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©Copyright Deyta, LLC, All Rights Reserved
The Path to Hospice Public Reporting
Rebecca Van Vorst, MSPHPennsylvania Homecare Association
2012 Annual ConferenceState College, PA
May 16, 2012
The Path to Hospice Public Reporting
Rebecca Van Vorst, MSPHPennsylvania Homecare Association
2012 Annual ConferenceState College, PA
May 16, 2012
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ObjectivesObjectives
• Describe the current regulatory requirements of the hospice quality reporting program.
• Identify the hospice quality measures endorsed by the National Quality Forum.
• Discuss three ways hospices can prepare now for future reporting requirements.
• Describe the current regulatory requirements of the hospice quality reporting program.
• Identify the hospice quality measures endorsed by the National Quality Forum.
• Discuss three ways hospices can prepare now for future reporting requirements.
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Knowledge is the key to survivalKnowledge is the key to survival
3
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The Hospice RoadmapThe Hospice Roadmap2005
Hospice COPs
Written
2008
COPs Become
Effective
Feb 2008
CMS PEACE Project
Report Released
March 2010
Affordable Care Act
Nov 2010
CMS Hospice AIM
Project Report Released
Jan 2011
CMS Quality Measures
TEP Convened
August 2011
Hospice Wage
Index Final Rule
Nov 2011
MedPAC Hosts Quality
Advisory Group
Jan 2012
Structural Measure
Voluntary Submission
Feb 2012
NQF Endorses EOL
Measures
Oct 1, 2012
Comfortable Dying
Measure Data Collection
Begins
Oct 1, 2012
QAPI Indicators in
Use are Reportable
Dec 31, 2012 Comfortable
Dying Measure Data
Collection and Structural
Measure Both End
Jan 1, 2013
Data Collection for April
2014 Reporting Begins
Jan 1, 2013
Structural Measure
Reporting Begins
Jan 31, 2013
Structural Measure
Reporting Ends
April 1, 2013 Comfortable
Dying Measure Reporting
Begins
Oct 2013 (FY 2014)
Hospices Not Reporting
Face Payment Reduction
?Public
Reporting
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5
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CMS Roadmap for QualityCMS Roadmap for Quality
Vision: The right care for the every person every time.
Aims: Make care safe, effective, efficient, patient-centered, timely, equitable.
Vision: The right care for the every person every time.
Aims: Make care safe, effective, efficient, patient-centered, timely, equitable.
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CMS Quality InitiativesCMS Quality Initiatives
• Industry encouraged to develop measures and collect data
• Standard measures identified
• Required reporting to CMS
• “Public” reporting for consumers – accountability
• Pay for performance = Value-based purchasing
• Industry encouraged to develop measures and collect data
• Standard measures identified
• Required reporting to CMS
• “Public” reporting for consumers – accountability
• Pay for performance = Value-based purchasing
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CMS Quality InitiativesCMS Quality Initiatives
• Industry encouraged to develop measures and collect data
• Standard measures identified
• Required reporting to CMS
• “Public” reporting for consumers – accountability
• Pay for performance = Value-based purchasing
• Industry encouraged to develop measures and collect data
• Standard measures identified
• Required reporting to CMS
• “Public” reporting for consumers – accountability
• Pay for performance = Value-based purchasing
Hospice
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Why Hospice NOW?Why Hospice NOW?
• CMS commitment to increasing availability and use of healthcare information
– Informed decision making– Quality improvement
• Legislative mandate– Section 3004: Affordable Care Act
• CMS commitment to increasing availability and use of healthcare information
– Informed decision making– Quality improvement
• Legislative mandate– Section 3004: Affordable Care Act
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• Requires quality reporting for hospice and other post-acute settings
– By October 1, 2012 the Secretary must publish hospice quality measures.
• Requires hospices to submit data – or lose reimbursement – for FY 2014 (10/1/13) and subsequent fiscal years
• Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions
• Aims to make quality data available to the public (no timeline given)
• Requires quality reporting for hospice and other post-acute settings
– By October 1, 2012 the Secretary must publish hospice quality measures.
• Requires hospices to submit data – or lose reimbursement – for FY 2014 (10/1/13) and subsequent fiscal years
• Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions
• Aims to make quality data available to the public (no timeline given)
10
Section 3004 of the Patient Protection and Affordable Care Act
March 23, 2010
Section 3004 of the Patient Protection and Affordable Care Act
March 23, 2010
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• Hospice wage index for fiscal year 2012– Continue the phase-out of the wage index
budget neutrality adjustment factor (BNAF)
• Change the hospice aggregate cap calculation methodology
• Revise the time frame for the face-to-face encounter
• Begin implementation of a hospice quality reporting program.
• Hospice wage index for fiscal year 2012– Continue the phase-out of the wage index
budget neutrality adjustment factor (BNAF)
• Change the hospice aggregate cap calculation methodology
• Revise the time frame for the face-to-face encounter
• Begin implementation of a hospice quality reporting program.
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Final Rule
August 4, 2011
Final Rule
August 4, 2011
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Hospice Public Reporting “Influencers”Hospice Public Reporting “Influencers”
• NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001
– Source of required comfortable dying measure
• Brown/NHPCO FEHC, introduced 2003• QAPI CoP, published 2005, effective Dec 2008
– Driver of required structural measure
• CMS-funded PEACE project, reported Feb 2008• CMS-funded AIM project, reported Nov 2010• MedPAC quality TEP meeting Nov 11
– Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges
• NQF endorsement of hospice measures Feb 2012
• NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001
– Source of required comfortable dying measure
• Brown/NHPCO FEHC, introduced 2003• QAPI CoP, published 2005, effective Dec 2008
– Driver of required structural measure
• CMS-funded PEACE project, reported Feb 2008• CMS-funded AIM project, reported Nov 2010• MedPAC quality TEP meeting Nov 11
– Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges
• NQF endorsement of hospice measures Feb 2012
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Quality ReportingQuality ReportingThe First YearThe First Year
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Two Measures Required NowTwo Measures Required Now
• Comfortable Dying Measure (NQF #0209)– Comfort within 48 hours of admission
SPECIFIC DEFINITION (NQF #0209)
• Structural Measure– Yes/No: Does your QAPI program include 3 or
more quality indicators related to patient care?
• Comfortable Dying Measure (NQF #0209)– Comfort within 48 hours of admission
SPECIFIC DEFINITION (NQF #0209)
• Structural Measure– Yes/No: Does your QAPI program include 3 or
more quality indicators related to patient care?
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The Comfortable Dying MeasureThe Comfortable Dying MeasureThe first hospice reportable outcome measureThe first hospice reportable outcome measure
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NQF #0209 Comfortable Dying - Pain Brought to a Comfortable Level Within 48 Hours of
Initial Assessment
NQF #0209 Comfortable Dying - Pain Brought to a Comfortable Level Within 48 Hours of
Initial Assessment
Percentage of patients who reported being uncomfortable because of pain at the initial
assessment after admission to hospice services whose pain was brought to a comfortable level,
as defined/reported by the patient, within 48 hours of the initial assessment
Percentage of patients who reported being uncomfortable because of pain at the initial
assessment after admission to hospice services whose pain was brought to a comfortable level,
as defined/reported by the patient, within 48 hours of the initial assessment
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Comfortable Dying MeasureComfortable Dying Measure
• One of the EROM – End Result Outcome Measures– Safe and comfortable dying– Self-determined life closure– Effective grieving
• Developed as the “Comfortable Dying” measure by NHWG and NHPCO task force in 2001
– Two rounds of pilot testing
• Assure as many patients as possible are comfortable within 2 days of the start of hospice care
• One of the EROM – End Result Outcome Measures– Safe and comfortable dying– Self-determined life closure– Effective grieving
• Developed as the “Comfortable Dying” measure by NHWG and NHPCO task force in 2001
– Two rounds of pilot testing
• Assure as many patients as possible are comfortable within 2 days of the start of hospice care
Designed to support good care management
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Key Concept:Comfortable Dying Measure
Key Concept:Comfortable Dying Measure
• Relies on patient report of “comfort”
• Two questions– “Are you uncomfortable because of pain?”– “Was your pain brought to a comfortable level
within 48 hours of the initial assessment?”
• NOT on a numerical pain severity score– Can and should use numerical ratings in
addition
• Relies on patient report of “comfort”
• Two questions– “Are you uncomfortable because of pain?”– “Was your pain brought to a comfortable level
within 48 hours of the initial assessment?”
• NOT on a numerical pain severity score– Can and should use numerical ratings in
addition
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The Comfortable Dying MeasureThe Comfortable Dying Measure• Are you uncomfortable because of pain?
– Asked during the Initial Assessment– Asked BEFORE any pain assessments are done– Must be answered by the patient
• Was your pain brought to a comfortable level within 48 hours of your Initial Assessment ?
– Only asked of those patients who said “Yes” to the first question
– Asked between 48 and 72 hours after the Initial Assessment
– Must be answered by the patient
• Are you uncomfortable because of pain?– Asked during the Initial Assessment– Asked BEFORE any pain assessments are done– Must be answered by the patient
• Was your pain brought to a comfortable level within 48 hours of your Initial Assessment ?
– Only asked of those patients who said “Yes” to the first question
– Asked between 48 and 72 hours after the Initial Assessment
– Must be answered by the patient19
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Measure DefinitionsMeasure Definitions
• Includes all eligible patients:– Able to communicate and understand the language of the
person asking the question; – Able to self-report an answer to first question; and – At least 18 years of age or older.
• Denominator: Number of patients who relied “yes” when asked if they were uncomfortable because of pain at the initial assessment (after admission to hospice services)
• Numerator: Number of patients whose pain was brought to a comfortable level (as defined by the patient) within 48 hours of initial assessment (after admission to hospice services)
• Includes all eligible patients:– Able to communicate and understand the language of the
person asking the question; – Able to self-report an answer to first question; and – At least 18 years of age or older.
• Denominator: Number of patients who relied “yes” when asked if they were uncomfortable because of pain at the initial assessment (after admission to hospice services)
• Numerator: Number of patients whose pain was brought to a comfortable level (as defined by the patient) within 48 hours of initial assessment (after admission to hospice services)
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The Comfortable Dying MeasureThe Comfortable Dying Measure
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Numerator = Only those patients from the denominator who:• Answer “YES” to the second question
Denominator = All patients who:• Are at least 18 years of age or older;• Are able to communicate and
understand the language of the person asking the question;
• Are able to self-report on admission; and
• Answer “YES” to the first question
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The Comfortable Dying MeasureThe Comfortable Dying Measure
22
Data Collection & Reporting Path
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The Comfortable Dying MeasureThe Comfortable Dying Measure
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• NO expectation that the measure score will be 100%
• Allows for the fact that some patients will not achieve a comfortable level
• Encourages hospices to make the effort to collect data for the second question
• Reflects expert opinion that most patients can and should have pain brought to a comfortable level within 2 days of the start of hospice care
• NO expectation that the measure score will be 100%
• Allows for the fact that some patients will not achieve a comfortable level
• Encourages hospices to make the effort to collect data for the second question
• Reflects expert opinion that most patients can and should have pain brought to a comfortable level within 2 days of the start of hospice care
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The Comfortable Dying Measure - TimelineThe Comfortable Dying Measure - Timeline
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Mandatory Data Collection Period
October 1 – December 31, 2012
Mandatory Data Submission Deadline
April 1, 2013
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The Structural MeasureThe Structural MeasureInforming the future Informing the future
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Two-part measure:
• Participation in a QAPI Program that includes at least 3 quality indicators related to patient care
– This is a YES or NO question
• If yes, submit a description of the quality indicators being used that relate to patient care
– Submission of a list of indicators, NOT the results
Two-part measure:
• Participation in a QAPI Program that includes at least 3 quality indicators related to patient care
– This is a YES or NO question
• If yes, submit a description of the quality indicators being used that relate to patient care
– Submission of a list of indicators, NOT the results
The Structural MeasureThe Structural Measure
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Indicators Related to Patient Care Domains:
• Providing care in accordance with documented patient/family goals
• Effective and timely symptom management• Care coordination• Patient safety
Indicators Related to Patient Care Domains:
• Providing care in accordance with documented patient/family goals
• Effective and timely symptom management• Care coordination• Patient safety
The Structural MeasureThe Structural Measure
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Data Collection Requirements:
• Indicator Topic – selected from a dropdown list• Indicator Name – full name of the indicator• Brief Description – complete description of the
indicator including any information that will help CMS understand what the indicator measures
• Numerator – variable that is on the top part of the fraction that describes the process, condition, event or outcome that satisfies the measure
• Denominator – variable that is on the bottom part of the fraction that describes the population evaluated
• Data Source – data source such as survey or EMR
Data Collection Requirements:
• Indicator Topic – selected from a dropdown list• Indicator Name – full name of the indicator• Brief Description – complete description of the
indicator including any information that will help CMS understand what the indicator measures
• Numerator – variable that is on the top part of the fraction that describes the process, condition, event or outcome that satisfies the measure
• Denominator – variable that is on the bottom part of the fraction that describes the population evaluated
• Data Source – data source such as survey or EMR
The Structural MeasureThe Structural Measure
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• Indicator Topic:
36 Categories + “Other”Examples:
– Pain assessment or management– Anxiety assessment or management– Communication with patient/family– Culturally sensitive caregiving– Emotional care before and/or at time of death– Bereavement care– Infection reporting and control– and many more… !
• Indicator Topic:
36 Categories + “Other”Examples:
– Pain assessment or management– Anxiety assessment or management– Communication with patient/family– Culturally sensitive caregiving– Emotional care before and/or at time of death– Bereavement care– Infection reporting and control– and many more… !
The Structural MeasureThe Structural Measure
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The Structural Measure - ExampleThe Structural Measure - ExampleIndicator Topic (dropdown menu)
Communication with patient/family
Indicator Name Percentage of respondents who had enough instruction to do what was needed to care for the patient.
Brief Description Question D2 on the FEHC survey. Calculated from all who respond
Numerator Total number of respondents reporting family participated in the patient's care while in hospice and who answered Yes
Denominator Total number of respondents reporting family participated in the patient's care while in hospice and answered this question
Data Source (dropdown menu)
Family Survey/Questionnaire
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The Structural Measure - TimelineThe Structural Measure - Timeline
Voluntary Data Collection Period
October 1 – December 31, 2011
Voluntary Data Submission Deadline
January 31, 2012
Mandatory Data Collection Period
October 1 – December 31, 2012
Mandatory Data Submission Deadline
January 31, 2013
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• More than 900 hospices submitted a total of 6721 indicators to CMS
• Deyta’s Voluntary Reporting Program:– 269 hospices took advantage of this program– 532 different indicators were submitted – 3 out of 4 hospices used indicators from the
FEHC survey– 60% of hospices used indicators focused on
patient’s comfort from pain– 41% of hospices tracked patient falls
• More than 900 hospices submitted a total of 6721 indicators to CMS
• Deyta’s Voluntary Reporting Program:– 269 hospices took advantage of this program– 532 different indicators were submitted – 3 out of 4 hospices used indicators from the
FEHC survey– 60% of hospices used indicators focused on
patient’s comfort from pain– 41% of hospices tracked patient falls
The Structural MeasureWhat we learned from voluntary reporting
The Structural MeasureWhat we learned from voluntary reporting
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Quality ReportingQuality ReportingBeyond 2013Beyond 2013
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Remember the “Influencers”Remember the “Influencers”
• NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001
– Source of required comfortable dying measure
• Brown/NHPCO FEHC, introduced 2003• QAPI CoP, published 2005, effective Dec 2008
– Driver of required structural measure
• CMS-funded PEACE project, reported Feb 2008• CMS-funded AIM project, reported Nov 2010• MedPAC quality TEP meeting Nov 11
– Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges
• NQF endorsement of hospice measures Feb 2012
• NHPCO/Outcomes Forum End Result Outcome Measures (EROM), introduced 2001
– Source of required comfortable dying measure
• Brown/NHPCO FEHC, introduced 2003• QAPI CoP, published 2005, effective Dec 2008
– Driver of required structural measure
• CMS-funded PEACE project, reported Feb 2008• CMS-funded AIM project, reported Nov 2010• MedPAC quality TEP meeting Nov 11
– Critical areas to measure, challenges with measuring quality of care, approaches for addressing challenges
• NQF endorsement of hospice measures Feb 2012
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• Requires quality reporting for hospice and other post-acute settings
• Requires hospices to submit data to CMS – or lose partial reimbursement in FY 2014
• Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions
Potential pool for additional required measures
• Requires quality reporting for hospice and other post-acute settings
• Requires hospices to submit data to CMS – or lose partial reimbursement in FY 2014
• Published quality measures must be endorsed by a consensus body (e.g., NQF), with exceptions
Potential pool for additional required measures
35
Remember the RegsRemember the Regs
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Palliative and End-of-Life ProjectPalliative and End-of-Life Project• Identify and endorse measures for public reporting
and quality improvement• Sought to endorse performance measures on:
– Assessment, management and relief of symptoms at EOL and for acutely ill patients pain, dyspnea, weight loss, weakness, nausea, serious
bowel problems, delirium, and depression
– Patient- and family-centered palliative and hospice care that address psychosocial needs and care transitions
– Patient, caregiver, and family experiences of care
• Maintenance review of nine palliative consensus standards
• April 4, 2011• Project funded by DHHS
• Identify and endorse measures for public reporting and quality improvement
• Sought to endorse performance measures on: – Assessment, management and relief of symptoms at EOL
and for acutely ill patients pain, dyspnea, weight loss, weakness, nausea, serious
bowel problems, delirium, and depression
– Patient- and family-centered palliative and hospice care that address psychosocial needs and care transitions
– Patient, caregiver, and family experiences of care
• Maintenance review of nine palliative consensus standards
• April 4, 2011• Project funded by DHHS
36
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NQF’s Consensus Development Process NQF’s Consensus Development Process
• 22 measures considered• Comment period: 121 comments - 33 organizations• 14 measures recommended for endorsement
– Voluntary consensus standards suitable for accountability and performance improvement
• 9 measures appropriate for hospice
• 22 measures considered• Comment period: 121 comments - 33 organizations• 14 measures recommended for endorsement
– Voluntary consensus standards suitable for accountability and performance improvement
• 9 measures appropriate for hospice
37
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Hospice Measures by TopicHospice Measures by Topic
• Pain ManagementPercentage of hospice or palliative care patients who
were screened for pain during the hospice admission evaluation
Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.
Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed.
• Pain ManagementPercentage of hospice or palliative care patients who
were screened for pain during the hospice admission evaluation
Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.
Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed.
38
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Hospice Measures by TopicHospice Measures by Topic
• Dyspnea ManagementPercentage of hospice or palliative care patients who
were screened for dyspnea during the hospice admission evaluation.
Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.
• Dyspnea ManagementPercentage of hospice or palliative care patients who
were screened for dyspnea during the hospice admission evaluation.
Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.
39
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Measures by TopicMeasures by Topic• Quality of Care at the End of LifeComposite Score: Derived from responses to 17 items on
the Family Evaluation of Hospice Care (FEHC) survey presented as a single score ranging from 0 to 100.
and Global Score: Percentage of best possible response
(Excellent) to the overall rating question on the FEHC survey. (maintenance)
• Quality of Care at the End of LifeComposite Score: Derived from responses to 17 items on
the Family Evaluation of Hospice Care (FEHC) survey presented as a single score ranging from 0 to 100.
and Global Score: Percentage of best possible response
(Excellent) to the overall rating question on the FEHC survey. (maintenance)
40
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Measures by TopicMeasures by Topic• Care Preference MeasuresPercentage of patients with chart documentation of
preferences for life sustaining treatments.Percentage of hospice patients with documentation in the
clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss
Number of patients who report being uncomfortable because of pain at the initial assessment who report pain was brought to a comfortable level within 48 hours. (maintenance)
• Care Preference MeasuresPercentage of patients with chart documentation of
preferences for life sustaining treatments.Percentage of hospice patients with documentation in the
clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss
Number of patients who report being uncomfortable because of pain at the initial assessment who report pain was brought to a comfortable level within 48 hours. (maintenance)
41
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PREPARING for required reportingPREPARING for required reporting
42 February 2012
“The great aim of education is
not knowledge, but action.”
- Herbert Spencer
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PreparationsPreparations
1. Read the Final Rulehttp://www.gpo.gov/fdsys/pkg/FR-2011-08-04/html/2011-19488.htm
2. Download the NHPCO instructions for using the Comfortable Dying measure (EROM Manual) http://www.nhpco.org/i4a/pages/Index.cfm?pageID=3376
1. Read the Final Rulehttp://www.gpo.gov/fdsys/pkg/FR-2011-08-04/html/2011-19488.htm
2. Download the NHPCO instructions for using the Comfortable Dying measure (EROM Manual) http://www.nhpco.org/i4a/pages/Index.cfm?pageID=3376
43 February 2012
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PreparationsPreparations
3. Start using the “Comfortable Dying” measure as soon as possible
MUST collect data as of 10/1/2012– Integrate into your more comprehensive pain
assessment and pain management procedures– Train and retrain - Assure that staff understand
The purpose of the measure Data collection and data recording procedures How to use the data to achieve optimal pain
management outcomes
– Think of the medical record as a data source AND a tool for optimizing outcomes
3. Start using the “Comfortable Dying” measure as soon as possible
MUST collect data as of 10/1/2012– Integrate into your more comprehensive pain
assessment and pain management procedures– Train and retrain - Assure that staff understand
The purpose of the measure Data collection and data recording procedures How to use the data to achieve optimal pain
management outcomes
– Think of the medical record as a data source AND a tool for optimizing outcomes
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PreparationsPreparations
4. Consider participating in a performance measurement system to obtain comparative data
– NHPCO DART system (NHPCO members only) – Quality Navigator – Deyta, LLC– Others
5. Monitor your results and conduct a PIP if necessary
4. Consider participating in a performance measurement system to obtain comparative data
– NHPCO DART system (NHPCO members only) – Quality Navigator – Deyta, LLC– Others
5. Monitor your results and conduct a PIP if necessary
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PreparationsPreparations
6. Check out the NQF endorsed measureshttp://www.qualityforum.org/Measures_List.aspx
7. Structural Measure– Define your list of measures– Confirm current measures and definitions
6. Check out the NQF endorsed measureshttp://www.qualityforum.org/Measures_List.aspx
7. Structural Measure– Define your list of measures– Confirm current measures and definitions
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Becky VanVorst, MSPH
Director of Education and Data Analytics
Deyta, LLC
518.753.8003 direct
518.956.3531 cell
Becky VanVorst, MSPH
Director of Education and Data Analytics
Deyta, LLC
518.753.8003 direct
518.956.3531 cell