Home Health & Hospice Week

Host of changes will require hospices to make significant operational shifts.

The long-awaited hospice COPs are finally out, and they will require some big - and costly - adjustments in the future.

The Centers for Medicare & Medicaid Services proposed the COP revisions in the May 27 Federal Register. Because so much time had elapsed since CMS proposed its last COPs in 1997, the agency had to re-propose the regulation rather than finalize it. "We have been waiting for these new COPs for years," notes consultant Heather Wilson of Weatherbee Resources Inc. in Centerville, MA.

And the re-proposal contains a lot of new material, experts note. One of the biggest changes is new requirements for comprehensive assessments, notes attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, WI.

CMS is setting out a comprehensive assessment requirement as its own new COP to emphasize its importance, the agency says in the proposed rule. Nationwide survey trends "indicate that the current assessment requirements are not sufficient," CMS explains.

"The fourth most frequently cited deficiency is that the plan of care did not include an assessment of the patient's needs."

Under the new assessment COP, hospices will have to conduct a comprehensive assessment (including a drug review) within 24 hours of a physician's order for hospice care, complete the assessment within four days of hospice election, update the assessment at least every 14 days and update it at recertification.

Additionally, hospices will have to review and update the plan of care at least every 14 days.

Requiring the continuous assessments and POC revamping is a good idea, because dying patients often have rapidly changing conditions and needs, says attorney Connie Raffa with Arent Fox in New York City. But the requirements are going to mean a whole lot more staffing and resources, Raffa contends.

No early assessments: Hospices that are used to conducting assessments before they receive an official physician's order for hospice will have to rearrange their scheduling, points out attorney Deborah Randall with Arent Fox's Washington, DC office. The new COP would prohibit hospices from using an assessment conducted before the order, Randall says.

And hospices whose current assessment procedures require updates of only certain parts of the care plan will have to switch to full-blown assessments at least every two weeks, Randall adds. Likewise, interdisciplinary communication on updates will have to move to more than "touching base" under the new guidelines, she points out.

Hospices won't have too much trouble hitting the new deadlines, Wilson predicts. But they may wrestle more with keeping information between the updated assessments and care plans consistent, she worries. That could easily become a survey problem.

And under the new COPs, surveyors will be paying a lot of attention to the assessment and care plan areas highlighted by CMS, Randall forecasts.

These new requirements come in spite of the fact that CMS claims the revised hospice COPs are less process-oriented and more focused on patient outcomes. "These requirements, though process-oriented in part, are predictive of good patient care and safety," CMS maintains in the rule.

But by putting extra requirements on initial assessments and not allowing early assessments, CMS may be raising barriers to hospice access, Randall criticizes. "Congress has tried to loosen up the burden on the front end" for electing hospice, she asserts. The new requirement "is not good for patients or patients' families," she argues.

Get to Know Your QI Requirements

Another big change will be the new quality assessment performance and improvement (QAPI) requirement that will replace the current quality assurance COP. Under this data-driven model, hospices will have to choose, measure, analyze and track quality indicators of their own choosing, the rule proposes. And they will have to conduct performance-improving projects on the measures.

Many hospices already are using outcomes-based improvement, Randall says. But "it will take a gargantuan effort to help many hospices make the shift to this regulatory structure" for QAPI, Michal predicts. "Education and proper regulatory compliance tools will be essential," she stresses.

CMS grants hospices flexibility in choosing their own measures, and points to existing quality measures already used by the National Hospice and Palliative Care Organization and Brown University as examples.

"Some hospices will appreciate the flexibility related to data collection," Wilson notes. "But it is likely that most hospices will participate in NHPCO's data set since it is well established and was referenced in the proposed regulations." Also, to participate in the data set is more efficient for hospices than to "reinvent the wheel," predicts Wilson, who is vice chair of NHPCO's regulatory subcommittee.

Warning: Hospices that adopt outcome tools that don't work out well for them may run a serious survey risk under the new COPs, Randall worries. If inaccurate outcomes measurements make a hospice look like it's doing poorly, the hospice could suffer survey repercussions, she fears.

Randall hopes CMS will train hospices and surveyors together on how the new QAPI COP will be surveyed. That's especially true because in many states, survey findings are publicly posted, she notes.

In many areas of the newly proposed COPs, the physician medical director's role is increased, ex-perts point out. One such area is the QAPI.

The rule proposes "that the medical director or physician designee be responsible for the hospice's quality assessment and performance improvement program. This program and implementation of its findings are critical to ensuring that patients receive effective and meaningful care."

But hospice is a nurse-driven industry, and most medical directors report to a nurse executive, Randall notes. CMS will be under pressure to enlarge the QAPI leadership role to the hospice's chief clinical officer - who will be a nurse in most cases , she says.

Will These COPs Actually Take Effect?

As usual, CMS has vastly underestimated the regulatory burden the new COPs will place on hospices, industry veterans say. Requiring lots of new assessment timepoints and a whole new quality improvement program will take staffing and money, Raffa says. But CMS insists little to no burden will be added.

"The regs assume hospice can meet these requirements at current reimbursement rates," Raffa tells Eli. "They can't." Most non-profits fundraise 20 percent of their budgets, she adds.

And hospices are wondering whether these proposed COPs will really go into effect, since the last set of proposed COPs just disappeared. Hospices hope "that the regulations will be finalized in the not too distant future," Wilson says.

CMS plans to finalize the COPs within the three-year timeframe required by law, a CMS official said in the May 25 Open Door Forum for home care providers.

"We think we've made good changes," the CMS staffer said. "We'll be interested in hearing what your comments are." Comments are due by July 26.

Don't forget: Hospices shouldn't start adhering to the new COPs just yet, Wilson warns. The current COPs are in effect until CMS finalizes the proposed conditions, she reminds providers. 

Editor's Note: Watch for more information on the proposed hospice COPs in a future issue of Eli's Home Care Week. The proposed COPs are in the May 27 Federal Register at www.access.gpo.gov/su_docs/fedreg/a050527c.html.