Hospice quality reporting update june 2014
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Hospice Quality Reporting Update: June 2014. Presented by: Anne Shelley, MBA, BSN, RN Susan Wallace, MSW, LSW. Objective. Discuss the updates to hospice quality reporting requirements. Hospice Quality Reporting Program. Structural Measure & Comfortable Dying Measure Concluded April 2014

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Hospice Quality Reporting Update: June 2014

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Hospice quality reporting update june 2014

Hospice Quality Reporting Update: June 2014

Presented by:

Anne Shelley, MBA, BSN, RN

Susan Wallace, MSW, LSW


Objective

Objective

  • Discuss the updates to hospice quality reporting requirements.


Hospice quality reporting program

Hospice Quality Reporting Program

  • Structural Measure & Comfortable Dying Measure

    • Concluded April 2014

  • Hospice Item Set

    • July 2014

  • Hospice Experience of Care Instrument/CAHPS

    • Early 2015


  • What is the his

    What is the HIS?

    • “Item Set” vs. “Standardized Assessment”

    • Based on seven NQF-endorsed measures

      • Treatment preferences (CPR, Hospitalization, Other life-sustaining treatments

      • Beliefs/values addressed

      • Pain screening and assessment (2)

      • Dyspnea screening and treatment (2)

      • Opioid and bowel regimen


    What is the his1

    What is the HIS?

    • Admission & Discharge

    • Completed for ALL patients

    • Submitted on a rolling basis

      • Completed: 14 days from admission, 7 days from discharge

      • Submitted: 30 days from admission/discharge

  • Linked to 2% market basket reduction


  • A new alphabet soup

    A NEW Alphabet Soup

    • QIES ASAP

    CASPER

    RTI

    QTSO

    HQRP

    NQF

    HIS

    HART

    MAP


    Preparation

    Preparation

    • Research

    • Staff Assignment

    • Medical Records Evaluation, Reconciliation with the HIS

    • Organizational Communication Plan

    • Staff Education

    • Implementation


    Research

    Research

    • http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html

      • HIS Manual

      • Training Slides (2/4 & 2/5)

      • Fact Sheet

  • https://www.qtso.com/hospice.html

    • Registration announcement

    • Technical Training Modules

    • Other announcements

  • https://www.qtso.com/hart.html


  • Staff assignment

    Staff Assignment

    • Who needs to be involved in planning?

      • QAPI/Compliance

      • Executive Director

      • P&P Interdisciplinary Group

      • Care Managers

      • Administrative staff

  • Preliminary estimate of staff hours required

    • Paper: 40 minutes per patient

    • EMR: 15-20 minutes per patient


  • Medical records evaluation reconciliation with the his

    Medical Records Evaluation, Reconciliation with the HIS

    • Contact EMR vendor

      • Are assessments aligned with HIS items and language?

      • Will reporting mechanisms be fully functional by July?

      • Will reporting mechanisms match CMS expectations?

  • Crosswalk the HIS to your records

  • Time Study


  • Organizational communication plan

    Organizational Communication Plan

    • Leadership

      • Resource Allocation/Redistribution

  • Communication to Board

  • Initial Education Plan for Staff

  • Ongoing Education Plan for Staff

    • Orientation/Training

    • Annual Updates


  • Staff education

    Staff Education


    Implementation

    Implementation


    What is the hospice experience of care instrument

    What is the Hospice Experience of Care Instrument?

    • Evaluation of the patient/family’s experience of care

      • Caregiver as proxy

      • Post-death

  • Similar to CAHPS surveys

  • Similar to the Family Evaluation of Hospice Care (FEHC)

  • Developed by Rand Corporation

  • Three versions based on place of death

    • Home, Inpatient, Nursing Facility


  • Hospice eocs cahps timeline

    Hospice EOCS (CAHPS): Timeline

    • First quarter 2015: 1-month “trial run” for submission

    • April 1, 2015: Begin continuous usage


    Vendors

    Vendors

    • Hospices must contract with CMS-approved vendor

    • Vendor applications: late 2014

    • Home Health CAHPS Vendors:

      • https://homehealthcahps.org/GeneralInformation/ApprovedSurveyVendors.aspx


    On the horizon

    On the Horizon


    Nqf endorsement process

    NQF Endorsement Process

    • Call for Measures

    • Call for Nominations

    • Measure Review

    • Comment

    • Voting

    • CSAC Decision

    • Board Ratification

    • Appeals


    Measures application partnership

    Measures Application Partnership

    • Measure concepts:

      • pain

      • goal attainment

      • patient engagement

      • care coordination

      • depression

      • caregiver’s role

      • timely referral to hospice


    April 2014 call for tep nominations

    April 2014: Call for TEP Nominations

    • Project Objectives Include:

    • Investigate the potential for expanding existing quality measures or measure concepts to the Hospice QRP.

    • Generate measure ideas/concepts that address gaps in the current Hospice QRP identified by stakeholders such as the Measures Application Partnership (MAP).


    Questions

    Questions?


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