Future of Hospice Public Reporting

1. Future of Hospice Public Reporting Presented by: Kim Kranz, RN, MS Sr. VP Hospice and Palliative Care May 19, 2011

2. Home Nursing Agency • 35 diverse, non-profit programs providing home and community based services • CHAP accredited, Medicare certified Home Health • CHAP accredited, Medicare certified Hospice • Named to the Best Place to Work in Pennsylvania since 2004 • Earned the distinction of “Best Practices in Homecare and Hospice” by Pennsylvania Homecare Association • Recognized from Modern Healthcare as one of the Top 100 Best Places to Work in Healthcare in the nation • Recognized for implementing Best Practices in Operations Management • Serving Central Pennsylvania for 41 years • 1,000 employees in thirteencounties 32% employee growth in six years Over 23,000 patients served in 2010

3. A Lifetime of Caring

4. Overview • A brief overview of the QAPI requirements • The background of the AIM Project • The quality measures and data of the AIM Project • Lessons learned from the AIM Project • Ways that you can implement the AIM Project measures and data • What is on the horizon in hospice quality measurement

5. § 418.58 Quality Assessment and Performance Improvement • Core of patient-focused and outcome oriented Conditions of Participation (CoP) • Goal is to monitor quality/performance, find opportunities for improvement, and improve • Focus is on achieving desired outcomes

6. § 418.58 Quality Assessment and Performance Improvement QAPI operates on two levels • Patient-level and hospice-level At both levels, hospices must: • Collect data to assess quality • Use the date to identify opportunities for improvement • Demonstrate performance improvement in one or more areas

7. Patient Level QAPI • Collect data on what happened for an individual patient • Assess/reassessment • IDG plan of care/ update plan of care • Implement and document care Use the data to improve quality of care and outcomes for that patient

8. Hospice Level QAPI Data Clinical • Aggregate patient-level data • Collect satisfaction data Non-Clinical • Administrative data • Marketing – Referral source contact • Outreach to community • Profitability • Fundraising Use the data to improve clinical operations and Non-clinical operations

9. § 418.58 Quality Assessment and Performance Improvement The hospice must develop, implement, and maintain an effective, ongoing, hospice-wide, data-driven QAPI program The hospice must ensure that the program: • Reflects the complexity of its organization and services • Involves all hospice services (including those services furnished under contract or arrangement) • Focuses on indicators related to palliative outcomes • Takes actions to demonstrate improvement in hospice performance The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS

10. PEACE Project PEACE Project (Prepare, Embrace, Attend, Communicate, Empower) • Completed in February 2008 • Listed 34 suggested measures along with data definitions and a tool for data collection • Available at www.qualitynet.org • Completed by the Carolinas Center for Medical Excellence, the North Carolina QIO

11. AIM Project Background AIM Project (Assessment, Intervention, Measurement) • August 2009 – November 2010 • Conducted by IPRO, the New York State QIO • Implemented in 7 hospices and 1 palliative care site within the state of New York that volunteered to participate in the project. The participating sites were representative of hospices nationwide.

12. AIM Project Background PROJECT GOALS Use the PEACE quality measures and a modified version of the PEACE data collection tool to assess the quality of care in participating hospice sites, identify areas for performance improvement and measure quality of care improvements after performance improvement projects are implemented.

13. AIM Project Background PROJECT GOALS Examine various factors related to the quality of the data collection tool and quality measures in accordance with NQF standards. Identify factors contributing to disparate and inequitable access to and use of hospice services.

14. AIM Project Background The AIM Project was divided into 8 tasks and resulted in 4 major products: • A comprehensive literature review of existing research related to disparities in end-of-life care • An intervention package which hospices and QIOs can use to measure and improve the quality of care provided to hospice patients • http://www.ipro.org/index/hospice-aim • A report on each quality measure to be used in the NQF endorsement process, as appropriate • A final report on the project

15. AIM Quality Measures M1: Percent of patients who were assessed for physical symptoms and screened for psychological symptoms during the admission visit. M2: Percent of patients with comprehensive assessment completed within 5 days of admission. M3: For patients who assessed positive for pain, the percent whose pain was at a rating of non or mild at the second pain assessment. M4: For patients who assessed positive for dyspnea at rest, the percent of patients who improved within 1 day of assessment. M5: For the patients who assessed positive for nausea, the percent who received treatment within 1 day of assessment. M6: Percent of patients on opioids who had a bowel regimen initiated within 1 day of opioid initiation.

16. AIM Quality Measures M7: For patients who screened positive for anxiety, the percent who received treatment within two weeks of screening. M8: Percent of families reporting the hospice attended to family needs for information about medication, treatment and symptoms. M9: Provision of an interpreter or translator for non-English speaking or deaf patients. M10: Percent of patients who had moderate to severe pain on a standard rating at any time in the last week of life. M11: Percent of patients with documentation in the clinical record of an advance directive or discussion that there is no advance directive. M12: Number of adverse events per 1000 patient-days; falls, medication errors, DME issues, and patient/family complaints.

17. AIM Quality Measure Example Percent of patients who were assessed for physical symptoms and screened for psychological symptoms during the admission visit. • Pain • Dyspnea • Nausea • Constipation • Depression • Anxiety Performance = Credit

18. Data Collection Methods • All data collected retrospectively • Data collected for one year • Manual record reviews • 5% - 10% of discharges per month (total: 63 – 225) • Eligibility criteria • 18 and older • On service >7 days • Data entered in tool • Sent to IPRO monthly

19. The Clinical Record Purpose • Means of Communication • Quality data production Construct • Accurate • Complete picture of patient’s stay on service • Patient and family’s needs • Severity of symptoms • Management strategies • Patient preferences and outcomes • Must be a well developed and operational system

20. Problems During the Data Process

21. Problems During the CQM Process For patients who assessed positive for dyspnea at rest, the percentage of patients who improved within 1 day of assessment. • Standardize method to score severity not used • Symptoms not quantified • Inconsistent documentation of symptom severity • Abstraction tools difficult to use • Care issues not addressed • Documentation on symptom assessments missing in record • Patient goals not documented • Diagnosis, co-morbidities • Data missing/difficult to find • Definitions not clear

22. Pain Control – 1st to 2nd Assessment For patients who assessed positive for pain, the percent whose pain was at a rating of none or mild at the second pain assessment. • √ Aware of missing data • √ Quantified symptom severity ratings • √ Use of PAINAD/FLACC

23. Treatment for Nausea For the patients who assessed positive for nausea, the percent who received treatment within 1 day of assessment • √ Aware of missing data • √ Instituted symptom review forms • √ Use of Edmonton Scale

24. Treatment for Anxiety For patients who screened positive for anxiety, the percent who receive treatment within two weeks of screening. • √ Use of standardized screening instrument • √ Consistency in word documentation • √ Process implemented

25. Getting Ready Conceptualize clinical records as data source Optimize documentation methods Review organizational structure Establish teams

26. Conceptualize Clinical Records as Data Source Review current documentation processes • Locate the variables of interest in clinical record • Understand what your data area telling you • Documenting multiple assessment in same visit Know what your EMR is capable of • Are scales built in? • Can programming be done to “force” a response? • If making programming changes, do early! If using paper records, how are they organized? • Checklists/text

27. Optimize Documentation Methods Document consistently! • Establish policies for data element locations Utilize rating scales for assessments • Be aware of the limitations of current clinical instruments. • May not be instruments available that fit your clinical needs. Document “something” to avoid missing data

28. Review Organizational Structure Look at your systems/practices supporting the quality process • Champion/supporter • Review past organization changes • Identify areas of strength and weakness • Staff processes • Staff training time • Key personnel • Priorities/Empowerment Complete an Organizational Self-Assessment • NCP 8 essential domains of quality care • Structure and process • Culturally appropriate care • Physical symptoms • Psychological symptoms • Social aspects of care • Spiritual assessment • Imminently dying • Ethical and legal aspects of care

29. Establish Quality Team Team Members • Include 3 – 8 people from all disciplines • Leadership • Nursing • Physician • Social Work • Spiritual • Bereavement • QI and Education • Administrative support/medical records • Agency Sponsor • Support quality team at agency level • Project Leader • Staff goes to this person with questions or for resolutions

30. The Horizon: Section 3004 • Section 3004 of the Patient Protection and Affordable Care Act (aka the Affordable Care Act). • By October 1, 2012 the Secretary must publish hospice quality measures. • The published quality measures must receive endorsement from a consensus body (e.g. NQF), with exceptions.

31. The Horizon: Section 3004 • CMS must take steps to make hospice quality measure data available to the public (no timeline given). • Beginning of FY 2014, hospices that do not submit required quality measure data will have their market basket rate reduced by 2% for that FY.

32. CMS Contracts • CMS has a contract with RTI International to develop the hospice quality reporting program. • This contract also focuses on the other providers that area affected by section 3004 (e.g. long-term care hospitals). • RTI has convened technical expert panels for each affected provider type. These panels will help guide the process and outcomes.

33. The Horizon: Section 3004 Dialogue with Stakeholders • CMS held a listening session with industry leaders in November 2010 and a special Open Door Forum in December 2010 • There will be future Open Door Forums on this subject, as needed (Information about future CMS Open Door Forums can be found at: http://www.cms.gov/OpenDoorForums/17_ODF_HHHDME.asp)

34. The Horizon: Section 3004 Regulatory Process • There will be a series of regulations to implement the quality reporting requirements • The first NPRM is scheduled to be published in Spring 2011 • 60 day public comment period

35. The Horizon: Section 3004 NQF • Upcoming call for measures (Spring 2011????) • RTI will assist CMS in stewarding select measures through the endorsement process • CMS has no influence over which measures will be endorsed