Home Health & Hospice Week

Hospice providers give CMS an earful on quality reporting proposals.

Hospices are hoping to see a lot of changes to Medicare's quality reporting plans when the final rule spelling them out is published shortly.

Chief among the complaints about the Cen-ters for Medicare & Medicaid Services' proposals is the lack of any spiritual or psychosocial measures for inclusion in the first round of expansion.

Background: After its voluntary test last year, CMS began requiring data reporting for two measures Oct. 1 --  the structural measure on whether a hospice has a Quality Assessment and Performance Improvement (QAPI) program that includes at least three quality indicators related to patient care; and National Quality Forum-endorsed measure #209 on pain management (see related story, p. 295). As opposed to the test last year, hospices can at least check off their quality indicator topics rather than enter free text descriptions of them.

Next, CMS plans to add more measures to the collection and implement a dataset to promote uniformity of the data collected, it says in the 2013 proposed home health prospective payment system rule, which included a section on hospice quality reporting (see Eli's HCW, Vol. XXI, No. 25).

Starting in 2015, CMS is considering collecting data on these additional hospice quality measures endorsed by NQF, it says in the rule published in the July 13 Federal Register:

• 1617 Patients treated with an opioid who are given a bowel regimen
• 1634 Pain Screening
• 1637 Pain Assessment
• 1638 Dyspnea Treatment
• 1639 Dyspnea Screening
• 0208 Family Evaluation of Hospice Care.

Commenters on the rule were generally supportive of the proposed measures. But they had one major gripe.

"Since hospice care is health care that provides for the physical, emotional, psychosocial and spiritual needs of dying patients and its goal is to palliate, not cure, it is essential that quality measures include" both spiritual and psychosocial quality measures, says Covenant Hospice in Florida in its comments on the proposed rule.

The currently proposed measures address only physical symptoms, points out one commenter from Kentucky.

Plus: "Hospice care ... extends beyond the death of the patient to include bereavement support for the caregiver," points out Delaware Hospice. "This focus is the hallmark of hospice and leads to the generally high satisfaction rates with hospice care. The proposed measures are missing critical components of measuring quality in hospice."

The Hospital and Health System Associa-tion of Pennsylvania "strongly recommends that CMS consider adoption of a measure that assesses the hospice providers' attention to patient and family end-of-life care wishes," HAP says.

The Visiting Nurse Service of New York was one of multiple commenters that suggested using NQF measures #1641 (Hospice and Palliative Care-Treatment Preferences) and 1647 (Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss) as spiritual/psychosocial measures.

While managing symptoms "is an important part of what hospices do, it provides a partial view of hospice care, and particularly fails to identify that which distinguishes hospice from other care models: the recognition of the whole person including emotional, psychological and spiritual domains, as well as its attention to care coordination and patient preferences," the Midwest Care Alliance explains in its comment letter.

Other comments covered these topics:

• FEHC. Commenters expressed multiple concerns about using NQF Measure #208, Family Evaluation of Hospice Care. In Uvalde Hospice's west Texas rural community, "the language is predominantly Spanish and most people will not even fill out a 2-page survey, much less a longer one," the provider says in its comment letter. Many other hospices reported similar non-response problems with the FEHC survey.

The FEHC's length "could serve as a deterrent to grieving family members," suggests the Hos-pice Association of America, a National Associa-tion for Home Care & Hospice affiliate.

Perhaps CMS should revise the FEHC to make it more user-friendly and push back its implementation date, suggests the Minnesota Network of Hospice & Palliative Care. The Ohio Council for Home Care & Hospice proposes using a shorter and simpler survey altogether.

• Timeline. CMS expressed a desire to implement a hospice quality dataset in 2014 and additional quality measure data collection in 2015. That timeline, particularly for the dataset, is unrealistic, many commenters maintained.

"This is a very aggressive timeline, especially given that the only testing of the item set proposed to take place is already underway and may be insufficient to identify burdens and barriers that hospices will encounter when rolling out the item set," MCA says in its comments.

Hospices must have the dataset form well ahead of time "so that they can become familiar with the process, have adequate time to train staff, and integrate the data collection process into their software systems," stresses the Hospice & Palliative Care Association of New York State. "We urge CMS to make the hospice data submission form available as soon as possible."

Try this: "Because of the burden and challenges these changes will place on hospice providers (and their software vendors), we urge CMS to give more time for implementation and/or consider lowering the number of measures to be implemented in a given year," HPCANYS says.

VITAS Innovative Hospice Care suggests implementing new measures gradually, according to its comment letter.

CMS should consider limiting the number of measures required altogether, notes Calvert Hospice in Maryland. "For a small hospice with limited QAPI staff, the addition of 6 mandatory data collection items would essentially dictate our entire QAPI program, and would not allow for the flexibility to collect other data that is relevant to our particular patient population," it says in its comments.

• Burden. CMS should be wary of "creating similar assessment and reassessment burdens that are inherent in the OASIS and MDS patient assessment tool and process," HAP warns.

Creating data collection processes for five new measures at once would prove particularly burdensome, MCA believes.

"Although we do support a hospice patient-level data item set, CMS must take into consideration the appreciable burden and complexity for providers in the implementation of a system to support a patient-level item data set," VITAS says.

Access problem: "The burden of the re-quirement for electronic medical record and its maintenance, increased regulatory requirements, and the collection and reporting of data is onerous," says Hospice Choice and Life's Touch Palliative Care in Wisconsin. "Combine that with decreased hospice reimbursement and my fear is that since we are a small organization in rural Wisconsin, we will not be in business in 5 years."

• Family impact. It's not only hospices that may be overly burdened by new data collection and reporting. "In 2010 thirty-five percent of hospice patients had a length of service of seven days or less," the National Hospice & Palliative Care Org-anization says in its comment letter. "Interaction with patients and families at this critical time must be focused on what is important to the patient/family caregiver and meeting their needs."

In other words, patients don't want to be sitting around answering endless assessment questions in the last hours of life, commenters emphasized.

"CMS should consider exempting hospices from using the standardized data collection tool or allowing truncated data collection when circumstances warrant (e.g., patient is actively dying; patient/family in crisis)," NHPCO suggests.

• Education. Hospices will need a lot of support and training from CMS to generate accurate quality data, multiple commenters stress. Under the Hospice AIM (Assessment, Intervention, Measure-ment) Project, "we learned that even the most seemingly simple and clear data points were open to interpretation that could lead to inconsistency in data collection," HPCANYS shares.
• Measures. While commenters expressed support for most of the NQF-endorsed measures CMS proposes using starting in 2015, they did have suggestions for change.

For example: HAP wants more specifics on which patients would be considered "vulnerable" and thus subject to the bowel regimen measure.

Note: The proposed rule is at www.gpo.gov/fdsys/pkg/FR-2012-07-13/pdf/2012-16836.pdf.