 data)

Hospice Patient Data % admitted at home, 16% in NH, 6% in hospital 75% White, 23% African American 89% Medicare, 5% Medicaid, 4% Private Ins 41%/59% Cancer to Non-Cancer diagnosis (44/56 in 2005 and 60/40 in 2001) ALOS 89 days, median LOS 33 days 29% died 180 days 62% died at home, 16% in NH, 10% in hospice facility, 9% in hospital

Why A Hospice Quality Initiative? Current national landscape pointing toward a Hospice Compare National and local concern about variability of hospice care CMS Focus on Quality, Accountability, and Public Disclosure New Conditions of Participation expected in May 2008 (first revision since 1983) To improve patient care – “to measurably show organizational excellence and demonstrate improvement efforts across all aspects of hospice operations and care”

Changing Focus of Proposed Hospice CoPs Past Focus Ensuring that Medicare certified facilities met the structural and procedural standards for patient health and safety Changed Focus Patient centered Emphasizes quality improvement and patient outcomes (QAPI requirements)

Proposed Standards for Hospices “The hospice must develop, implement and maintain an effective, ongoing, hospice- wide, data-driven quality assessment process improvement program”

QAPI Standards (Standards 1 and 2) Program Scope Measure quality (including adverse events) and operations Measurably improve palliative outcomes and EOL support Program Data Drive QAPI with data Monitor and ID opportunities for improvement Timing and detail determined by governing body

QAPI Standard (Standard 3) Program Activities Consider incidence, prevalence, severity Address and prevent adverse events Focus on high risk, high volume, problem prone areas Improve and monitor over time

QAPI Standards (Standards 4 and 5) Performance Improvement Projects Reflect scope and complexity of hospice Document what, why, and how successful Executive responsibilities Define, implement, and maintain QAPI Address quality and patient safety priorities Set patient safety expectations

Past Hospice Quality Focus Hospices have historically relied on anecdotal evidence, less focus on outcome data Good death + Happy family= Quality Most currently do chart reviews, collect and review program data, collect feedback from family and referral source via surveys Many participate in current state and national evaluation efforts

State Efforts Collection and reporting of state hospice data Benchmarking project – optional participation offered to members Provider-friendly Family Evaluation of Hospice Care 2006 Variability of Care Study 2000,2002 and 2004 State Survey on Public Attitudes about End of Life Care 2006 State Pain Survey 1997 and 2007 SC DHHS Hospice Patient Satisfaction survey

National Efforts NHPCO National Data Set Family Evaluation of Hospice Care (FEHC) Family Evaluation of Palliative Care (FEPC) Family Evaluation of Bereavement Services Quality Collaboratives End Outcomes Project (since 2000) –Comfortable Dying –Self-determined Life Closure –Safe Dying –Effective Grieving

The New Quality Initiative Framework The National Hospice and Palliative Care Organization is leading the way with “Quality Partners: Stronger, Together” State organizations and hospice providers and individuals can be “partners” Developed “for hospice, by hospice” Provides tools and resources to help programs assess, monitor and improve care and services

Quality Partners is NHPCO’s national program to assure that all hospice provider organizations deliver quality care to patients and families.

Quality Partners Initiative Goals To give patients and families the quality care they deserve To decrease variability locally and nationally To foster an industry-wide commitment to evidenced based standards To demonstrate hospice care as the “gold standard” in end of life care To shape and improve end of life care

Quality Partners Ten Components Patient & Family Centered Care Ethical Behavior & Consumer Rights Clinical Excellence & Safety Inclusion & Access Organizational Excellence Workforce Excellence Standards Compliance with Laws & Regulations Stewardship & Accountability Performance Measurement

Patient & Family Centered Care Providing care and services that are responsive to the needs and exceed the expectations of those we serve

Ethical Behavior and Consumer Rights Upholding high standards of ethical conduct and advocating for the rights of patients and their family caregivers

Clinical Excellence & Safety Ensuring clinical excellence and promoting safety through standards of practice

Organizational Excellence Building a culture of quality and accountability within the organization that values collaboration and communication and ensures ethical business practices

Workforce Excellence Fostering a collaborative, interdisciplinary environment that promotes inclusion, individual accountability and workforce excellence, through professional development, training, and support to all staff and volunteers

Standards Adopting the NHPCO Standards of Practice for Hospice Programs and/or the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care as the foundation for the organization

Compliance with Laws & Regulations Ensuring compliance with all applicable laws, regulations, and professional standards of practice, and implementing systems and processes that prevent fraud and abuse

Stewardship & Accountability Developing a qualified and diverse governance structure and senior leadership who share the responsibilities of fiscal and managerial oversight

Performance Measurement Collecting, analyzing, and actively using performance measurement data to foster quality assessment and performance improvement in all areas of care and services

Inclusion & Access Promoting inclusiveness in the community by ensuring that all people – regardless of race, ethnicity, color, religion, gender, disability, sexual orientation, age, or other characteristics – have access to hospice programs and services

For Each Component Self assessment checklist Cornerstone document NHPCO Standards, organized by component Resources and tools Background reading Performance Measures

Self Assessment Ability to rate each hospice on a rating scale Each component has a checklist Based on best practices from NHPCO Standards Ability to enter data into a web-based interface and get a printed report

Resources and Tools Technical materials Forms, samples, best practices Links to web resources Helpful articles Links to Info Center with a comprehensive list of journal articles and books

Self-Assessment Reports Provide detailed information based on a five-point scale Allows hospices to compare with others in the state and nationally “Traffic light” indicators indicate and prioritize areas for improvement –Green, Yellow, Red

Goals for Providers Improve care Prepare for surveys and accreditation Prepare for anticipated changes in Hospice Conditions of Participation (May 2008) Meet the anticipated QAPI requirements Build an organization and a team dedicated to quality

The Carolinas Center Response 31 st State “Quality Partner” (Aug.2006) Encourage providers to become “Quality Partners” Deliberately weave “quality” into all current operations and practices – internal operations, board of directors, member education, publications, etc. Focused education efforts beginning in 2007 and throughout 2008 for CEOs, boards, frontline staff Increase member participation in benchmarking opportunities Convene a 2-State Quality Workgroup/Council to work through the process at the state level— assessment, plan, implement

Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents wise choice of many alternatives. William A. Foster

Questions? Tamra N. West The Carolinas Center for Hospice and End of Life Care