Eli's Hospice Insider

Published on Tue Nov 20, 2018 PDF

Plus: Watch for your next Compare preview report in early December.

A big change to how potential patients and referral sources view your quality data is imminent.

The Centers for Medicare & Medicaid Services will post hospices’ scores for “NQF #3235 Hospice and Palliative Care Composite Process Measure — Comprehensive Assessment at Admission” in its Hospice Compare refresh “later in November 2018,” a CMS official said in the Nov. 14 Open Door Forum for home health and hospice providers.

Hospices got a chance to see their score for the new measure in their September preview report, the CMS staffer reminded forum attendees. The new measure comes with a streamlining of the seven Hospice Item Set based measures that comprise it: Treatment Preferences (NQF #1641); Beliefs/Values (NQF #1647); Pain Screening (NQF #1634); Pain Assessment (NQF #1637); Dyspnea Screening (NQF #1639); Dyspnea Treatment (NQF #1638); and Bowel Regimen (NQF #1617).

Instead of displaying each of these seven items individually, the site will offer them “in an expandable/collapsible format under the composite measure itself, thus allowing users the opportunity to view the component measure scores that were used to calculate the main composite measure score,” the final rule explained.

CMS has posted more details about the new measure, including a set of Frequently Asked Questions, in a fact sheet at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/Hospice-Comprehensive-Assessment-QM-Background-and-Methodology-Fact-Sheet.pdf.

Don’t Forget The Deadline For Public Reporting Data

The Medicare official also reminded hospices of the new 4.5-month data reporting deadline for Hospice Compare data. Under the provision finalized in the 2019 final rule, data from HIS records “with target dates within the correlating quarter become a frozen ‘snapshot’ of data for public reporting purposes,” CMS explained in the rule. “Any record-level data correction after the date on which the data are frozen will not be incorporated into measure calculation for the purposes of public reporting on the CMS Hospice Compare website,” the rule noted.

In other words: After the 4.5-month deadline, which kicks in with the quarter beginning Jan. 1, the data will be “permanently frozen” on Hospice Compare, the CMS staff explained in the forum.

Watch for: To find out more about both of these changes, watch for registration to open for a Dec. 13 webinar on the topics, the rep said.

Other hospice items addressed in the forum include:

• Preview reports. The next round of Hospice Compare preview reports will be available Dec. 3, the CMS official said.
• CAHPS data discrepancies. Don’t be surprised if the CAHPS survey data displayed on Hospice Compare doesn’t match the data your vendor gives you exactly. The “results provided by your vendor aren’t the official scores,” a Medicare official said in the forum. That’s because your vendor may not apply risk adjustment as CMS does.

CMS risk adjusts the scores to make fair comparisons across provider types possible, the CMS staffer explained. “Leveling the playing field across hospices” is CMS’s goal, she said.

“To be clear, unadjusted scores can be used for quality improvement,” the Medicare official added. “You do not need to replicate the official scores” for your hospice’s personal use.

• CAHPS size exemption dates. Don’t forget that the reference year you use to apply for a size exemption from CAHPS is not the year for which you are requesting the exemption, the CMS staffer said in the forum.

For example: The application for 2018 is due Dec. 31. It is based on your patient count for calendar year 2017. Likewise, the application for exemption from 2019 CAHPS requirements will use data from CY 2018.