Hospice Quality Reporting (HQRP) Data and Trends
The Data is in- Quality Reporting in Hospice (HQRP)
Although the Hospice Quality Reporting Program (HQRP) began in August 2017 with the Hospice Item Set (HIS) scores being made public on the Hospice Compare website, hospices still have limited information about the trends and changes in scores since HIS and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey began.
The following piece details the background of HQRP and explores the trends and scores over the last couple of years, as well as shares some insights on changes to the quality program that the Centers for Medicare and Medicaid Services (CMS) may be considering. Here also, we’ll set the stage for HQRP, including background and changes; examine trends and benchmarks in hospice item set; and forecast what’s next in the direction quality reporting is likely to take.
CMS Hospice 2017 Final Rule – CAHPS Hospice
Let’s begin with the CMS hospice final 2017 rule. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey was designed to measure and assess the experiences of patients who died while receiving hospice care, as well as the experiences of their informal primary caregivers. The CAHPS hospice survey is the first national hospice experience of care survey that includes standard administration protocols that allow for fair comparison across hospices.
In so much, CMS plans to publicly report hospice data when at least 12 months of data are available, which began in April 2015 after dry run quarter. According to Chris Attaya, vice president of product strategy at SHP (Strategic Healthcare Programs) who said during a recent DeVero educational webinar, “Hospice Quality Reporting Data & Trends,” that CMS noted in the rule that the CAHPS hospice survey will be reported on an eight-quarter rolling average, which is actually different than what we’ve seen in other reporting.
Worth noting is that hospices that have fewer than 50 survey eligible decedents/caregivers in the period from Jan. 1, 2016, through Dec. 31, 2016, are exempt for the FY 2019 payment determination.
CMS CAHPS hospice changes
CMS announced in 2016 that the 11 quality measures that are calculated from CAHPS hospice survey have been simplified and consolidated. Three measures have been eliminated and their questions added to other existing quality measures, leaving six composite and two global measures. According to Attaya, we can see some of the data that CMS has started sharing, including CAHPS scores from Apr. 1, 2016, through Ma. 31, 2016 — the recently posted national CAHPS hospice survey dataset on www.data.medicare.gov reflects these changes.
Summary of the 2017 Hospice Final Rule – HIS
As part of the changes to the final rule of HIS, the seven-day length-of-stay requirement has been removed for all hospice patients. Additionally, “treatment preferences” and “beliefs/values” measures require that the questions be asked no more than seven days prior to admission, Attaya said during his recap.
The big changes, however, include a new “composite” measure and a new measure set for “hospice visits when death is imminent”, which will come from HIS 2.0, and CMS said it plans to continue to pursue new data collection considerations post-HIS 2.0.
CMS HQRP January 2017 Update
The CMS Hospice Compare website, which will provide valuable information regarding the quality care provided by Medicare-certified hospice agencies throughout the nation, was expected to be available in the late summer of this year, which actually appeared for in August for HIS, but the CAHPS compare site is slated for release during winter 2018, Attaya said.
Additionally, the seven currently available HIS-based quality measures, as well as eight CAHPS hospice-based quality measures will be reported on the hospice compare website. Also, the two new HIS-based measures (hospice and palliative care composite measure, and hospice visits when death is imminent measure pair) will not be incorporated into hospice compare at this time.
Like other CMS compare websites, the Hospice Compare website will, in time, feature a quality rating system that gives each hospice a rating of between one of five stars – relative to scores and outcomes.
CMS made reference to following inpatient rehabilitation facility and long-term care hospitals compare sites.
That comparison raises the following questions:
- Will CAHPS be on the second tab?
- Will there be state averages?
- On other sites there is a six-month delay on CAHPS, but nine-month delay on other measures. Will we see the same pattern here?
There also are similarities to Home Care Compare:
- CAHPS scores will be reported using a combination of composite (multi-question and universal (single question) domains
- Process measures are compared to both state and national benchmarks
- HIS-based HQRP measures will be reported using a rolling 12-month period that is updated each quarter.
CMS is promoting the refresh dates for reporting so that you can see when Hospice Care is going to be refreshed on the site, and which quarters that were reflected in the data compare.
As of April 2017, HIS 2.0 includes: New data elements collected at admission assessment has three new data collection items and one modified item:
- A0550: Patient zip code – source relative to patients based on social economics?
- A1400: Payer information (11 choices)
- J0900: Skip logic removed on J0900C when pain severity is “none”
- J0905: Pain active problem
There are bigger changes in discharge assessment – the discharge assessment has 14 new data collection items, all in a new section called “Service Utilization,” including:
- O5000: Level of care in final three days
- O5010: Number of care in final seven days
- O5020: Level of care in final seven days
- O5030: Number of hospice visits in three to six days prior to death
Trends and Benchmarks in HIS and CAHPS Hospice Data
According to data collected from SHP’s database of 1,400 hospices, Zeb Clayton, vice president of client service at SHP, CAHPS hospice data even in the first year the scores were the highest, but they have come down a bit. CAHPS scores are not very volatile – there’s a 1 percent or 2 percent swing over time – and that can both be good and bad – and we’re not likely to see satisfaction scores all over the map, but it can take work to get them to rise. “If you can get them up, you’re likely to be better than the benchmark,” said Clayton.
CAHPS hospice scores – the quarterly trends – as an overall indication of quality show that 84 percent is a “pretty good” indicator. CAHPS hospice scores – the lowest ratings – show that there are some problem questions. “If you’re working on improving a domain, you might be doing great, but there may be one that is dragging your score down,” Clayton said. “Focus on that to see where you have room to improve. For example, ‘Family kept informed about when hospice would arrive’ or ‘help provided during evenings, weekends or holidays’ and ‘requested help was provided when needed,’ ‘training provided about pain medicine side effect.’ Hospice care training is a challenge for most hospices.”
Also, when assessing key drivers where you find comparisons of ratings to other survey questions – when you score well in one area – review which questions you scored well in relation to them, too. In a nutshell, “you have to constantly be improving because everyone else is working to improve,” Clayton said.
HIS Composite Assessment at Admission – there has been a steady improvement in this metric. The percentage of patients that met every component that of this measure has steadily improved since quarter three of 2014. Constant attention to this measure is very important, Clayton said.
HIS Visits when Death is Imminent – is a new measure. There are two components to this measure. One requires at least one visit in last three days of life; the other requires at least two visits in the last seven days of life. According to available data, the last three days of life measure showed that 87.6 percent had met this measure. Of the patients that did not meet this measure, 78.4 percent did not have a visit from an eligible discipline in the required time window – a simple fix for an agency providing care. For example, the percent of routine home care visits in last three days of life were provided by an aide or an RN.
For those patients receiving two visits in the last seven days of life, 76.1 percent met the measure; 13.7 percent of all patients had only one visit; 9.6 percent had one or more visits but not from a qualifying discipline; .6 percent had no visits.
What’s next? CMS states:
- The HQRP promotes the delivery of person-centered, high-quality and safe care by hospices.
- CMS has sought to adopt measures recommended by multi-stakeholder organizations and developed with the input of providers, purchasers, and payers.
- Comparing performance between hospices requires that measures be constructed from data collection in a standardized and uniform manner.
It’s worth noting that the HIS composite score shows that the 50th percentile is 95.4 percent. The question then becomes, how are you and your organization supposed to compete against providers and hospices with such high scores?
Moving forward, CMS is mulling new concepts for future years of program development. While CMS has not proposed any new measures as part of the FY2018 rule, the proposed rule does provide discussion of priority area measure concepts under consideration for future years, including:
- Potentially avoidable hospice care transitions
- Access to levels of hospice care – continuous home care and respite
Essentially, this may set the tone for the future of the program. Additionally, we’ll likely see a determination to the definition of what is hospice quality, and what is a good death? Also, expect guidance on how to meet patient’s goals, and how you are providing the level of care patients expect to be provided? How do you measure impact on providers, and patient’s goals?
In regard to the definition of hospice quality, will there be a congruence with place of death and wishes, psychological aspects of care, spiritual well-being, bereavement services, volunteer services offered by hospice, occupational therapy outcomes, care planning, timely communication with patient’s goals, cost of care, and care coordination among providers?
Public reporting has begun, yet hospice organizations must identify where opportunities for quality improvement exist. While home healthcare has some previous experience in managing such cycles, hospice care providers now have the opportunity to do so.
In so doing, you must understand caregivers perspectives and closely monitor and develop best practices; and be prepared for the program’s impact.
There is more detail available if you want to know about the developments hospice quality reporting. While this recap (above) of the webinar sponsored by DeVero provides foundational details for hospice care organizations, there’s much more detail to be had by listening to the entire recording.
Learn more about DeVero hospice software solutions