Home Health & Hospice Week

Start collecting new HIS item data April 1.

Get ready to answer for your visit utilization in the last days of patients’ lives, under a newly adopted quality measure.

Back in April, the Centers for Medicare & Medicaid Services proposed two new quality measures for hospices. In the 2017 final rule for hospice payment released July 29, CMS adopts the measures as proposed.

One is “Hospice Visits When Death is Imminent,” which actually combines two metrics:

• “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,” CMS says in the final rule.
• “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.”

“Measure 1 addresses case management and clinical care,” CMS explains in the rule scheduled for publication in the Aug. 5 Federal Register.

“Measure 2 gives providers the flexibility to provide individualized care that is in line with the patient, family, and caregiver’s preferences and goals for care and contributing to the overall well-being of the individual and others important in their life.”

Unique: This measure, unlike the other existing measures, is the only one that addresses care at the end of life. With this measure added, “this quality measure set will fill a gap by addressing hospice care provided at the end of life,” CMS says in the final rule. “No current HQRP measures address care beyond the hospice initial and comprehensive assessment period.” (For a list of current and new measures, see sidebar, this page).

Multiple commenters on the proposed rule questioned this measure’s effectiveness at actually gauging quality. Many factors can contribute to fewer visits at end of life, ranging from comprehensive and effective preparation for end of life for families and caregivers to cultural and religious beliefs, commenters told CMS.

“While we agree that a greater number of visits does not always indicate higher quality care, based on the published literature and expert input, we believe that most patients benefit from some visits near the end of life,” CMS responds in the final rule. “For this reason, this measure set is specified to measure receipt of at least 1 clinician visit (Measure 1) and at least 2 visits from other staff (Measure 2), rather than measuring the total number of visits.”

Commenters also urged CMS to include post mortem and bereavement visits in the measure.  “These services are outside the scope of this quality measure pair, which focuses specifically on visits when death is imminent,” CMS responds.

And other commenters urged CMS to include phone calls. “Calls can be helpful in facilitating ongoing care and communication,” the rule allows. “However … we consider these calls as a supplement to, and not a replacement for, in-person care, particularly when death is imminent.”

Timeline: CMS has proposed four new Hospice Item Set measures to collect data for this measure. Pending their approval from the Office of Management and Budget, “hospice providers would begin data collection for this measure for patient admissions and discharges occurring after April 1, 2017,” CMS says in the final rule.

CMS Maximizes Public Reporting With LOS Exclusion Change

CMS also adopts as final the other new measure it proposed, “Hospice and Palliative Care Composite Process Measure.” The measure is a composite of seven already existing measures.

“The 4 domains captured by this composite measure are the Structure and Process of Care Domain; the Physical Aspects of Care Domain; the Spiritual, Religious, and Existential Aspects of Care Domain, and the Ethical and Legal Aspects of Care Domain,” CMS explains in the rule. 

LOS change: When CMS proposed this measure back in April, it also proposed “retiring” the exclusion of patients with lengths of stay seven days or fewer for six of the seven measures in the composite.

A number of hospices were not happy with that change. “Commenters noted that upon admission for imminently dying patients, a comprehensive assessment is not in the interest of patients and caregivers, nor may it be feasible for hospices to deliver because the focus is ... appropriately directed to other priorities,” CMS notes in the final rule. “One commenter stated that the level and intensity of hospices’ services are different for patients with short LOS and that the items captured in this measure are not reflective of quality of care for patients imminently dying.”

Commenters suggested alternatives such as leaving the exclusion in place, creating a different measure for short-stay patients, and risk-adjusting for short-stay patients.

CMS did not take any of commenters’ advice in this area. “Developing and adopting measures that benefit patient outcomes and do not lead to negative unintended consequences of the utmost importance to CMS,” the agency maintains in the rule. But “excluding stays with LOS less than 7 days result in many hospices not having sufficient denominator size to allow for public display of their quality scores,” CMS continues. “Although the LOS exclusion has a sizable impact on the number of hospices eligible to have their data publicly displayed, the impact of the LOS exclusions on the distribution of hospices’ scores is generally small for all of the QMs. Therefore, removing the LOS exclusion criteria will increase the number of hospices eligible for public reporting while having a minimal impact on the QM scores.”

CMS notes that it already risk-adjusts the measures that comprise the new composite measure, but it will keep risk adjustment for LOS in mind for the future.

At least there won’t be any new data burden for this measure. “No new data collection will be required,” CMS emphasizes in the rule. “Data for the composite measure will come from existing items from the existing 7 HQRP component measures.”

Timeline: But CMS will wait to begin calculating the measure until April 2017 anyway. “This means patient admissions occurring after April 1, 2017 would be included in the composite measure calculation,” the agency clarifies in the final rule.

Note: See the proposed Hospice Item Set changes supporting the new measures by searching for “CMS-R-245” at www.cms.gov/RegulationsandGuidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.