CMS Wants Proof of Hospice Value: Prove it With QAPI

1. Tidewater Hospice Lynda Laff Susan Saxon, Administrator Laff Associates Tidewater Hospice (843) 671-4170 (843) 757-9388 llaff@laffassociates.com SusanSaxon@TidewaterHospice.com CMS Wants Proof of Hospice Value: Prove it With QAPI

2. Value Based Purchasing CMS Report To Congress November 21, 2007 Authorized Value Based Purchasing Plan Phase out current system for quality reporting in hospitals (first step) Payment contingent on performancerather than simply on reporting

3. VBP Program Goals Improve Clinical Quality Address underuse, overuse, and misuse of services Encourage patient-centered care Reduce �potentially avoidable events� (formerly known as adverse events) and improve patient safety Transform Medicare from a passive payer to an active purchaser of high quality, efficient care Avoid unnecessary costs in care Current Medicare payment systems are based on resource consumption and quantity of care NOT quality or unnecessary costs avoided Stimulate investments in effective information technology and the re-engineering of systems Make results transparent and useable

4. Hospice Condition ofParticipation � 418.58  Transparency of information Encourage patient-centered care Reduce adverse events and improve patient safety To ensure that hospice resources are being used effectively and efficiently Ability to Compare Provider Performance � Benchmark Evidence of quality care�in other words�Data Driven Quality and Performance!

5. Publicly Reported Outcomes There is a Pattern� Hospitals are currently required to report performance on Quality Outcomes through *HCAHPS(standardized patient satisfaction) Home Care will be required to report HHCAPS in 2011 There will be withholds for not reporting and potential incentives for positive outcomes Hospice is now on the radar! *Hospital Consumer Assessment of Healthcare Providers and Systems

6. Hospice Growth 1982 - 2007

7. Rising Per Patient Costs

8. Changing Face of Hospice

11. Medicare Part A Expenditures

12. CMS Hospice Data Analysis Data is inconclusive and obscure Median profit margin for large for-profit hospices = 18% Median for large non-profit hospice = 2% No detail in Hospice cost report data No Information provided on; Types of personnel providing care Actual services provided Frequency or duration of patient visits

13. More Transparency July 2008 Hospices were required to begin reporting the number of visits by type Excluded bereavement process Excluded MSW indirect time January 2010 Visits must be reported by type in 15 minute increments *MedPac suggests that changes will lead to a  re-evaluation of the hospice payment system *Medicare Payment Advisory Commission

14. Hospice CoPs � 418.58 Transparency of information Encourage patient-centered care Reduce adverse events and improve patient safety To ensure that hospice resources are being used effectively and efficiently Ability to compare provider performance � benchmark Evidence of quality care�in other words�Data Driven Quality and Performance!  Sound Familiar?

15. QAPI Condition ofParticipation � 418.58 Use DATA to Improve Your Performance Develop, implement, and maintain aneffective, continuous quality assessmentand performance improvement program Use proven and reliable tools and processes Monitor and improve performance continually Respond to the needs, desires, and satisfaction levels of the patients and families Ensure effectiveness and efficiency

16. Condition of Participation� 418.58 Quality Assessment:Performance Improvement Scope of QAPI program�include ALL pertinent indicators How and why you chose specific quality measures How you ensure consistent data collection How you use data in patient care planning How you aggregate and analyze data How you use the data analysis to select PI projects How you implement PI projects How you use data to evaluate the effectiveness of those projects

17. Develop A QAPI Plan Who will be responsible for QAPI program What services and processes are to be assessed What data to be documented and aggregated When high volume, problem prone care and services are provided How often data will be collected and analyzed and how will the findings be used How you will implement action plan findings into ongoing care plan development What method(s) will be used to evaluate improvement How often you will report on performance

18. It�s All About The Data� PI activities Key Hospice demographic data collection and benchmarking Patient and Family Satisfaction Adverse Event Monitoring Process Outcomes Patient Outcomes

19. Benchmark Important Statistics Average length of service (LOS) Total % of patients discharged due to death Percent of Patients who died in greater than 180 days Percent and LOS of patients by diagnosis Percent of adverse events related to total census Falls Wounds not Present On Admission Percent of GIP days

20. Adverse Events

21. Select Measurable Indicators Measurable Indicators Relevant to YOUR agency and YOUR patient population High volume and problem prone measures Potential areas of risk Processes and outcome measures common in your agency Include all locations and level of service as appropriate Automate data collection whenever possible using established databases whenever possible Demographics Selected indicators

22. Incorporate All Levels of Care Routine home care Respite care General Inpatient Care Skilled Facility as Residence Continuous Care Focus Efforts Largest concentration of patients Highest risk and / or problem prone

23. Tidewater Hospice Small privately owned hospice Average daily census of 25 patients Performance Improvement plan initiated Infection control, surveillance, and analysis Employee occurrence monitoring Patient adverse event monitoring

24. Performance Improvement Program Quarterly clinical record audits completed Process measures in place Documentation of Local Coverage Determinations (LCD)for each patient Signed physician certification of terminal illness Presence of orders for care and treatment Timeliness of completion of interdisciplinary care plan Timeliness of necessary assessments Interventions implemented according to care plan

25. Tidewater Hospice May 2008 Performance improvement program reviewed Infection control log Occurrence Reports Clinical record audits Symptom management

26. Findings of Initial Review Qualification of types infections monitored UTI. URI, Wound Finite definition of adverse event CMS definition = �any action or inaction by a hospice that caused harm to a hospice patient� Clinical record audits Format and process Set frequency and reporting of audit findings Written evidence of follow-up action plans at defined intervals Symptom Assessment limited to pain control Data collection not ongoing or reliably measurable

27. Tidewater Hospice June 2008 Edmonton Assessment Tool used as a guide Symptom monitoring � Pain, SOB and constipation Pain or SOB = a score of 4 Intervention within 4 hours of identification of score = 4 Re-assessment within 24 hours, 48 hours until resolution Assessment at least 1 time every 8 days

28. Tidewater Hospice June 2008 Constipation assessment Assessment at least every 8 days Must document date of last bowel movement No bowel movement in 4 or more days = constipation Intervention within 4 hours Follow-up assessments until results or patient/family satisfied

29. June Audits Action Plan Clarification of patient / family �accepted� level of pain, SOB and patient�s �normal� bowel routine Added: Patient / family acceptable level of pain, SOB to visit assessments Patient�s normal bowel movement frequency (number of days) to visit assessment �Patient / family satisfied ? yes ? no� on each symptom assessment Changed Wong-Baker FACES scale from 1 � 5 scale to1 � 10 scale

30. July 2008 Actions � Interventions Clinicians & patients had difficulty with 1 � 10 scale Initiated additional education for clinicians and patients Clarified: 1 � 3 = mild symptom; 4 � 6 = moderate symptom; 7 � 10 = severe with 10 being the�worst symptom gets� Clarified difference in FACES 1-10 scale for non-verbal patients; 1-10 scale for patients able to verbalize pain Reviewed how nurses were actually assessing pain More intuitive versus scale oriented Focused on teaching them to attacha number to the �intuitiveness� Added �worst pain in 24 hours� todetermine actual level of pain control

31. August 2008 Actions/Interventions Developed separate follow-up note to define 4, 24, 48 and 72 hour follow up assessments Redesigned visit notes to include all data collection items and standardized interventions; QAPI collection data identified for ease in extraction from notes Updated visit notes to include descriptor on when/how to use both pain scales Began using automated data collection tool

32. Current Collectionand Reporting All admissions entered into automated tool Symptom assessments on each visit Data from assessments collected twice monthly Dynamic automated reports can be generated monthly and quarterly Data results presented to staff monthly Key performance measures reported to Board of Directors quarterly

33. Use Data To Improve Care Review and discuss data from symptom assessmentsin IDG Provided visuals to easily identify and quantify levels of adequate or inadequate patient symptom control Served as a means to refine our care delivery process for those patients with inadequate control

34. Pain Assessment

35. Key Performance Indicators

36. Data Driven Performance Improvement Data drives strategic decisions Action Plans; Standardize patient diagnosis coding for diagnoses with LCD Monitored diagnoses under CMS scrutiny Strategic Marketing What types of patients? Which Physicians? Levels of care � focus on routine home care Locations (SNF, Assisted Living)customers can be problematic

37. Current Action Plans Admission criteria Must meet LCD Must desire palliative care Adverse events Focus on % of occurrence by location Location where highest % of falls occur Location where highest % of wounds occur Clinical education Qualifications for admission of patient to hospice Understanding of Local Coverage Determination Thorough and accurate documentation to support eligibility Patient assessment and documentation of symptomsat each visit

38. Primary DiagnosisDistribution

39. Admissions by Location Distribution

40. Deaths By Location

41. Tidewater Data Routine Home Care = 87.3% of patient days 42.9% of patients on service = 7 days 6.9% of patients on service > 90 days

42. Lynda Laff Susan Saxon, Administrator Laff Associates Tidewater Hospice (843) 671-4170 (843) 757-9388 llaff@laffassociates.com SusanSaxon@TidewaterHospice.com Contact Information