1 Stand-Alone 2 Co-located (or embedded)

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1 MODULE 1. Office/Clinic Program Description and Metrics Outpatient Clinic / Office-based Practice Description 1.A Data for [YEAR] reported for: 1.B Service Setting 1 Is this program serving an urban, suburban or rural community? 2 Who administers your long-term care program? 1 Urban 2 Suburban 3 Rural 1 Health system 2 Hospital 3 Hospice 4 Home Health Agency 5 Long-term Care facility/organization 6 Physician Group 7 Other [TEXT] 2a If administered by a hospital, select hospital. [TEXT] 2b if administered by a health system, select health system. [TEXT] 3 Is your clinic or office-based palliative care practice stand-alone or co-located with other clinical services? 1 Stand-Alone 2 Co-located (or embedded) Office-based palliative care practices may operate independently or be integrated with another practice setting (such as a cardiology or oncology center). Stand-alone: Dedicated palliative care office practice Co-Located: Embedded palliative care practice with various degrees of administrative and clinical integration 4 Do you have a formal partnership with one or more home health agencies, hospices, or specialty centers, long-term care or hospitals? 5 Does your palliative care program work in collaboration with any of these service providers? 6 Has your palliative care program been In operation 0/1 N/Y 12 a full months? 6a If not 12 months, how many months of data are you reporting? Total annual Patient Caseload (all patients, not limited to pallative care) 0/1 Home health agency 0/1 Hospice 0/1 Specialty Center (i.e., Cancer Center) 0/1 Hospital 0/1 Long-term Care facility 0/1 Other [TEXT] Other, specify 0/1 Friendly visitor program 0/1 Respite care 0/1 Meals-on-Wheels 0/1 Visiting doctors 0/1 Other [TEXT] Other, specify MODULE 2. Palliative Care Program Metrics and Patient Demographics 1 Which population(s) did your palliative care team serve during the reporting period? 2 Indicate the percentage of new female and male patients seen by your palliative care team during the reporting period. 0/1 Pediatric 0/1 Infant (birth to 1 year) 0/1 Children (>1 year to 12) 0/1 Adolescent (>12 to 17) 0/1 Adult (18 and older) Female Male Report total patient caseload for your clinic/office. This is for the program overall, and not limited to palliative care patients. Please select all ages served by your palliative care program during the reporting period. If selecting "Pediatric," there is an option to provide further details on that population, although this is not required. Provide the gender distribution for new inpatient palliative care consults. If a single patient received more than 1 initial palliative care consult, include only once. Gender should be how a patient identifies themselves. This should total 100%. 3 Indicate the percentage of new patients by age group seen by your palliative care team during the reporting period. 0 to 1 years 2 to 17 years 18 to 44 year Page 1 of 8 Provide the age distribution for new inpatient palliative care consults. If a single patient received more than 1 initial palliative care consult, include only once. This should total 100%.

2 should total 100%. [Percent) 45 to 64 years 4 Please provide the race/ethnic distribution of new patients seen by your palliative care team during the reporting period. 5 Please provide the distribution of new patients seen by your office/clinic palliative care team during the reporting period by living situation at time of referral. MODULE 3. Patient Visits - Clinic/Office palliative care services only 1 How many new palliative care consults did your palliative care team complete during the reporting period? 65 to 85 years 86 years or more Black/African-American non-hispanic White/Caucasian non-hispanic Asian non-hispanic Chinese Japanese Filipino Korean Asian Indian Vietnamese Other Asian American Indian/Alaska Native non-hispanic Hawaiian Native/Pacific Islander non-hispanic Hispanic/Latino Mexican Puerto Rican Cuban Other Hispanic/Latino Living alone [Percent} Living with healthy spouse or other adult Living with spouse or other adult with limiting medical/physical conditions Living with adult child(ren) Living with another family member [Percent} Living in an Assisted Living Facility Other living situation [Text] Other (specify) Provide the race/ethnic distribution for new inpatient palliative care consults. If a single patient received more than 1 initial palliative care consult, include only once. This should total 100%. The secondary categories are not required but, if available, should total the primary category percentage. Please provide the total number of consults based on new orders written during the reporting period. If a patients was admitted to palliative care services, discharged, and admitted again in the same year, this is considered 2 consults. 1a Of these, how many were unique patients? If a patient had more than one admission during the year, then it is possible to have more than one consult per patient. Please provide the total number of unique patients receiving one or more palliative care consults. 2 What was the total number of subsequent visits (i.e., follow-up visits) completed by your palliative care team during the reporting period? 2a 3 What was the total number of follow-up calls completed by your pallative care team during the reporting period? 3a What is the average and median number of followup visits per patient? What is the average and median number of followup calls per patient? [Mean] [Median] [Mean] [Median] 4 What is the average and median number of patient [Mean] encounters per month (both visits and calls)? [Median] These are in-person follow-up visits. 5 Considering all initial palliative care consult visits, who does these visits? Provide percent distribution of initial consult visits by provider. Physician Advanced Practice Registered Nurse (APRN) - includes Registered Nurse (RN) Licensed Practicing Nurse (LPN) Certified Nursing Assistant (CNA) Psychiatrist / Psychologist Social Worker Page 2 of 8

3 6 Considering all patient visits, who typically completes these visits? Provide percent distribution of all palliative care visits by provider. 7 Considering all patient follow-up calls, who typically completes these calls? Provider percent distribution of call by provider. MODULE 4. Referral Source, Diagnosis and Code Status 1 Where do your referrals come from? Provide the percentage distribution of palliative care referrals by referral source. 2 What are the primary diagnoses of your patient population? Provide the percentage distribution of palliative care patients by primary diagnosis. Case Manager Navigator Community Health Worker Chaplain / Spiritual Care provider Other [Text] Other (specify) Physician Advanced Practice Registered Nurse (APRN) - includes Registered Nurse (RN) Licensed Practicing Nurse (LPN) Certified Nursing Assistant (CNA) Psychiatrist / Psychologist Social Worker Case Manager Navigator Community Health Worker Chaplain / Spiritual Care provider Volunteer Other [Text] Other (specify) Physician Advanced Practice Registered Nurse (APRN) - includes Registered Nurse (RN) Licensed Practicing Nurse (LPN) Certified Nursing Assistant (CNA) Psychiatrist / Psychologist Social Worker Case Manager Navigator Community Health Worker Chaplain / Spiritual Care provider Volunteer Other [Text] Other (specify) Hospital Hospice Group home Home Health agency Current patient of this practice Other Office-based or outpatient primary care practice Specialist practice Community service agency / organization Patient or family Other [Text] Other, specify Cancer Hematological Non-hematological Cardiac Heart Failure Cardiac Arrest MI Other Cardiac Pulmonary COPD Pneumonia Other Pulmonary Complex chronic conditions/failure to thrive/frailty Renal Vascular Congenital/chromosomal Infectious/Immunological Provide the referral source distribution for new palliative care consults. This should total 100%. Please provide the disease/diagnostic grouping distribution of new inpatient palliative care consults. This should total 100%. The secondary categories are not required but, if available, should total the primary category percentage. Page 3 of 8

4 Gastrointestinal Hepatic Hematology Endocrine/Metabolic In-utero complication/condition Neurologic/stroke/neurodegenerative Dementia Trauma Other [Text] Other, specify 3 Code status at time of consult? Full code Limited code Do not attempt resuscitation (DNR) Unknown Full Code: patient preference is to receive all available resuscitative efforts. Limited Code: any limitation in resuscitation efforts short of comfort measures only (also referred to as "partial code"). DNR/DNI (Allow Natural Death): patient preference is not to receive any resuscitative efforts. If the patient wishes to receive any, but not all resuscitative efforts such as ICU-level monitoring, pressors, cardiversion, bipap then code status is partial. 4 What percent of initial patient contacts were completed within one day of referral for palliative care (same day or next day)? Initial patient contacts includes phone calls or conversations with patients or caregivers to schedule an initial visit or provide general information. If a referral occurred on a weekend, Monday is the next day. MODULE 5. Palliative Care Services and Standardized Processes 1 Which of the following services does your palliative care team offer patients? 2 Percent of initial palliative care visits (new consults) with chart documentation of goals of care completed (either before or during visit). 0/1 Advance care planning 0/1 Symptom Management 0/1 Emotional Support 0/1 Spiritual Support 0/1 Medication Management 0/1 Information about disease/prognosis 0/1 Caregiver Support 0/1 Referrals to community services 0/1 Case Management / Patient Navigator After initial visit. 3 Percent of initial palliative care patient visits (new consults) with chart documentation of surrogate decision maker or documentation that there is no surrogate (either before or during visit). 4 Percent of initial palliative care patient visits (new consults) with chart documentation of a discussion of emotional or psychological needs (either before or during visit). 5 Percent of initial palliative care patient visits (new consults) with chart documentation of discussion of spiritual/religious concerns or documentation that the patient did not want to discuss (either before or during visit). Discussion of spiritual or religious concerns may occur between patient and/or family and clergy or pastoral worker or patient and/or family and member of the interdisciplinary team. Documentation of only patient s religious or spiritual affiliation does not count for inclusion in numerator. (NQF #1647) 6 Percent of initial palliative care patient visits (new consults) with chart documentation of a social assessment, including patient's responsibilities, support network and need for community referrals. Page 4 of 8

5 7 Percentage of palliative care patients with any (1 or more) chart documentation of preferences for life sustaining treatments. 8 Percent of palliative care patients that had documentation in their medical record of Advance Directive (living will and healthcare proxy/surrogate decision maker) 9 Percent of palliative care patients that had documentation in their medical record of DNR (Do Not Resuscitate) 10 Percent of palliative care patients that had documentation in their medical record of POLST/MOLST (Physician/Medical Orders for Life- Sustaining Treament) 11 What percentage of new paliative care consults resulted in a change in treatment plans? Before initial consultation After consultation Before initial consultation After consultation Before initial consultation After consultation Before initial consultation After consultation Documentation of life-sustaining treatment preferences should reflect patient self-report; if not available, discussion with surrogate 12 Of patients with full code status at time of consult, percent with a status change documented. Numerator: The number of palliative care patients with a full code status at time of initial consult that had a subsequent documented code status change Denominator: The total number palliative care patients with a full code status at the time of initial consult. MODULE 6. Electronic Medical Records 1 Does your clinic/office palliative care program use an Electronic Medical Record (EMR/EHR) for management of the patient's health care? 0/1 No/Yes Exclude electronic records used only for billing purposes and required documentation, such as OASIS. 1a What EMR do you use? If your organization uses more than 1 EMR, provide the name of the primary EMR. 2a Do you use the EMR for: Patient demographics 2b 2c 2d 2e Do you use the EMR for: Electronic reminders for tests (labs, imaging, etc.) Do you use the EMR for: Computerized Physicians Order Entry (CPOE) - prescriptions, labs, tests, etc. Do you use the EMR for: Test results (chest x-rays, labs, etc.) Do you use the EMR for: Clinical Decision Support System (CDSS) contraindications, allergies, guidelines, etc. 2f Do you use the EMR for: Clinical notes 2h 2i Do you use the EMR for: Sharing medical records electronically with other agencies Do you use mobile technology, like a tablet or laptop computer, to record patient information at the point of care into the EMR? 3 Does your pallative care team provide telemedicine services? 1 Yes - we use mobile technology connected to our EMR 2 Yes - we use mobile technology, not connected 3 No - we do not use mobile technology 1. Yes, audio and video (e.g., Skype) 2. No, audio only (phone only) 3. No Telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment. (medicaid.gov) 3a What percentage of your patients use telemedicine services? MODULE 7. Discharge Status and Length of Service Page 5 of 8

6 1 Of all patients admitted for palliative care services during this reporting period, how many were discharged alive from palliative care services? 2 Of all patients admitted for palliative care services during this reporting period, how many died while on palliative care services? 2a Of these deaths, how many died at home? 3 Of all patients discharged from office/clinic palliative care alive, where were patients discharged to? Please provide the percentage distribution. 4 Length of Service: All patients discharged alive from Clinic/Office Palliative Care 4 Length of Service: Palliative Care patients discharged to Skilled Nursing Facility (SNF) 5 Length of Service: Palliative Care patients discharged to Hospice 6 Length of Service: Patients deceased on palliative care services 7 Percent of palliative care patients with one or more hospital admission during their palliative care service 8 Percent of palliative care patients with one or more ICU admission during their palliative care service 9 Percent of palliative care patients with one or more emergency department (ED) visit during their palliative care service Discharged to Skilled Nursing Facility Discharged to a Hospice facility Discharged to a home hospice program [Mean] Days on Palliative Care services [Median] Days on Palliative Care services [Mean] Days on Palliative Care services [Median] Days on Palliative Care services [Mean] Days on Palliative Care services [Median] Days on Palliative Care services [Mean] Days on Palliative Care services [Median] Days on Palliative Care services Patients with hospital admissions Patients with ICU admissions Patients with ED visits MODULE 8. Staffing 1 Does your palliative care team work with palliative care patients in the clinic/office exclusively? 1a If not, approximately what percentage of the team's time is dedicated to clinic/office-based palliative care patients? 2 Considering all of palliative care patients, what is the breakdown of the palliative care team's role? 0/1 No/Yes If the team sees these or other palliative care patients in other settings (hospital, home, etc.), then the answer is no. Consult only Primary care provider Co-Management Mixed Model - either consultation, primary attending or co-management based on circumstances Consult Only. The goal of the consultation service is to support the referring provider. The consultation team offers recommendations to the primary attending physician. Primary care provider. The palliative care team assumes primary responsibility for the patient's care. Co-Management. The palliative care team partners with the primary provider(s) to care for the patient, typically assuming total care for particular clinical issues. Mixed Model. The palliative care team assumes different roles, depending on the patient's needs, the referring provider's needs and capacity, and the setting. The team's approach can change as care needs change. 3 Which of these disciplines constitute your service team? 0/1 Physician (MD/DO) Page 6 of 8

7 team? 0/1 Advanced Practice Registered Nurse (APRN) - includes NP, CNS, CRNA, CNM 0/1 Physician Assistant (PA) 3 Funded Staff - Total Head Count Funded Staff - Full Time Equivalent (FTE) In-Kind Staff - Total Head Count In-Kind Staff - Full Time Equivalent (FTE) Volunteer Staff - Total Head Count Volunteer Staff - Full Time Equivalent (FTE) 4 Indicate the number of staff members with palliative care certification 0/1 Registered Nurse 0/1 Medical Residents / Fellows 0/1 Licensed Practical Nurse (LPN) 0/1 Certified Nursing Assistant (CNA) 0/1 Psychologist 0/1 Psychiatrist 0/1 Social Worker 0/1 Patient Navigator 0/1 Case Manager 0/1 Chaplain/Spiritual Care 0/1 Physical/Occupational Therapist 0/1 Speech Therapist 0/1 Music/Art Therapist 0/1 Child life specialist 0/1 Dietician/Nutritionist 0/1 Pharmacist 0/1 Administrator (non-physician) 0/1 Hospice Liaison 0/1 Medical Director (non-clinical time) 0/1 Administrative Support 0/1 Other [Text] Other, specify [Count] Physician (MD/DO) [Count]Advanced Practice Registered Nurse (APRN) - includes NP, CNS, CRNA, CNM [Count]Physician Assistant (PA) [Count] Registered Nurse [Count] Medical Residents / Fellows [Count] Licensed Practical Nurse (LPN) [Count] Certified Nursing Assistant (CNA) [Count] Psychologist [Count] Psychiatrist [Count] Social Worker [Count] Patient Navigator [Count] Case Manager [Count] Chaplain/Spiritual Care [Count] Physical/Occupational Therapist [Count] Speech Therapist [Count] Music/Art Therapist [Count] Child life specialist [Count] Dietician/Nutritionist [Count] Pharmacist [Count] Administrator (non-physician) [Count] Hospice Liaison [Count] Medical Director (non-clinical time) [Count] Administrative Support [Count] Other [Count] Physicians [Count] Advanced Practice Registered Nurse [Count] Registered Nurse [Count] Chaplain/Spiritual Care [Count] Social Worker For each, report head count and FTE separately for funded, in-kind, and volunteer staff. Include the following: Physicians board-certified in Hospice and Palliative Medicine by the American Board of Medical Specialties (ABMS) or the American Academy of Hospice and Palliative Medicine (AAHPM). Advanced Practice Nurses and Registered Nurses Page 7 of 8

8 5 How often does your full palliative care team meet to discuss patient care caseloads? 1 Full team meets at least once a week 2 Full team meets very other week 3 Meetings are scheduled weekly, but not all team members are required to attend 4 Meetings are scheduled for every other week, but not all team members are required to attend 5 Meetings are scheduled as needed on a case-by-case basis 6 No formal meeting schedule, team members consult as needed Coverage 6 Does your pallative care team provide 24/7 coverage? 0/1 N/Y 24/7 coverage is defined as Monday-Friday consultation availability and 24/7 telephone support. Patients, families and hospital staff need palliative care services that are available for both routine and emergency services. Please see DE Weissman, DE Meier, Operational Features for Hospital Palliative Care Programs: Consensus Recommendations If no, what times do you have coverage? 0/1 Weekday, days Check off the times where your palliative care program 0/1 Weekday, evenings has coverage for initial palliative care consultations. 0/1 Weekday, nights 0/1 Weekend, days 0/1 Weekend, evenings 0/1 Weekend, nights Coverage can be: 1) On-site 2) Telephone/Return: Your staff responds to care questions as needed; staff will come in at any hour to ensure quick responses to consult requests and to follow up with existing patients. 3) Telephone Only: Your staff responds to care questions by telephone. They do not come in off work hours to provide consults or conduct follow-up visits. Page 8 of 8