Midwest Palliative and End of Life Care Conference October 22-24, 2017 Hospice Quality Reporting and Kara Justis, MBA Director Kimberly Skehan, RN, MSN Senior Manager Simione Healthcare Consultants, LLC Today s Program Describe the CMS Quality Reporting Measures for both the Hospice Item Set (HIS) and the CAHPS Hospice Survey and recognize the correlation of these data elements to daily clinical practice and Hospice outcomes. Identify key strategies to maximize customer service opportunities specifically targeting HIS and CAHPS Hospice Survey questions. Define customer service in referral, admission and care processes. Utilize case scenarios and group discussion to demonstrate how exceptional customer service skills and daily clinical practice may directly influence Quality Reporting Measures results. Q&A s 2 Hospice Quality Reporting Program Overview 3 Simione Healthcare Consultants, LLC 1
Why Do We Need These Requirements? Affordable Care Act requires CMS to: Collect data from claims and cost reports. Revise the payment system and rates for hospice services. Better Data: Measure quality, safety and efficacy of care. Design payment systems and process claims for reimbursement. Prevent and detect healthcare fraud and abuse. Performance monitoring Public Reporting/P4P. Monitoring resource utilization. 4 Quality Measures - Regulatory Background Regulatory Background: Medicare Conditions of Participation for Hospice 418.58 Quality Assessment/Performance Improvement. Section 3004 of the Patient Protection and Affordable Care Act (ACA) authorizes the Health and Human Services Secretary to establish a quality reporting program for hospices. 5 HQRP Requirements Current Hospice Quality Reporting Requirements: Hospice Item Set 70% submission threshold (as of 1/1/16). 80% submission threshold (as of 1/1/17). 90%submission threshold (as of 1/1/18 and thereafter) 30 day submission deadline for HIS admission and discharge assessment. REMINDER: 2% reduction in market basket rate for failure to participate in HQRP Reminder to download/print validation reports and address all errors timely to avoid 2% penalties. CMS has expanded functionality of Casper reports to assist with monitoring since December 2016. 6 Simione Healthcare Consultants, LLC 2
HQRP Reporting Requirements CAHPS Hospice Survey Effective 4/1/15. Require ongoing monthly participation through an approved vendor who submits data quarterly according to the CMS deadlines. Failure to submit Hospice CAHPS results in 2% reduction in the Market Basket Rate for the following year. Some exemptions apply. 7 The Financial Impact of Quality Quality Measures Can Impact Finance: HQRP Reporting Requirements. HIS Accuracy. H-CAHPS Surveys. VBP in future? Impact of Outcomes on Referral Relationships. Internal Operations-Cost Efficiencies. Streamlining operations Productivity LOS 8 VBP and Hospice Why is this important for HOSPICE? Hospice will likely be Included in VBP in future. Look at HQRP, H-CAHPS, Claims Data. Public Reporting. Quote from HHS Sylvia Burwell: Overall Goals for Medicare Shift from FFS. Payments tied to Quality or Value Through alternative payment models 30% by end of 2016 50% by end of 2018 Overall Goal 85% 9 Simione Healthcare Consultants, LLC 3
Key Priorities Key areas to implement in preparation for these initiatives and establishing a quality and data driven agency include the following: Efficient operations and understanding of agency financial status. Establishing Key Performance Indicators/metrics. Strength of Quality Program and commitment to continuous improvement of quality measures. 10 2017 Final Rule HQRP Recap Two new quality measures finalized: 2 new quality measures implemented, effective April 1, 2017: Hospice Visits When Death is Imminent Measure Pair - assessing hospice staff visits to patients and caregivers in the last week of life; and Hospice and Palliative Care Composite Process Measure - assessing the percentage of hospice patients who received care processes consistent with existing guidelines. 11 2017 Final Rule HQRP Recap Hospice Visits When Death is Imminent (Measure Pair - assessing hospice staff visits to patients and caregivers in the last week of life): Measure 1: assesses the percentage of patients receiving at least 1 visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life; Measure 2: assesses the percentage of patients receiving at least 2 visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life. 12 Simione Healthcare Consultants, LLC 4
2017 Final Rule HQRP Recap Second Measure: Hospice and Palliative Care Composite Process Measure Comprehensive Assessment at Admission: Includes the current HQRP quality measures (Pain Screening, Pain Assessment, Dyspnea Treatment, Patients Treated with an Opioid who are given a Bowel Regimen, and Treatment Preferences & Beliefs/Values Addressed if desired by patient). Calculates the percentage of patients for whom HIS Admission records contain data on all seven current HQRP quality measures. The individual component of the composite measure are assessed separately for each patient and then aggregated into one score for each hospice. 13 2018 Final Rule-HQRP No New Measures. No elimination of Measures. Two Claims-Based Measures Under Consideration and Development: Potentially avoidable hospice care transitions. Access to levels of hospice care Focus on CHC and GIP Inclusion of social risk factors in HQRP. CMS requested comments in proposed rule Will continue to monitor and identify additional measures for consideration. 14 2018 Proposed Rule-HQRP Hospice Evaluation and Reporting Tool (HEART). Enhanced data collection instrument in early stages of development: Modification of HIS to be more in line with other post acute care settings. 2 primary objectives: To provide the quality data necessary for HQRP requirements and the current function of the HIS; and Provide additional clinical data that could inform future payment refinements. No timeframe set for implementation yet. 15 Simione Healthcare Consultants, LLC 5
2018 Proposed Rule-HQRP Public Reporting and Hospice Compare Site: Hospice Compare is operational NOW!!-August 2017 Public reporting will ultimately include both the 7 quality measures currently collected through HIS AND the results of the Hospice CAHPS survey. Initially will publish ONLY the 7 current HIS measures. Hospice CAHPS survey measures will be added Winter 2018. New measures-timeframe TBD. Measures will be reported if the hospice has a minimum denominator size of 20 clients based on 12 rolling months of data. Approximately 10% of hospices lack sufficient data for reporting. 16 2018 FINAL RULE HQRP Star Rating: No date yet. Not if but when. WATCH THIS: Sources of clinical documentation used for certifying terminal illness. CMS received comments and will consider for future rulemaking, if needed. Will work with MACs to confirm data being collected to support eligibility. 17 Hospice Item Set Review 18 Simione Healthcare Consultants, LLC 6
Hospice Item Set (HIS) HIS V2.00 is a set of data elements that can be used to calculate 7 quality measures - 6 NQF-endorsed measures and 1 modified NQF-endorsed measure: NQF #1641 Treatment Preferences. Modified NQF #1647 Beliefs/Values Addressed. NQF #1634 & NQF #1637 Pain Screening and Pain Assessment. NQF #1639 & NQF #1638 Dyspnea Screening and Dyspnea Treatment. NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen. Plus two new measures: Visits when death is imminent (measure pair). Hospice and Palliative Care Composite Process Measure Comprehensive Assessment at Admission. 19 HIS Questions Answered on admission and discharge of the patient (within 14 days of admission, 7 days of discharge). NOT an assessment instrument, although the questions may be incorporated into the nursing assessment process. These are be submitted to CMS (similar to OASIS, MDS) within 30 days. Component of public reporting in the future (Not yet defined). Reports available to hospices on results. 20 HIS Questions (Continued) All patients admitted need HIS completed, regardless of age, level of care or LOS. CMS will carve out patients under age 18 and LOS less than 7 days but data is still required to be collected and submitted on these patients. 21 Simione Healthcare Consultants, LLC 7
HIS Resources HIS User Manual V2.00, HIS forms and Guidance: https://www.cms.gov/medicare/quality-initiatives- Patient-Assessment-Instruments/Hospice-Quality- Reporting/Hospice-Item-Set-HIS.html Check website regularly for updates. 22 HIS - Key Operational Issues Time for data entry if not integrated into EMR system. Work flow issues. Technical issues with submission. Data accuracy. Train staff using the HIS V2.00 User Manual as a guide remember that the correct use of the data set will have an impact on hospice s future: Public reporting Payment reform Refer to CMS website for Q&As. 23 Hospice CAHPS Survey 24 Simione Healthcare Consultants, LLC 8
CMS Timeline for 2017-2018 Hospice CAHPS Hospice Survey Reporting 25 CAHPS Hospice Survey Current Hospice CAHPS survey tool approved by CMS and can be found at www.hospicecahpssurvey.org. Incorporates questions for all patient locations: Facility - Hospital Nursing Home Home Written survey and telephone script. Hospice must select and use an approved outside vendor. Hospices will submit data to the vendor monthly. Exception: LESS than 50 deaths in the previous calendar year. Hospices meeting this requirement will need to complete an exemption form. Similar processes as with home care survey. 26 CAHPS Hospice Survey Exemptions/ineligible groups include: Pt under 18 at time of death. Pt died within 48 hrs of admission to hospice care. Unable to locate caregiver or not available. Pts whose primary caregiver is a legal guardian unlikely to be familiar with care experiences. Primary CG has a foreign address. Caregiver requests not to be contacted. 27 Simione Healthcare Consultants, LLC 9
CAHPS Hospice Survey Survey administration begins 2 months following the month of patient death. Data collection process must be completed within 42 days after initial contact. Data submitted to the CAHPS Hospice Survey Data Warehouse quarterly. 28 Hospice CAHPS Survey Reminders Manual is available on website: www.hospicecahpssurvey.org Continue to check website for updates and FAQs. 29 CAHPS Hospice Survey Current Version: H-CAHPS V3.0 11 CAHPS Hospice Survey Quality Measures. 47 Questions. Each measure maps directly to one or more questions on the survey. 30 Simione Healthcare Consultants, LLC 10
CAHPS Hospice Survey Quality Measures and Constituent Items Composite Measures: Hospice Team Communication. Getting Timely Care. Treating Family Member with Respect. Providing Emotional Support. Getting Help for Symptoms. Getting Hospice Care Training. 31 CAHPS Hospice Survey Quality Measures and Constituent Items Single Item Measures: Providing Support for Religious and Spiritual Beliefs. Information Continuity. Understanding the Side Effects of Pain Medication. Global Measures: Overall Rating of Hospice. Recommend Hospice. 32 Hospice Communication with Patients and/or their Caregivers Hospices ARE permitted to: Inform all caregivers about the survey. Conduct quality improvement activities, including asking patients/family members questions to promote well-being. Hospices are NOT permitted to: Ask any CAHPS Hospice Survey-like questions or use CAHPS Hospice Survey-like response categories. Attempt to influence caregivers to answer questions in a particular way. Offer incentives of any kind. 33 Simione Healthcare Consultants, LLC 11
CAHPS Hospice Survey Questions How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member? While your family member was in hospice care, when you or your family member asked for help from the hospice team, how often did you get help as soon as you needed it? While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand? While your family member was in hospice care, how often did the hospice team keep you informed about your family member s condition? While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member s condition or care? 34 CAHPS Hospice Survey Questions While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect? While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member? While your family member was in hospice care, did you talk with the hospice team about any problems with your family member s hospice care? How often did the hospice team listen carefully to you when you talked with them about problems with your family member s hospice care? Did your family member get as much help with pain as he or she needed? Did the hospice team give you the training you needed about what side effects to watch for from pain medicine? Side effects of pain medicine include things like sleepiness. Did any member of the hospice team discuss side effects of pain medicine with you or your family member? Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member? 35 CAHPS Hospice Survey Questions How often did your family member get the help he or she needed for trouble breathing? Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing? How often did your family member get the help he or she needed for trouble with constipation? How often did your family member get the help he or she needed from the hospice team for feelings of anxiety or sadness? Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? Moving your family member includes things like helping him or her turn over in bed, or get in and out of bed or a wheelchair. Did the hospice team give you the training you needed about how to safely move your family member? Did the hospice team give you as much information as you wanted about what to expect while your family member was dying? While your family member was in hospice care, how often did the nursing home staff and hospice team work well together to care for your family member? 36 Simione Healthcare Consultants, LLC 12
CAHPS Hospice Survey Questions While your family member was in hospice care, how often was the information you were given about your family member by the nursing home staff different from the information you were given by the hospice team? While your family member was in hospice care, how often did the hospice team listen carefully to you? Support for religious or spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your religious or spiritual needs. While your family member was in hospice care, how much support for your religious and spiritual beliefs did you get from the hospice team? While your family member was in hospice care, how much emotional support did you get from the hospice team? In the weeks after your family member died, how much emotional support did you get from the hospice team? 37 CAHPS Hospice Survey Questions Using any number from 0 to 10, where 0 is the worst hospice care possible and 10 is the best hospice care possible, what number would you use to rate your family member s hospice care? Would you recommend this hospice to your friends and family? 38 CAHPS Hospice Survey Questions Administrative questions assist with determining exemptions. Survey Consent to Share Supplemental Questions. 39 Simione Healthcare Consultants, LLC 13
What Should Hospices Be Doing Now? Educate Staff regarding both HIS and CAHPS Hospice Survey questions and the impact on agency outcomes. Patient/family education on admission. Incorporate Hospice CAHPS survey results into Hospice QAPI Program for monitoring, trend analysis and performance improvement. 40 HIS and CAHPS Hospice Survey - Connections Potential uses of Quality Reporting Data for Hospice agency strategic and operational decision making: Key crossover areas: Pain Breathing/Dyspnea. Opioid Use/Bowel Regime. Note areas that non-direct care staff will have impact: Timeliness of response to calls - including weekend/oncall. Timeliness of visits - this includes admissions. Dignity and Respect/Caring. 41 H-CAHPS Best Practices - Examples Examples of Best Practice Interventions: Root Cause Analysis to monitor and address specific care issues addressed in H-CAHPS. Provide education for ALL agency staff regarding H- CAHPS questions. Other disciplines in home can reinforce education and communication. Including Hospice Aides and Volunteers! 42 Simione Healthcare Consultants, LLC 14
H-CAHPS Best Practices - Examples Listen carefully to you? Ask what is important to patient and caregiver; what would they like to achieve? What is important to them? Call about 1 week after admission to check service and potential for any concerns. Getting Hospice Care Training: Summarize at the end of the visit; today I reviewed the side effects of your pain medications. Use teach-back approach, when appropriate. 43 H-CAHPS Best Practices - Examples Examples of Best Practice Interventions (cont d.): Identify how daily clinical practice and operations can impact these responses and hospice outcomes. Utilize IDG, case management and interim case conference protocols with internal staff AND facility staff SNF/Inpatient/ALF, etc.) to ensure that all disciplines are communicating and coordinating services; reinforce common care planning priorities. 44 H-CAHPS Best Practices - Examples Examples of Best Practice Interventions (cont d.): Coordinate schedules so there is a consistent presence but balanced with team members to minimize overload on patient/family. Ensure timely admission for all disciplines and call patient/family night before or by 9AM morning of visit to inform of visit time. Notify patient/family if unable to visit at scheduled time. Include non-direct care staff in H-CAHPS and customer service training. 45 Simione Healthcare Consultants, LLC 15
H-CAHPS Best Practices - Examples Note areas that non-direct care staff will have impact: Timeliness of response to calls-including weekend/oncall. Timeliness of visits - this includes admissions. Dignity and Respect/Caring. 46 After Hours Response Remember: When a patient/family member calls, they need our assistance. Demonstrating our support through our presence may improve the patient/family experience = possibly improve H-CAHPS Survey results. After hours staff must demonstrate timely response to patient/family needs and documentation/reporting to MD and daytime staff. 47 Quality Reporting Data: Opportunities for Hospice Agencies Objective measures - can begin to compare QUALITY, not only claims data. HIS must be collected in a consistent manner ( apples to apples ). Train staff in key quality measures-his and CAHPS Hospice Survey to increase awareness of how they address these areas with the patient/family. Identify how HIS and Hospice CAHPS outcome measures will impact hospice operations and reimbursement. Identify how daily clinical practice and operations can impact these responses and hospice outcomes. Incorporate into QAPI program. Customer Service is Key! 48 Simione Healthcare Consultants, LLC 16
Defining Legendary Customer Service Bad Customer Service Good Customer Service Legendary Customer Service! 49 Legendary Customer Service It s about them not about us! Focus on the patient and family Fundamental change. What hospice is & who qualifies/program focus. How we help patients & families/customer focus. If we keep this in mind from the beginning, the patient and family experience improves. 50 Customer Service In the Referral and Admission Process Quality Starts When the Phone Rings! What does it sound like when your phone rings? How does the very first interaction with your agency impact the patient and family experience? How does YOUR first interaction with the patient and family impact their experience? 51 Simione Healthcare Consultants, LLC 17
Critical Issue Your greatest differentiator could be service Live voice. No answering service, voice mail, and minimum wait. One call is all. For many customers Most frequent interaction: Our phone service. Conversations, messages, emails, faxes. In person or over the phone - exemplary customer service is KEY. 52 Always remember.. In the caller's eyes, The person on the phone IS your entire organization. The experience IS the product. 53 Who Are Our Customers? Referral partners. Consumer callers Owning their health care decisions. Professional callers. Internal customers. Hospital and Facility patients. 54 Simione Healthcare Consultants, LLC 18
What is Needed? What improvements are needed to impact the Hospice Experience of Care at each of these touch points? What does is your current customer service experience in each of these areas? 55 Poor Customer Service Poor handling of consumer calls. Poor customer service with professional referral sources. No internal customer service. Lack of sense of urgency in the referral and admission process. Poor customer service in facilities. 56 Poor Customer Service - Consumer Calls Data dump approach We have. All about us. Inquisition approach Screening Not holding on to the ball. 57 Simione Healthcare Consultants, LLC 19
Poor Customer Service - Referral Partners Make-them-jump-through-hoops approach Can you fax us the H&P and a face sheet? Make it easy for your referral partner Are you the easiest agency to work with? How responsive is your team? 58 Poor Customer Service - Internal Partners What would your clinical teams say about your intake department? Do you play the blame game and expect perfect referrals and admissions? What is the culture in your organization around admissions? 59 Poor Customer Service - Urgency Lack of a sense of Urgency at all touch points indicates poor customer service! What does URGENCY mean? Improved response time and an increase in the percentage of same-day admits. Improved conversion rates from all referrals. 60 Simione Healthcare Consultants, LLC 20
Conversion Rate? Not Taken Under Care? What does this really mean? What do our NTUCs look like? How does that impact our sense of urgency? What are our main reasons for Not Taken Under Care? 61 Patient and Family Barriers - Top Reason for NTUCs How do we handle patient and family barriers to care in the referral process? Define the common barriers to care. Are there barriers to care from the referral community? 62 What Does It Sound Like? Overcoming barriers - Examples Not ready yet. Not until next week. Don t say hospice. Don t want strangers in the house. Wait until the entire family is present. 63 Simione Healthcare Consultants, LLC 21
Key Strategies/Examples From the Field Focusing on the individual patient and family needs from the beginning of the process improves the experience. Execute an agency-wide customer service strategy that focuses on referrals and admissions. Start with determining what your customer service level is now. 64 Key Strategies/Examples From the Field Develop processes to make sure the focus of the referral process is to make access to care easy for patients and families. Inspect what you expect: Mystery Calls. Observation and Coaching. Most families say they wish they knew about hospice sooner. Focusing on patient/family needs from beginning makes a difference. 65 Mystery Calls The importance of mystery calls. Using mystery calls Coaching Tracking progress. Holding staff accountable. 66 Simione Healthcare Consultants, LLC 22
Process Policies and procedures. Resource manual. Complex case protocol. Closing the loop. 67 Metrics Referrals/Admissions. Conversion rate. Time from referral to admission. Productivity Call reports Volume, abandoned calls, hold time. Hospice Item Set Outcomes. Hospice CAHPS Outcomes. 68 Remember It s about Them Not Us The patient/family experience starts with our first contact - even before! Legendary Customer Service is a culture Top down messaging. The right people Hiring and training. Define your strategy and your goals. Measure your success. Quality begins when the phone rings. 69 Simione Healthcare Consultants, LLC 23
Questions? 70 SIMIONE.COM Simione Healthcare Consultants provides solutions for your core home care and hospice challenges organizational, financial, sales & marketing, technology, and mergers & acquisitions. Over 1000 organizations use our practical insight and tools to reduce costs, mitigate risk and improve efficiencies to steward the way they conduct business. Kimberly Skehan, RN, MSN Kara Justis, MBA Senior Manager Director 4130 Whitney Avenue 4130 Whitney Ave. Hamden, CT 06518 Hamden, CT 06518 203.287.9288 (o) 203.287.9288 (o) 860-729-4680 (c) 314.971.5833 (c) 800.949.0388 (toll-free) 800.949.0388 (toll-free) kskehan@simione.com kjustis@simione.com Simione Healthcare Consultants, LLC 24