HCAHPS: The Next Generation

An Addendum to The HCAHPS Handbook Lyn Ketelsen, RN, MBA

This information is intended to serve as an addendum to The HCAHPS Handbook: Hardwire Your Hospital for Pay-forPerformance Success (Fire Starter Publishing). The information and tactics herein will be further developed, along with other critical insights and recommendations, in the revised and expanded 2013 version of the book to be published this fall.

In 2011 and 2012 healthcare leaders in the acute care setting made a major paradigm shift. We moved away from vendor-based patient satisfaction tools and focused our efforts on the Centers for Medicare & Medicaid Services’ (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. While the vendor-based tools primarily measured the “feelings” patients had regarding their care, HCAHPS more accurately reflects an organization’s levels of quality and safety. Research shows that as HCAHPS results rise, so do clinical quality outcomes. (The graphic below, showing how an improvement in HCAHPS results correlates to a decrease in pressure ulcers, is just one example of the link between patient perception of care and quality.) This reality, combined with its transparency of reporting, raises the bar on performance. Of course, HCAHPS also directly affects us financially. In the last few months we have come to understand what impact our patient perception of care feedback has had and will likely continue to have on reimbursement. That’s a lot of change—especially on top of the other changes sparked by the Patient Protection and Affordable Care Act—and it’s just the beginning. Now, we have entered the next phase of HCAHPS. Effective with July 1, 2012, eligible discharges, CMS gave hospitals the opportunity to add five voluntary questions to the survey. Then, beginning in January 2013, the new questions became mandatory for all HCAHPS users.

What Are the Five New Questions? Three of the new HCAHPS questions—abbreviated as CTM-3 (Care Transition Measure)—will examine how well patients are transitioning to home or to their next phase of the care continuum. They will determine the acute care setting’s levels of engagement and effectiveness in managing this process. These questions were added due to a tremendous body of evidence showing that many patients leave the hospital not knowing how to approach their next phase of care. They may make medication errors, which in turn may lead to adverse events and re-hospitalization. By adding these questions to the survey, CMS hopes to focus care providers’ attention on the issues that make positive responses and thus improvements to this aspect of the care continuum more likely.

HCAHPS: The Next Generation

The CTM-3 questions, which make up the Care Transition Domain, are as follows:

Question 1: The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital.

Question 2: When I left the hospital, I had a good understanding Creating a 0-100 score: Step 1:

Calculate the sum of responses across the three items (score Strongly Disagree = 1; Disagree = 2; Agree = 3; Strongly Agree = 4).

Step 2:

Count the number of questions answered.

Step 3:

Calculate the mean response (sum divided by count).

Step 4:

Use linear transformation to convert to 0-100 score.

Below is a table outlining the conversion of the 1-4 scale to a 100-point scale.

of the things I was responsible for in managing my health.

Question 3: When I left the hospital, I clearly understood the purpose for taking each of my medications.

It’s important to note that the scale used for these questions has also changed. Results will be reported on a 0-100 basis using a scale of Strongly Agree, Agree, Disagree, and Strongly Disagree or Don’t Know/Don’t Remember/Not Applicable. The method for calculating this score is described to the left. In addition, the survey will include two new “about you” or demographic questions. While these questions will not be included in the public reporting, they will be used to calculate the case mix and mode adjustments:

Question 4: During this hospital stay, were you admitted to this hospital through the Emergency Room? Yes No

Why was the Emergency Room question added? Until June 2010, this information was collected from hospitals as an administrative code and was used as a patient-mix adjustment variable for HCAHPS scores. CMS presented evidence that this variable is meaningful to its payment calculation and thus added it back in.

Question 5: In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor

The mental health question was added due to requests from hospitals and researchers. Recent studies suggest that up to 20 percent of hospitalized patients suffer from severe depression. When other mental illnesses are considered, the incidence approaches 50 percent. Research has shown that there was significant decline in HCAHPS scores in patients identified in standardized mental illness assessment questionnaires in the pre- and post-operative ambulatory setting as severely depressed. Patient responses to this question will be factored into CMS reimbursement calculations.

Why the New HCAHPS Questions Matter As health reform changes are phased in, continuum of care is more important than ever. In October of 2012, CMS began penalizing hospitals for excess 30-day readmissions. And the implications go far beyond financial ones: our patients Page 2

HCAHPS: The Next Generation

are still our patients even after they are discharged. We naturally want to be confident they are receiving great care and continuing to heal outside the hospital walls. For these reasons, CMS’s decision to encourage hospitals to ensure that patients clearly understand continuum of care instructions might be viewed as a gift. Consider the following statistics: Twenty percent of patients discharged from the hospital experience an adverse event within three weeks. An adverse event is defined as an injury resulting from medical management rather than the underlying disease. The most common adverse events are medication related; they often can be avoided or mitigated.1 Estimated medication errors harm 1.5 million people each year in the United States according to the Institute of Medicine, at an annual cost of at least $3.5 billion.2 Within 30 days of discharge, approximately 2.6 million Medicare beneficiaries are re-hospitalized, at a cost of over $26 billion every year. The Medicare Payment Advisory Commission estimated that up to 76 percent of these readmissions may be preventable. Of Medicare beneficiaries who are readmitted within 30 days, 64 percent receive no postacute care between discharge and readmission.3 Direct communication between hospital physicians and primary care physicians occurred infrequently (in 3-20 percent of cases studied) according to a recent Agency for Healthcare Research and Quality (AHRQ) literature review. It was also found that the availability of a discharge summary at the first post-discharge visit was only 12-34 percent, affecting the quality of care in approximately 25 percent of follow-up visits.4 About 2.3 million (2 percent) ED visits are from patients who were discharged from the hospital within the previous seven days according to the 2008 National Health Statistics Report.5 A study of discharged patients found: Only 41 percent were able to state their diagnoses. Only 37 percent were able to state the purpose of their medications. Only 14 percent knew the common side effects of all their medications.6 When we improve continuum of care, we improve clinical outcomes, reduce preventable readmissions, and maximize

reimbursement. Healthcare.gov has defined the elements of a good transition: Transitions of care are a set of actions designed to ensure coordination and continuity. Based upon a comprehensive care plan. Use of well-trained practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status. Include logistical arrangements and education of patient and family, as well as coordination among the health professionals involved in the transition. Recommended Elements for Care Transitions: Patient (or caregiver) training to increase activation and self care skills. Patient-centered care plans are negotiated with patient and family and are responsive to the medical and social situation and the availability of services that are shared across settings of care. Standardized and accurate communication and information exchange between the transferring and receiving provider in time to allow the receiving provider to effectively care for the patient. Medication reconciliation and safe medication practices. Logistical arrangements including transportation for healthcare-related travel and procurement and timely delivery of medical equipment. Ensuring the sending provider maintains responsibility for care of the patient until the receiving clinician/location confirms the transfer and assumes responsibility for the patient’s follow-up care. At Studer Group, our goal is to offer specific tools and tactics to ensure that all quality, safety, financial, and satisfaction goals are met or exceeded. We are currently collecting and vetting the most impactful tools and tactics aimed at creating and sustaining the conditions that yield consistently high results on the new HCAHPS questions. They will be revealed in our updated and expanded edition of The HCAHPS Handbook: Hardwire Your Hospital for Pay-for-Performance Success. Here is an early glimpse at some actions that are yielding a good ROI for organizations:

1. Use Key Words at Key Times. These carefully cho-

sen words help the patient understand his or her care better. Page 3

HCAHPS: The Next Generation

They also reduce anxiety and build trust. For example, a nurse might say, “It is important for your safety that you understand the purpose of each of your medications. The number one reason for patients having complications and being readmitted is due to taking their medications incorrectly. Let’s review each of them so that we can ensure you know the purpose and the possible side effects. I will want you to be able to repeat this back to me so that I know you understand.”

2. Implement Bedside Shift Reports. By involving the

patient in critical conversations regarding their medications and post-discharge care plans, we go a long way toward ensuring that they understand the details of a safe transition. To connect this classic tactic to the new HCAHPS criteria, care providers might include in the Bedside Shift Report a discussion centered on who is responsible for what. Ensure that in the template of your SBAR format for report you include a discussion about the care transition plan. For instance: “As we continue to prepare for your transition home, here is where we are currently with your plan: Your care provider post-discharge will continue to be Dr. Smith, your PCP. We will ensure he has records of what occurred during your hospitalization. We also have heard your request and documented that you prefer not to have physical therapy after you return home but rather will manage this yourself through your own personal resources. However, we will continue to do physical therapy through your stay to keep you progressing. Today you will have PT come two times. Finally, as we assist you in managing your health status, we are going to continue to work with you during the rest of the hospitalization in preparing you for the smoking cessation plans so that you can continue those efforts at home. That means no smoke breaks today.”

3. Make Post-Visit Calls. Done properly and executed

consistently across the organization, these calls reduce readmissions and save lives. They also create better clinical outcomes, decrease patient anxiety, and in general provide a better experience for patients. During these calls, it’s important to ask questions aimed at making sure patients understand their post-discharge instructions and the purpose of the medications.

4. Make interdisciplinary rounds that include case management, Pharm D, care providers, and family members. During these rounds, be sure to ask plenty of

questions on how best to integrate the patient’s post-discharge healthcare plan with his or her wants and needs and unique family situation. “Your mom is going to need quite a bit of support after her discharge with her daily activities for

about two weeks. This will include bathing, cooking meals, assisting with transfers from bed to chair, and so forth. Is there a member of the family who has the ability to stay with her during that time or do we need to consider other options?”

5. Use communication boards that provide dynamic access to the progress of the actions being taken to ensure care transition activities are fully executed.

For example, the white board might include a house graphic in which the nurse places an “M” once she has discussed the purpose of medications prescribed. Once patient and family wishes have been discussed and documented, the nurse might draw a heart around the house. The revised and updated edition of The HCAHPS Handbook, coming in fall 2013, will provide more details on how to most effectively implement these tactics and many more throughout your organization. ### About the Author: During her nearly 30-year career as an RN, Lyn Ketelsen has experienced healthcare in a variety of settings. Her clinical nursing background is Pediatrics and Neonatal Intensive Care. She has also worked with Acute Care, Managed Care, Clinics, Ambulatory, and ERs. Since joining Studer Group over ten years ago, Lyn has worked with hundreds of organizations to build cultures of operational excellence and improve patient, employee, and physician satisfaction. Her partners consistently achieve and sustain results and several have won awards for their performance. In conjunction with the Alliance for Healthcare Research, Lyn coauthored the largest study ever conducted on reducing call lights, which was published in AJN in September 2006. This study resulted in the development and implementation of Hourly Rounding®, which is now a standard of care in nursing internationally. Lyn played an important leadership role in the preparation of Studer Group’s successful Baldrige application and site visit that culminated in a Baldrige Award in 2010. Endnotes 1 Forster, Alan J., et al. “The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital.” Ann Intern Med 138, no.3 (2003): 161-67. 2 Harris, Gardiner. “Report Finds a Heavy Toll from Medication Errors.” The New York Times. 21 July 2006. . 3 MedPAC. “Chapter 5: Payment policy for inpatient readmissions.” Report to the Congress: Promoting Greater Efficiency in Medicare. June 2007. . 4 Kripalani, S., et al. “Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.” JAMA 297, no. 8 (2007): 831-41. 5 Burt, Catharine W., Linda F. McCaig, and Alan E. Simon. “Emergency Department Visits by Persons Recently Discharged from U.S. Hospitals.” National Health Statistics Reports 6 (24 July 2008). 6 Maniaci, M.J., M.G.Heckman, and N.L. Dawson. “Functional health literacy and understanding of medications at discharge.” Mayo Clin Proc. 83, no. 5 (May 2008): 554-58.

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Discover the NEWEST Proven Tactics for Consistently High

HCAHPS Results

Now that the next generation of HCAHPS is here, it’s critical to hardwire the tactics that enable you to provide the exceptional quality of care your patients expect and deserve. The revised and updated 2013 edition of The HCAHPS Handbook can serve as a valuable resource for doing that. It will provide: Vital information on the five new HCAHPS questions that became mandatory in January 2013. New tactics to improve quality and patient perception of care in areas pinpointed by the new Care Transition Domain. Fresh evidence straight from Studer Group’s National Learning Lab on which tactics are most successful at moving metrics on all HCAHPS questions. Insights on critical tweaks you can make to refine and perfect the tactics you’re already using. The HCAHPS Handbook has quickly become an authoritative resource for healthcare organizations seeking to maximize clinical quality, patient perception of care, and reimbursement. The revised and updated version is a must for those who strive to constantly improve themselves and protect the margin that allows them to live their mission. The revised and updated 2013 edition of The HCAHPS Handbook is coming in fall 2013. To reserve your copy, visit www.FireStarterPublishing.com/HCAHPShandbookexpanded or call 866-354-3473.

About Studer Group: Studer Group® works with over 850 healthcare organizations in the U.S. and beyond, teaching them how to achieve, sustain, and accelerate exceptional clinical, operational, and financial outcomes. As the metrics the industry publicly reports get expanded—and as reimbursement is increasingly tied to these results—organizations are forced to get progressively better at providing top-quality care with fewer dollars. Studer Group helps partners install an execution framework called Evidence-Based LeadershipSM (EBL) that aligns their goals, actions, and processes. This framework creates the foundation that enables them to transform the way they provide care in this era of rapid change. This commitment to helping organizations accelerate their ability to execute led to Studer Group’s receiving the 2010 Malcolm Baldrige National Quality Award. To learn more about Studer Group, please visit www.studergroup.com. www.studergroup.com • 850.934.1099