By Maureen Kelleher, RN, MBA
SimiTree Senior Manager
The FY2022 Hospice Quality Reporting Program (HQRP) contains four quality measures that capture care across the hospice stay. These measures will continue through FY2023. These measures are:
- HIS-Based Hospice Comprehensive Assessment at Admission (NQF #3235)
- Claims-Based Hospice Care Index (HCI)
- Claims-Based Hospice Visits in the Last Days of Life (HVLDL)
- CAHPS Hospice Survey
Hospice Item Set (HIS) requirements continue to be based on timeliness of submissions. Hospices must submit at least 90 percent of all HIS records within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring Jan. 1, 2022–Dec. 31, 2022. The completion dates for answering the specific questions also remain the same; however, the quality scores are based on submissions within 30 days. This should already be an established practice for hospice programs.
If you are a new hospice program, you will want to be sure your EMR system has the HIS questions built into the software and is capable of, at minimum, pulling a file in the correct format of the necessary data. Some systems may have an interface for submissions. Most, however, do not and you will need to save the file to your desktop to upload via your QIES account and secure access. There is no exception for small programs for this quality measure.
CAHPS Hospice Survey
Ongoing monthly participation (from January through December of each year) in the CAHPS Hospice Survey is required, with an approved third-party vendor that submits data according to the quarterly deadlines on behalf of the hospice. A list of the approved vendors can be found on the CAHPS Hospice Survey website. For CAHPS surveys, there is an exception for smaller programs who have less than 50 decedents in a year.
Hospice Care Index (HCI)
The Hospice Care Index (HCI) indicators include: Continuous Home Care or General Inpatient Provided, Gaps in Skilled Nursing Visits exceeding 7 days, Early Live discharges within 7 days after admission, Late Live Discharges on or after 180 days after admission, Burdensome Transitions (Type 1): Live discharges followed by hospitalization and subsequent hospice readmission within two days of hospital discharge, Burdensome Transitions (Type 2) ): Live Discharges from Hospice followed by hospitalization and the patient dying in the hospital, Per-beneficiary Medicare Spending, Skilled Nursing Care Minutes per RHC day, Skilled Nursing Minutes on Weekend, and Visits Near Death (at least one visit by a skilled nurse or social worker during the last 3 days of the patient’s life. This data is automatically collected from claims. Therefore, hospices are considered 100 percent compliant with the submission of these data (a gift from CMS).
Hospice Visits in the Last Days of Life
Hospice Visits in the Last Days of Life (HVLDL) measures patients who receive in-person visits from a registered nurse or medical social worker on at least two out of the final three days of the patient’s life. This data is also automatically collected from claims. Therefore, hospices are considered 100 percent compliant with the submission of these data (a gift from CMS).
CMS has added hospices to the Star Rating system and this has been available to the public since August 2022. You can find your program’s star rating here. Currently, the financial impact for these measures is based on compliance with submitting the data and half of the measures are automatically done for hospice. The future financial impact may be based on the actual quality scores and star ratings.
It is critical that all visit notes are completed and visits are added to your claims prior to claim submission to ensure the information pulled for the quality measures is as accurate as possible.
Maureen Kelleher, RN, MBA
SimiTree Senior Manager