Home Health & Hospice Week

Some patients should be excluded from this new quality reporting measure, providers tell CMS.

You should already be collecting data on your patients' pain management, but many hospices are hoping Medicare throws out some of that data in calculating outcomes.

So said a multitude of hospices in their comments on the 2013 home health prospective payment system final rule, which included a section on hospice quality reporting (see Eli's HCW, Vol. XXI, No. 25).

Currently, the Centers for Medicare & Medicaid Services plans to include data from patients who, under National Quality Forum-endorsed measure #209 on pain management, report pain upon admission and then are unable to respond to the measure 48 hours later due to death, disease progression, etc.

"Only patients who can self-report at both the initial assessment and the 48-hour mark should be included," urges Hospice of Dubuque in its comment letter on the rule published in the July 13 Federal Register. "Otherwise, for public reporting, the percentages reported by hospices that experience very short lengths of stay will be negatively skewed against those with longer stays."

Many patients are referred late to hospice, points out A*Med Community Hospice in Texas. "They come on with pain or shortness of breath and once the pain is controlled or anxiety due to shortness of breath, they are able to relax and let go and they die within a day or two," the A*Med representative says in the hospice's comments. "It doesn't make sense that this would count as a negative outcome."

The bottom line: "I have worked many years in hospice and have seen evidence that patients can't let go and die until their pain is relieved or anxiety is relieved," the A*Med rep continues.

To include patients who can't respond "does not provide CMS or the public with a true picture of how well the hospice is able to provide comfort within 48 hours to those patients who are able to complete the survey," stresses Arkansas Hospice in its comments. "Keeping those patients who cannot self-report within 48 to 72 hours in the denominator skews the data and will not give anyone an idea of the quality of care this measure is seeking to capture."

Death and disease progression aren't the only reasons patients may not be able to respond, points out Leading Age (formerly the American Association of Homes and Services for the Aging). Some pediatric patients and those with dementia also may be unable to express their pain.

Some ideas: CMS should allow hospice clinicians to use pain scale tools such as pain faces or the ESAS-R scale, Leading Age suggests. And others (such as hospice staff or caregivers) should be able to report their observations for the measure, other commenters suggest.

Revision: The 48-hour timeframe for reporting may be too long anyway, suggests Agrace Hospice-Care in Wisconsin. "The current pain measure does not align with best practice, in that a nurse would not wait 48 hours to evaluate pain that was present on admission," the hospice says in its comment letter. "Having to measure the patient's response in this late timeframe means that the nurse is reassessing at an earlier time for best practice, and then an additional time simply to meet the requirements of data collection."

Stay tuned: Observers expect CMS to publish the 2013 home health PPS final rule any day.