1. Presented by: Anne Shelley, MBA, BSN, RN Susan Wallace, MSW, LSW Hospice Quality Reporting Update: June 2014

2. Objective Discuss the updates to hospice quality reporting requirements.

4. Hospice Quality Reporting Program Structural Measure & Comfortable Dying Measure Concluded April 2014 Hospice Item Set July 2014 Hospice Experience of Care Instrument/CAHPS Early 2015

5. What is the HIS? “Item Set” vs. “Standardized Assessment” Based on seven NQF-endorsed measures Treatment preferences (CPR, Hospitalization, Other life- sustaining treatments Beliefs/values addressed Pain screening and assessment (2) Dyspnea screening and treatment (2) Opioid and bowel regimen

12. What is the HIS? Admission & Discharge Completed for ALL patients Submitted on a rolling basis Completed: 14 days from admission, 7 days from discharge Submitted: 30 days from admission/discharge Linked to 2% market basket reduction

13. A NEW Alphabet Soup QIES ASAP RTI NQF HART CASPER QTSO MAP HQRP HIS

14. Measure Development Measures Application Partnership (MAP) National Quality Forum (NQF) Program Design Centers for Medicare & Medicaid Services (CMS) RTI International Measure Collection QIES Technical Support Office (QTSO) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) Hospice Abstraction Reporting Tool (HART) Certification and Survey Provider Enhanced Reports (CASPER)

15. Preparation Research Staff Assignment Medical Records Evaluation, Reconciliation with the HIS Organizational Communication Plan Staff Education Implementation

16. Research http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/Hospice-Quality- Reporting/Hospice-Item-Set-HIS.html http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/Hospice-Quality- Reporting/Hospice-Item-Set-HIS.html HIS Manual Training Slides (2/4 & 2/5) Fact Sheet https://www.qtso.com/hospice.html Registration announcement Technical Training Modules Other announcements https://www.qtso.com/hart.html

17. Staff Assignment Who needs to be involved in planning? QAPI/Compliance Executive Director P&P Interdisciplinary Group Care Managers Administrative staff Preliminary estimate of staff hours required Paper: 40 minutes per patient EMR: 15-20 minutes per patient

18. Medical Records Evaluation, Reconciliation with the HIS Contact EMR vendor Are assessments aligned with HIS items and language? Will reporting mechanisms be fully functional by July? Will reporting mechanisms match CMS expectations? Crosswalk the HIS to your records Time Study

19. Organizational Communication Plan Leadership Resource Allocation/Redistribution Communication to Board Initial Education Plan for Staff Ongoing Education Plan for Staff Orientation/Training Annual Updates

20. Staff Education

21. Implementation

22. What is the Hospice Experience of Care Instrument? Evaluation of the patient/family’s experience of care Caregiver as proxy Post-death Similar to CAHPS surveys Similar to the Family Evaluation of Hospice Care (FEHC) Developed by Rand Corporation Three versions based on place of death Home, Inpatient, Nursing Facility

23. Hospice EOCS (CAHPS): Timeline First quarter 2015: 1-month “trial run” for submission April 1, 2015: Begin continuous usage

24. Vendors Hospices must contract with CMS-approved vendor Vendor applications: late 2014 Home Health CAHPS Vendors: https://homehealthcahps.org/GeneralInformation/ApprovedS urveyVendors.aspx https://homehealthcahps.org/GeneralInformation/ApprovedS urveyVendors.aspx

25. On the Horizon

26. NQF Endorsement Process Call for Measures Call for Nominations Measure Review Comment Voting CSAC Decision Board Ratification Appeals

27. Measures Application Partnership Measure concepts: pain goal attainment patient engagement care coordination depression caregiver’s role timely referral to hospice

28. April 2014: Call for TEP Nominations Project Objectives Include: Investigate the potential for expanding existing quality measures or measure concepts to the Hospice QRP. Generate measure ideas/concepts that address gaps in the current Hospice QRP identified by stakeholders such as the Measures Application Partnership (MAP).

29. Questions?