Home Health & Hospice Week

CMS promises HHAs ample prep time with “early 2020” release.

If you think OASIS is a heavy load now, just wait until January 2021.

A little over a year from now, the Centers for Medicare & Medicaid Services will add 22 new standardized patient assessment data element (SPADE) items, plus some sub-items (see box, p. 328), CMS says in the home health final rule for 2020 published in the Nov. 8 Federal Register. At the same time, CMS will add two new quality measures on health information transfer and three new OASIS items to support them (see story, p. 327).

CMS will also take away one OASIS item on pain (see story, p. 329), but that deletion won’t come anywhere close to balancing out the additions, experts point out.

CMS included the changes in its 2020 proposed rule released in July, and finalizes them almost as-is in the final rule. The only exceptions are a change to when home health agencies must collect some of the new Social Determinant of Health (SDOH) items. “In response to stakeholder comments, we are finalizing that HHAs that submit the Preferred Language and Interpreter Services SPADEs with respect to admission will be deemed to have submitted with respect to both admission and discharge,” the agency says in the final rule.

Commenters on the proposed rule had argued that more SDOHs required at discharge should also change to admission-only collection. “We disagree with the commenters that Health Literacy, Transpor­tation and Social Isolation are unlikely to change from admission to discharge,” CMS responds in the rule. “For example, some patients may develop health issues, such as cognitive decline, during their stay that could impact their response to health literacy thus changing their status at discharge.”

Likewise: “Losing a loved one or caregiver, which can happen at any time, could impact some- one’s response on social isolation and access to transportation,” CMS continues.

A SPADE Phase-In Is Out

Comment letters protesting the additional burden of the SPADE OASIS items were common. “A number of commenters expressed overall concern with the adoption of the SPADEs due to an anticipated increase in administrative burden for providers,” CMS acknowledges in the final rule.

Commenters argued against the new items, lodging an array of complaints ranging from conflict with the Trump administration’s Patients over Paperwork initiative to the duplicative and irrelevant nature of some of the items (see Eli’s HCW, Vol. XXVIII, No. 38).

In the final rule, CMS points out that the SPADE items are required by the IMPACT Act of 2014, with the aim of developing cross-setting quality measures in the post-acute care setting. (And a potential cross-setting PAC payment system.)

CMS also highlights that it proposed many of the SPADE items in 2018, but postponed most of them to give HHAs time to get used to the new elements it did adopt. The agency also wished to conduct “extensive testing” on the items, the final rule says.

Now, “HHAs have had an opportunity to familiarize themselves with other new reporting requirements that we have adopted under the IMPACT Act. We have also conducted further testing of the proposed SPADEs … and believe that this testing supports their use in our PAC assessment instruments,” CMS says.

The agency doesn’t deny that the new SPADE items will add work; it just argues that the extra work will be worth it. “While the introduction of SPADEs will require some additional burden, we maintain that there will be significant benefit associated with each of the SPADEs to providers and patients,” the final rule says.

Those benefits include that the items “are clinically useful (for example, for care planning), they support patient-centered care, and they will promote interoperability and data exchange between providers,” CMS argues.

Plus: “We are hopeful that by requiring the collection of standardized data, the SPADEs may spur providers … to adopt health information technology that eases the burden associated with data collection and data exchange,” the rule says. And “the collection of these SPADEs … will improve discharge planning, as well as address errors that can occur during transition from one setting to the next.”

While the additional burden isn’t in dispute, “there are both positives and negatives to take away from the changes included in the final rule,” judges Leading Age in its analysis of the final rule. One positive is the increased safety offered by the health information transfer measures.

In its comments on the proposed rule, the National Association for Home Care & Hospice lamented the extra workload, but acknowledged that it was required by law. The trade group, along with many other commenters, asked CMS to include the changes all at once if it must, but then leave the OASIS tool alone for five years to provide some stability.

Wait and see: But CMS isn’t ready to commit to the freeze. “In response to the request for not making any new revisions, we will take this recommendation under consideration,” CMS responds in the rule.

CMS also rebuffs requests to phase in the SPADEs to give HHAs a break. “Our development and selection process for the SPADEs prioritized data elements essential to comprehensive patient care,” the agency emphasizes in the final rule.

CMS does say it will grant another common public request — to release an OASIS draft early to allow HHAs ample time to prepare for the big change. “We plan to publish a draft of the revised OASIS instrument in early 2020,” CMS reveals.

As with a phase-in, CMS also shot down multiple requests to hold off on adopting any new quality measures until they are endorsed by the National Quality Forum. “When a feasible and practical measure has not been NQF-endorsed for a specified area or medical topic,” the law allows the Department of Health and Human Services “to specify a measure that is not NQF-endorsed as long as due consideration is given to the measures that have been endorsed,” CMS insists in the rule.

Accordingly, “there is currently no feasible NQF-endorsed measure that we could adopt … that better addresses the Transfer of Health Information measure domain,” CMS maintains. “We plan to submit the measures for NQF endorsement consid­eration as soon as feasible.”

Note: The final rule is at www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24026.pdf.