Hospice Quality Reporting: Getting It Right

Hospice Quality  Reporting: Getting It Right Martha Tecca [email protected] 603-443-0283 Objectives • Outline CMS quality reporting requirement ...
Author: Vanessa Flynn
5 downloads 0 Views 849KB Size
Hospice Quality  Reporting: Getting It Right Martha Tecca [email protected] 603-443-0283

Objectives • Outline CMS quality reporting requirement s for the comfortable dying measure an d the structural measure • Define ways to improve data collection for consistent reporting • Prepare to utilize CMSreportable data for QAPI and demonstrat ing quality

1

CMS Hospice Quality Reporting “Baby steps” toward consumer-ready data

Two Measures Required • Structural Measure • Yes/No: Does your QAPI program include 3+ quality indicators related to patient care? If yes … • Check boxes: Considering all patient care quality indicators used in your QAPI program, identify categories and sources

• Comfortable Dying Measure • Comfort within 48 hours of initial assessment (NQF #0209) REVISED PROTOCOL

2

Reporting Timeline Measure Structural Use of patient  care QAPI  indicators

Report

Capture Data

To Do Now

Jan 31  2013

“Look back Period” Oct‐Dec  2012

Document and  refine measure list; Optimize clinical  documentation and  IT system  implementation

Oct‐Dec 2012

Confirm definition  and protocols;  Refine data capture; Calculate measure; Improve!

Comfortable  April 1  Dying 2013 NQF 0209

“Comfortable Dying Measure” NHPCO Patient Outcome Measure formerly “EROM” NQF Measure #0209

Source: www.mitchalbom.com from Tuesdays with Morrie

3

Comfortable Dying Measure Background

• Designed in 1998-9 by the Outcomes Forum (NHPCO/NHWG effort), aiming to understand end-of-life care and outcomes • Result: A Pathway for Patients and Families Facing Terminal Illness – a framework: • Safe and comfortable dying • Self-determined life closure • Effective grieving

• End Result Outcome Measures (now POM) implemented/promoted since 2000

Comfortable Dying Measure Background, continued

• NHPCO is NQF measure sponsor • Initially endorsed in 2006 as part of call for end of life cancer measures • Endorsed for palliative and hospice care in February 2012 • “POM”– Patient Outcome Measures (formerly EROM) definition and protocol on NHPCO website

4

Comfortable Dying Measure NHPCO POM (formerly EROM); NQF #0209

• Percentage of patients who were uncomfortable because of pain at the initial assessment (after admission to hospice) who report pain was brought to a comfortable level within 48 hours • Based on 2 patient-answered questions: • On initial assessment: Are you uncomfortable because of pain? • 2-3 days after initial question asked: Was your pain brought to a comfortable level within 48 hours of the initial assessment?

• No interpretation of a pain scale • No surrogate responses

Comfortable Dying Measure More details

• Gather data for ALL admissions • Eligible population: • • • •

Able to self-report Communicate/understand language of question 18+ years of age (FOR CMS REPORTING) Report pain at initial assessment, using exact question, according to the protocol

• Question protocol (both questions): • Ask question, before numerical or other pain scale rating is requested • Only patient may answer • Document response or unable to self-report and reason

5

Comfortable Dying Measure Procedure

• As part of comprehensive pain assessment after admission (initial assessment): • ask “are you uncomfortable because of pain” before asking for rating; record response or reason not eligible

• As part of good care management: • For those in pain, plan and implement pain management intervention • Follow up – as you would normally • 2-3 days after assessment, ask “was your pain brought to a comfortable level within 48 hours” before asking for rating; record response or unable to respond and reasons

“2‐3 Days” Clarification • Follow up question must be asked 2-3 days after the initial question was asked. • The follow up may be asked any time on the through midnight on the 3rd day. • No responses received before the 2nd day or after the 3rd day may be included.

Copyright M&M Strategies 2012

April 25-26, 2012

12

6

Comfortable Dying Measure Procedure, continued

• As part of effective QAPI: • Calculate and report this measure, along with other pain management measures* • Use patient assessment data, along with data-driven care planning to manage patient’s care • At the agency level, review internal trends and compare with external benchmarks • Identify opportunities for improvement and: o address through care management practices o determine whether PIP is warranted

• Demonstrate improvement!

• Report to CMS, start with 10/2012 data * Sources of standard pain measures: PEACE/AIM, FEHC, ESAS; NQF-endorsed measures

Focus on Pain Management Example measure selection

• Comfortable dying measure† • Pain screening on admission† • Clinical pain assessment w/in 24 hrs of screening positive for pain† • Pain reduced w/in 48 hrs (from pain scale) • Pain reduced through stay (admit - last week) • Severe pain w/in last week of life • FEHC – rating of amount of pain meds • FEHC – info received on pain meds (2) † NQF-endorsed

7

Comfortable Dying Measure The data you need

• For Q1 (on initial assessment): • # of patients who responded “yes” • # of patients who responded “no” • # of patients excluded • who are unable to respond • # of patients with no data

• For Q2 (on follow up, 2-3 days later): • # of patients who responded “yes” • # of patients who responded “no” • # of patients who unable to self-report at follow up • By reason: (death, discharged alive, disease progression, other reason …) • # of patients who with no data

Comfortable Dying Measure

Reportable data elements – no measure calculation 1. # admissions during the data collection period 2. # patients who answered “YES” to Q1 “Are you uncomfortable because of pain?” on initial assessment 3. # patients who answered “NO” to Q1 4. # patients excluded from the measure

5. # patients who answered “YES” to Q2 “Was your pain brought to a comfortable level within 48 hours of the start of hospice care?” at follow-up 6. # patients who answered “NO” to Q2 7. # patients unable to self-report at follow up

8

Data Collection Process From CMS User Guide, Step 1 of 3

Copyright M&M Strategies 2012

April 25-26, 2012

17

Data Collection Process From CMS User Guide, Step 2 of 3

Copyright M&M Strategies 2012

April 25-26, 2012

18

9

Data Collection Process From CMS User Guide, Step 3 of 3

Copyright M&M Strategies 2012

April 25-26, 2012

19

Comfortable Dying Measure  Reporting How To • Data submission tool/format not yet finalized • Agency level, summary data for each data element NO PATIENT LEVEL DATA • Submissions allowed through 11:59:59pm EST 4/1/2013 • Bookmark CMS Hospice website • Details of site availability for reporting • HelpDesk information http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-Quality-Reporting/Spotlight.html

10

Comfortable Dying Measure Measure Calculation

• Denominator: • “Yes” patient responses to question on initial assessment: “Are you uncomfortable because of pain?”

• Numerator: • “Yes” patient responses to follow up question 2-3 days after initial assessment: “Was your pain brought to a comfortable level within 48 hours of the initial assessment?” NOTE: This denominator is used for CMS/NQF/POM measure

• Do calculate alternative measures for PI. • Many exclude those who cannot respond to Q2 from denominator • NHPCO recommends a “problem score” using “NO” responses to Q2 as the numerator; “YES” responses to Q1 as denominator.

Frequently Asked Questions • What if the patient is sleeping? Can I use the family’s response? • NO. Attempt follow up later.

• Can I use our standard pain scale to determine pain on admission? • NOT FOR THIS MEASURE.

• Does this mean I shouldn’t use a pain scale? • NO. It is important to maintain a comprehensive, datadriven pain management practice.

• Does a physician or nurse have to ask the questions?

• First question, yes. Volunteers or others, trained in consistent data capture and recording, may ask the follow up question.

11

The Structural Measure Provides CMS with details about the indicators used in your QAPI program

The Structural Measure: Why? • QAPI CoP requires utilization of quality indicators • Indicators are not specified • There has been little formal QAPI program review • CMS must require reporting of additional quality measures • aiming for the most meaningful, least burdensome measures

• Structural Measure will demonstrate breadth and content of existing QAPI programs

12

QAPI Requirement What you need to do

• Select a full complement of quality measures • Monitor performance regularly • Track and analyze adverse events • Compare performance to your own and industry benchmarks • Manage care delivery and organizational improvement • Conduct PIPs for highest priority opportunities

What is “The Structural Measure”? Three questions

• Q1: Does your hospice have a QAPI program that includes three or more quality indicators related to patient care? (Y/N) • Q2: If your hospice’s QAPI program includes at least one patient care-related quality indicator, include each indicator (with details in form; NO DATA) • Q3: Please indicate the data source(s) for your QAPI indicators. Check all that apply. (check box) You must report, but CMS will not evaluate how you respond

13

Structural Measure Indicators Indicators related to patient care

• Address a patient/family-focused care domain, such as… • • • • •

Patient/family goals Patient preferences Symptom management Care coordination Patient safety

• Data from medical records, surveys, incident reports or logs • Do NOT address non-clinical organizational/business goals

Reporting on Indicators Simplified from voluntary reporting to reduce burden! • No free-text response options (name, description, numerator, denominator, data source) • Check off topic areas in which they have at least one indicator • Ten domains of care, with some sub-domains - Physical symptom management - Care coordination and transitions preferences - Communication/education - Structure and process of care - Patient/family experience/ratings of care and/or services

– Patient safety – Patient/family – Psychosocial – Spiritual – Grief, bereavement and emotional support

14

Reporting on Indicators Domain/subdomain checklist examples • Domain: Communication/ education • TOPICS

• Domain: Physical symptom management •

o Communication re: hospice care broadly o Family education/communication about dying process o Family/caregiver confidence o Family education about managing symptoms o Family education about equipment o Family education about safety o Family education about patient care choices/surrogate designation

Subdomain: Dyspnea • TOPICS: o Screening o Assessment o Interventions/treatment o Symptom control/comfort o Management/control/c omfort in last 1-2 weeks of life o Patient/family education o Patient/family experience/ ratings of care

Internal Documentation

Know this information for each QAPI indicator used Indicator Name

Indicator Topic* Brief Description Numerator Denominator Data Source

Percentage of families who report  they were always kept informed of  the patient’s condition Family ratings of communication Question on the FEHC, using  “favorable” scoring Total number of respondents who     answered Always  All respondents Family survey/questionnaire

* Review checklist/dropdown menu in User Guide and choose the best topic

15

Reporting Questions 2 & 3 Super easy!

• Q2: Topics (“Domains”) • • • •

Download the User Guide from CMS Review the domain checklist/dropdown menu Determine where your indicators fit best Place a checkmark next to the topics for which you have at least one indicator

• Q3: Data source(s) • Check all that apply  Electronic medical record  Paper medical record  Family survey/questionnaire  Patient survey/questionnaire  Incident report/log

What Should We Report? “We collect so much data!”

• Indicators or measures used in the QAPI program for which you are: • • • • •

Collecting data Aggregating and/or trending the data Reviewing the data Using the data to make improvements Making operational decisions based on the data

• Can be untested, agency-defined indicators

16

Choose 3? NO. Report all indicators you use • Structural measure requests data about your program. • Q1 asks whether program has “3 or more” indicators related to patient care … Yes or No. • That is the only “3”!

• Report on the measures you use in your QAPI program. Make it a priority to review and refine your QAPI program

The QAPI Cycle Quality Assessment and Performance Improvement

Source: The QAPI Requirement

17

Likely Future Requirements? • NQF endorsements • Five forecast in Proposed Rule • • • • •

Pain screening on admission Pain assessment w/in 24 hours Dyspnea screening Treatment of dyspnea w/in 24 hours FEHC

• Additional and/or refined measures likely • Bowel regimen after opioid initiation

Structural Measure FAQs As presented by CMS …

• Does the comfortable dying measure “count” as an indicator for the structural measure? • YES

• Can I report about indicators I didn’t use for the whole look back period? • YES

• What do I do if an indicator fits multiple topics? • Read the explanations in the User Manual to determine best fit • There is no “right answer” … use what best represents how you are using the indicator • Choose only ONE topic checkbox

18

Structural Measure Reporting  How to New and different login from voluntary reporting period

• NEW web address coming • Submissions allowed through 11:59:59pm EST 1/31/2013 • Bookmark CMS Hospice website • Details of site availability for reporting • HelpDesk information

http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-Quality-Reporting/Spotlight.html

Future of Public Reporting Influencing the evolution of standardized hospice measurement

19

Accelerating toward Public  Reporting • CMS Quality Reporting – “baby steps” • Proposed rule hints at next measures

• NQF endorsements and ongoing refinement • Bookmark www.qualityforum.org for the latest

• CMS-funding for “development” of family evaluation of hospice care survey • FEHC is model

• State public reporting efforts • Some required, most voluntary

• ACOs and other care partners are “the public” … and they want to know about quality

Action Priorities – Quality  Measures, Systems and  Processes Staying in front of the requirements Preparing to play a role in the evolving system

20

How Should Hospices Focus? To comply, to improve, to build partner relationships • Be prepared for CMS reporting requirements • Quality, claims and cost reporting (all evolving)

• Do QAPI right… as a strategy and culture • Measure broadly, assess pragmatically, focus improve efforts

• Demonstrate value to care partners • Build capabilities to capture and report more patient-specific data … take full advantage of IT systems • • • •

More electronic, more standards, more flexible Chart-based, incident logs, patient-reported Outcome, process, safety measures People, systems and resources/partners

What Measures Matter? Building an arsenal of data and capabilities

• Required comfortable dying measure NOW! • FEHC NOW! • Additional symptom management measures • Screening, assessment, treatment, outcomes

• Customer perception beyond the family • Patients, referral sources, care partners

• NQF-endorsed quality measures

• Hospice first; others that address needs

• Medicare Shared Savings (ACO) indicators • Satisfaction, readmission rate, condition-specific, falls screening, med reconciliation …

21

Resources • CMS • http://www.cms.gov/Hospice-Quality-Reporting/

• 2013 Hospice Wage Index – Federal Register • https://www.federalregister.gov/articles/2012/07/27/201 2-18336/medicare-program-hospice-wage-index-forfiscal-year-2013

• National Quality Forum • http://www.qualityforum.org/Measures_List.aspx

• NHPCO, for Comfortable Dying Measure • http://www.nhpco.org/i4a/pages/Index.cfm?pageID=5 828 • Contact [email protected]

Questions?

Martha Tecca M&M Strategies [email protected] 603-795-4802

22

Suggest Documents