1. ©Copyright Deyta, LLC, All Rights Reserved The Path to Hospice Public Reporting Rebecca Van Vorst, MSPH Pennsylvania Homecare Association 2012 Annual Conference State College, PA May 16, 2012 The Path to Hospice Public Reporting Rebecca Van Vorst, MSPH Pennsylvania Homecare Association 2012 Annual Conference State College, PA May 16, 2012

2. ©Copyright Deyta, LLC, All Rights Reserved Objectives Describe the current regulatory requirements of the hospice quality reporting program. Identify the hospice quality measures endorsed by the National Quality Forum. Discuss three ways hospices can prepare now for future reporting requirements. Describe the current regulatory requirements of the hospice quality reporting program. Identify the hospice quality measures endorsed by the National Quality Forum. Discuss three ways hospices can prepare now for future reporting requirements.

3. ©Copyright Deyta, LLC, All Rights Reserved Knowledge is the key to survival 3

4. ©Copyright Deyta, LLC, All Rights Reserved The Hospice Roadmap

5. ©Copyright Deyta, LLC, All Rights Reserved 5

6. CMS Roadmap for Quality Vision: The right care for the every person every time. Aims: Make care safe, effective, efficient, patient-centered, timely, equitable.

7. ©Copyright Deyta, LLC, All Rights Reserved CMS Quality Initiatives Industry encouraged to develop measures and collect data Standard measures identified Required reporting to CMS “Public” reporting for consumers – accountability Pay for performance = Value-based purchasing Industry encouraged to develop measures and collect data Standard measures identified Required reporting to CMS “Public” reporting for consumers – accountability Pay for performance = Value-based purchasing

8. ©Copyright Deyta, LLC, All Rights Reserved CMS Quality Initiatives Industry encouraged to develop measures and collect data Standard measures identified Required reporting to CMS “Public” reporting for consumers – accountability Pay for performance = Value-based purchasing Industry encouraged to develop measures and collect data Standard measures identified Required reporting to CMS “Public” reporting for consumers – accountability Pay for performance = Value-based purchasing Hospice

9. ©Copyright Deyta, LLC, All Rights Reserved Why Hospice NOW? CMS commitment to increasing availability and use of healthcare information – Informed decision making – Quality improvement Legislative mandate – Section 3004: Affordable Care Act CMS commitment to increasing availability and use of healthcare information – Informed decision making – Quality improvement Legislative mandate – Section 3004: Affordable Care Act

10. ©Copyright Deyta, LLC, All Rights Reserved Requires quality reporting for hospice and other post-acute settings – By October 1, 2012 the Secretary must publish hospice quality measures. Requires hospices to submit data – or lose reimbursement – for FY 2014 (10/1/13) and subsequent fiscal years Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions Aims to make quality data available to the public (no timeline given) Requires quality reporting for hospice and other post-acute settings – By October 1, 2012 the Secretary must publish hospice quality measures. Requires hospices to submit data – or lose reimbursement – for FY 2014 (10/1/13) and subsequent fiscal years Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions Aims to make quality data available to the public (no timeline given) 10 Section 3004 of the Patient Protection and Affordable Care Act March 23, 2010

11. ©Copyright Deyta, LLC, All Rights Reserved Hospice wage index for fiscal year 2012 – Continue the phase-out of the wage index budget neutrality adjustment factor (BNAF) Change the hospice aggregate cap calculation methodology Revise the time frame for the face-to-face encounter Begin implementation of a hospice quality reporting program. Hospice wage index for fiscal year 2012 – Continue the phase-out of the wage index budget neutrality adjustment factor (BNAF) Change the hospice aggregate cap calculation methodology Revise the time frame for the face-to-face encounter Begin implementation of a hospice quality reporting program. 11 Final Rule August 4, 2011

12. ©Copyright Deyta, LLC, All Rights Reserved Hospice Public Reporting “Influencers” NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001 – Source of required comfortable dying measure Brown/NHPCO FEHC, introduced 2003 QAPI CoP, published 2005, effective Dec 2008 – Driver of required structural measure CMS-funded PEACE project, reported Feb 2008 CMS-funded AIM project, reported Nov 2010 MedPAC quality TEP meeting Nov 11 – Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges NQF endorsement of hospice measures Feb 2012 NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001 – Source of required comfortable dying measure Brown/NHPCO FEHC, introduced 2003 QAPI CoP, published 2005, effective Dec 2008 – Driver of required structural measure CMS-funded PEACE project, reported Feb 2008 CMS-funded AIM project, reported Nov 2010 MedPAC quality TEP meeting Nov 11 – Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges NQF endorsement of hospice measures Feb 2012

13. ©Copyright Deyta, LLC, All Rights Reserved Quality Reporting The First Year 13

14. ©Copyright Deyta, LLC, All Rights Reserved Two Measures Required Now Comfortable Dying Measure (NQF #0209) – Comfort within 48 hours of admission SPECIFIC DEFINITION (NQF #0209) Structural Measure – Yes/No: Does your QAPI program include 3 or more quality indicators related to patient care? Comfortable Dying Measure (NQF #0209) – Comfort within 48 hours of admission SPECIFIC DEFINITION (NQF #0209) Structural Measure – Yes/No: Does your QAPI program include 3 or more quality indicators related to patient care?

15. ©Copyright Deyta, LLC, All Rights Reserved The Comfortable Dying Measure The first hospice reportable outcome measure

16. ©Copyright Deyta, LLC, All Rights Reserved NQF #0209 Comfortable Dying - Pain Brought to a Comfortable Level Within 48 Hours of Initial Assessment Percentage of patients who reported being uncomfortable because of pain at the initial assessment after admission to hospice services whose pain was brought to a comfortable level, as defined/reported by the patient, within 48 hours of the initial assessment

17. ©Copyright Deyta, LLC, All Rights Reserved Comfortable Dying Measure One of the EROM – End Result Outcome Measures – Safe and comfortable dying – Self-determined life closure – Effective grieving Developed as the “Comfortable Dying” measure by NHWG and NHPCO task force in 2001 – Two rounds of pilot testing Assure as many patients as possible are comfortable within 2 days of the start of hospice care One of the EROM – End Result Outcome Measures – Safe and comfortable dying – Self-determined life closure – Effective grieving Developed as the “Comfortable Dying” measure by NHWG and NHPCO task force in 2001 – Two rounds of pilot testing Assure as many patients as possible are comfortable within 2 days of the start of hospice care Designed to support good care management

18. ©Copyright Deyta, LLC, All Rights Reserved Key Concept: Comfortable Dying Measure Relies on patient report of “comfort” Two questions – “Are you uncomfortable because of pain?” – “Was your pain brought to a comfortable level within 48 hours of the initial assessment?” NOT on a numerical pain severity score – Can and should use numerical ratings in addition Relies on patient report of “comfort” Two questions – “Are you uncomfortable because of pain?” – “Was your pain brought to a comfortable level within 48 hours of the initial assessment?” NOT on a numerical pain severity score – Can and should use numerical ratings in addition

19. ©Copyright Deyta, LLC, All Rights Reserved The Comfortable Dying Measure Are you uncomfortable because of pain? – Asked during the Initial Assessment – Asked BEFORE any pain assessments are done – Must be answered by the patient Was your pain brought to a comfortable level within 48 hours of your Initial Assessment ? – Only asked of those patients who said “Yes” to the first question – Asked between 48 and 72 hours after the Initial Assessment – Must be answered by the patient Are you uncomfortable because of pain? – Asked during the Initial Assessment – Asked BEFORE any pain assessments are done – Must be answered by the patient Was your pain brought to a comfortable level within 48 hours of your Initial Assessment ? – Only asked of those patients who said “Yes” to the first question – Asked between 48 and 72 hours after the Initial Assessment – Must be answered by the patient 19

20. ©Copyright Deyta, LLC, All Rights Reserved Measure Definitions Includes all eligible patients: – Able to communicate and understand the language of the person asking the question; – Able to self-report an answer to first question; and – At least 18 years of age or older. Denominator: Number of patients who relied “yes” when asked if they were uncomfortable because of pain at the initial assessment (after admission to hospice services) Numerator: Number of patients whose pain was brought to a comfortable level (as defined by the patient) within 48 hours of initial assessment (after admission to hospice services) Includes all eligible patients: – Able to communicate and understand the language of the person asking the question; – Able to self-report an answer to first question; and – At least 18 years of age or older. Denominator: Number of patients who relied “yes” when asked if they were uncomfortable because of pain at the initial assessment (after admission to hospice services) Numerator: Number of patients whose pain was brought to a comfortable level (as defined by the patient) within 48 hours of initial assessment (after admission to hospice services)

21. ©Copyright Deyta, LLC, All Rights Reserved The Comfortable Dying Measure 21 Numerator =Only those patients from the denominator who: Answer “YES” to the second question Denominator =All patients who: Are at least 18 years of age or older; Are able to communicate and understand the language of the person asking the question; Are able to self-report on admission; and Answer “YES” to the first question

22. ©Copyright Deyta, LLC, All Rights Reserved The Comfortable Dying Measure 22 Data Collection & Reporting Path

23. ©Copyright Deyta, LLC, All Rights Reserved The Comfortable Dying Measure 23 NO expectation that the measure score will be 100% Allows for the fact that some patients will not achieve a comfortable level Encourages hospices to make the effort to collect data for the second question Reflects expert opinion that most patients can and should have pain brought to a comfortable level within 2 days of the start of hospice care NO expectation that the measure score will be 100% Allows for the fact that some patients will not achieve a comfortable level Encourages hospices to make the effort to collect data for the second question Reflects expert opinion that most patients can and should have pain brought to a comfortable level within 2 days of the start of hospice care

24. ©Copyright Deyta, LLC, All Rights Reserved The Comfortable Dying Measure - Timeline 24 Mandatory Data Collection Period October 1 – December 31, 2012 Mandatory Data Submission Deadline April 1, 2013

25. ©Copyright Deyta, LLC, All Rights Reserved The Structural Measure Informing the future

26. ©Copyright Deyta, LLC, All Rights Reserved Two-part measure: Participation in a QAPI Program that includes at least 3 quality indicators related to patient care – This is a YES or NO question If yes, submit a description of the quality indicators being used that relate to patient care – Submission of a list of indicators, NOT the results Two-part measure: Participation in a QAPI Program that includes at least 3 quality indicators related to patient care – This is a YES or NO question If yes, submit a description of the quality indicators being used that relate to patient care – Submission of a list of indicators, NOT the results The Structural Measure

27. ©Copyright Deyta, LLC, All Rights Reserved Indicators Related to Patient Care Domains: Providing care in accordance with documented patient/family goals Effective and timely symptom management Care coordination Patient safety Indicators Related to Patient Care Domains: Providing care in accordance with documented patient/family goals Effective and timely symptom management Care coordination Patient safety The Structural Measure

28. ©Copyright Deyta, LLC, All Rights Reserved Data Collection Requirements: Indicator Topic – selected from a dropdown list Indicator Name – full name of the indicator Brief Description – complete description of the indicator including any information that will help CMS understand what the indicator measures Numerator – variable that is on the top part of the fraction that describes the process, condition, event or outcome that satisfies the measure Denominator – variable that is on the bottom part of the fraction that describes the population evaluated Data Source – data source such as survey or EMR Data Collection Requirements: Indicator Topic – selected from a dropdown list Indicator Name – full name of the indicator Brief Description – complete description of the indicator including any information that will help CMS understand what the indicator measures Numerator – variable that is on the top part of the fraction that describes the process, condition, event or outcome that satisfies the measure Denominator – variable that is on the bottom part of the fraction that describes the population evaluated Data Source – data source such as survey or EMR The Structural Measure

29. ©Copyright Deyta, LLC, All Rights Reserved Indicator Topic: 36 Categories + “Other” Examples: – Pain assessment or management – Anxiety assessment or management – Communication with patient/family – Culturally sensitive caregiving – Emotional care before and/or at time of death – Bereavement care – Infection reporting and control – and many more… ! Indicator Topic: 36 Categories + “Other” Examples: – Pain assessment or management – Anxiety assessment or management – Communication with patient/family – Culturally sensitive caregiving – Emotional care before and/or at time of death – Bereavement care – Infection reporting and control – and many more… ! The Structural Measure

30. ©Copyright Deyta, LLC, All Rights Reserved The Structural Measure - Example Indicator Topic (dropdown menu) Communication with patient/family Indicator NamePercentage of respondents who had enough instruction to do what was needed to care for the patient. Brief DescriptionQuestion D2 on the FEHC survey. Calculated from all who respond NumeratorTotal number of respondents reporting family participated in the patient's care while in hospice and who answered Yes DenominatorTotal number of respondents reporting family participated in the patient's care while in hospice and answered this question Data Source (dropdown menu) Family Survey/Questionnaire

31. ©Copyright Deyta, LLC, All Rights Reserved The Structural Measure - Timeline Voluntary Data Collection Period October 1 – December 31, 2011 Voluntary Data Submission Deadline January 31, 2012 Mandatory Data Collection Period October 1 – December 31, 2012 Mandatory Data Submission Deadline January 31, 2013

32. ©Copyright Deyta, LLC, All Rights Reserved More than 900 hospices submitted a total of 6721 indicators to CMS Deyta’s Voluntary Reporting Program: – 269 hospices took advantage of this program – 532 different indicators were submitted – 3 out of 4 hospices used indicators from the FEHC survey – 60% of hospices used indicators focused on patient’s comfort from pain – 41% of hospices tracked patient falls More than 900 hospices submitted a total of 6721 indicators to CMS Deyta’s Voluntary Reporting Program: – 269 hospices took advantage of this program – 532 different indicators were submitted – 3 out of 4 hospices used indicators from the FEHC survey – 60% of hospices used indicators focused on patient’s comfort from pain – 41% of hospices tracked patient falls The Structural Measure What we learned from voluntary reporting

33. ©Copyright Deyta, LLC, All Rights Reserved Quality Reporting Beyond 2013

34. ©Copyright Deyta, LLC, All Rights Reserved Remember the “Influencers” NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001 – Source of required comfortable dying measure Brown/NHPCO FEHC, introduced 2003 QAPI CoP, published 2005, effective Dec 2008 – Driver of required structural measure CMS-funded PEACE project, reported Feb 2008 CMS-funded AIM project, reported Nov 2010 MedPAC quality TEP meeting Nov 11 – Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges NQF endorsement of hospice measures Feb 2012 NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001 – Source of required comfortable dying measure Brown/NHPCO FEHC, introduced 2003 QAPI CoP, published 2005, effective Dec 2008 – Driver of required structural measure CMS-funded PEACE project, reported Feb 2008 CMS-funded AIM project, reported Nov 2010 MedPAC quality TEP meeting Nov 11 – Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges NQF endorsement of hospice measures Feb 2012

35. ©Copyright Deyta, LLC, All Rights Reserved Requires quality reporting for hospice and other post-acute settings Requires hospices to submit data to CMS – or lose partial reimbursement in FY 2014 Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions Potential pool for additional required measures Requires quality reporting for hospice and other post-acute settings Requires hospices to submit data to CMS – or lose partial reimbursement in FY 2014 Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions Potential pool for additional required measures 35 Remember the Regs

36. ©Copyright Deyta, LLC, All Rights Reserved Palliative and End-of-Life Project Identify and endorse measures for public reporting and quality improvement Sought to endorse performance measures on: – Assessment, management and relief of symptoms at EOL and for acutely ill patients  pain, dyspnea, weight loss, weakness, nausea, serious bowel problems, delirium, and depression – Patient- and family-centered palliative and hospice care that address psychosocial needs and care transitions – Patient, caregiver, and family experiences of care Maintenance review of nine palliative consensus standards April 4, 2011 Project funded by DHHS Identify and endorse measures for public reporting and quality improvement Sought to endorse performance measures on: – Assessment, management and relief of symptoms at EOL and for acutely ill patients  pain, dyspnea, weight loss, weakness, nausea, serious bowel problems, delirium, and depression – Patient- and family-centered palliative and hospice care that address psychosocial needs and care transitions – Patient, caregiver, and family experiences of care Maintenance review of nine palliative consensus standards April 4, 2011 Project funded by DHHS 36

37. ©Copyright Deyta, LLC, All Rights Reserved NQF’s Consensus Development Process 22 measures considered Comment period: 121 comments - 33 organizations 14 measures recommended for endorsement – Voluntary consensus standards suitable for accountability and performance improvement 9 measures appropriate for hospice 22 measures considered Comment period: 121 comments - 33 organizations 14 measures recommended for endorsement – Voluntary consensus standards suitable for accountability and performance improvement 9 measures appropriate for hospice 37

38. ©Copyright Deyta, LLC, All Rights Reserved Hospice Measures by Topic Pain Management Percentage of hospice or palliative care patients who were screened for pain during the hospice admission evaluation Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening. Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed. Pain Management Percentage of hospice or palliative care patients who were screened for pain during the hospice admission evaluation Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening. Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed. 38

39. ©Copyright Deyta, LLC, All Rights Reserved Hospice Measures by Topic Dyspnea Management Percentage of hospice or palliative care patients who were screened for dyspnea during the hospice admission evaluation. Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening. Dyspnea Management Percentage of hospice or palliative care patients who were screened for dyspnea during the hospice admission evaluation. Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening. 39

40. ©Copyright Deyta, LLC, All Rights Reserved Measures by Topic Quality of Care at the End of Life Composite Score: Derived from responses to 17 items on the Family Evaluation of Hospice Care (FEHC) survey presented as a single score ranging from 0 to 100. and Global Score: Percentage of best possible response (Excellent) to the overall rating question on the FEHC survey. (maintenance) Quality of Care at the End of Life Composite Score: Derived from responses to 17 items on the Family Evaluation of Hospice Care (FEHC) survey presented as a single score ranging from 0 to 100. and Global Score: Percentage of best possible response (Excellent) to the overall rating question on the FEHC survey. (maintenance) 40

41. ©Copyright Deyta, LLC, All Rights Reserved Measures by Topic Care Preference Measures Percentage of patients with chart documentation of preferences for life sustaining treatments. 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 Number of patients who report being uncomfortable because of pain at the initial assessment who report pain was brought to a comfortable level within 48 hours. (maintenance) Care Preference Measures Percentage of patients with chart documentation of preferences for life sustaining treatments. 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 Number of patients who report being uncomfortable because of pain at the initial assessment who report pain was brought to a comfortable level within 48 hours. (maintenance) 41

42. ©Copyright Deyta, LLC, All Rights Reserved PREPARING for required reporting 42 February 2012 “The great aim of education is not knowledge, but action.” - Herbert Spencer

43. ©Copyright Deyta, LLC, All Rights Reserved Preparations 1.Read the Final Rule http://www.gpo.gov/fdsys/pkg/FR-2011-08- 04/html/2011-19488.htm 2.Download the NHPCO instructions for using the Comfortable Dying measure (EROM Manual) http://www.nhpco.org/i4a/pages/Index.cfm? pageID=3376 http://www.nhpco.org/i4a/pages/Index.cfm? pageID=3376 1.Read the Final Rule http://www.gpo.gov/fdsys/pkg/FR-2011-08- 04/html/2011-19488.htm 2.Download the NHPCO instructions for using the Comfortable Dying measure (EROM Manual) http://www.nhpco.org/i4a/pages/Index.cfm? pageID=3376 http://www.nhpco.org/i4a/pages/Index.cfm? pageID=3376 43 February 2012

44. ©Copyright Deyta, LLC, All Rights Reserved Preparations 3.Start using the “Comfortable Dying” measure as soon as possible MUST collect data as of 10/1/2012 – Integrate into your more comprehensive pain assessment and pain management procedures – Train and retrain - Assure that staff understand  The purpose of the measure  Data collection and data recording procedures  How to use the data to achieve optimal pain management outcomes – Think of the medical record as a data source AND a tool for optimizing outcomes 3.Start using the “Comfortable Dying” measure as soon as possible MUST collect data as of 10/1/2012 – Integrate into your more comprehensive pain assessment and pain management procedures – Train and retrain - Assure that staff understand  The purpose of the measure  Data collection and data recording procedures  How to use the data to achieve optimal pain management outcomes – Think of the medical record as a data source AND a tool for optimizing outcomes

45. ©Copyright Deyta, LLC, All Rights Reserved Preparations 4.Consider participating in a performance measurement system to obtain comparative data – NHPCO DART system (NHPCO members only) – Quality Navigator – Deyta, LLC – Others 5.Monitor your results and conduct a PIP if necessary 4.Consider participating in a performance measurement system to obtain comparative data – NHPCO DART system (NHPCO members only) – Quality Navigator – Deyta, LLC – Others 5.Monitor your results and conduct a PIP if necessary

46. ©Copyright Deyta, LLC, All Rights Reserved Preparations 6.Check out the NQF endorsed measures http://www.qualityforum.org/Measures_List.aspx 7.Structural Measure – Define your list of measures – Confirm current measures and definitions 6.Check out the NQF endorsed measures http://www.qualityforum.org/Measures_List.aspx 7.Structural Measure – Define your list of measures – Confirm current measures and definitions

47. ©Copyright Deyta, LLC, All Rights Reserved Becky VanVorst, MSPH Director of Education and Data Analytics Deyta, LLC rvanvorst@deyta.com 518.753.8003 direct 518.956.3531 cell Becky VanVorst, MSPH Director of Education and Data Analytics Deyta, LLC rvanvorst@deyta.com 518.753.8003 direct 518.956.3531 cell