CAHPS Hospice Survey - Special Report

Preparation of the CAHPS Hospice Survey

A SPECIAL REPORT PREPARED BY US HEALTH CARE RESEARCH

1319 Classen Drive

Oklahoma City, OK 73103

405.689.0444

www.ushcrc.com©2014 US Health Care Research LLC

Reproduction not permitted.

An Overview of the CAHPS®

Hospice SurveyBeginning in the first quarter of 2015, Hospice CAHPS (also known as the

Hospice Experience of Care Survey) will be a mandatory component of the

Hospice Quality Reporting Program (HQRP). As a pay-for-reporting

requirement, hospices that fail to comply with the rule will receive a two

percent reduction in their annual payment update for the fiscal year.

There are two tidbits of good news:

1. While this is another box for hospices to check off their already long

laundry list of things to do, it won’t add much to their everyday workload.

In fact, the majority of the work will be in the hands of a vendor—in this

case, US Health Care Research.

2. The CAHPS Hospice Survey is an opportunity to improve care and

services. The CAHPS Hospice Survey can be used to guide your QAPI.

Participation Requirements

All Medicare-certified hospices are required to participate in the CAHPS

Hospice Survey

Two Exemptions

Participation Exemption for Size

Exemption for Newness

Served 50 or more deceased patients must participate in the Dry Run

Hospices that served 50 or more deceased patients from January

1, 2014 and December 31, 2014 will need to partner with a survey

vendor to sample and collect survey responses from caregivers for

at least one of the following months – January, February, or March

2015.

Ongoing surveying beginning April 2015

2% reduction in the hospice’s APU for

failure to participate.405.689.0444 | www.ushcrc.com | [email protected]

https://www.facebook.com/USHCResearch

https://twitter.com/USHlthCareRes

http://www.linkedin.com/company/us-health-care-research

CMS Goals for Annual Returns

405.689.0444 | www.ushcrc.com | [email protected]

Hospice Size Annual Survey Return Goal

700+ annual decedents n=300

50-699 annual decedents n=21-300

<50 annual decedentsCan apply for Participation for Size Exemption. Form

must be submitted by August 15, 2015.




What can you do to receive your full APU?

Do you quality for survey participation

exemption?

Participation Exemption for Size Hospices that served fewer than 50

deceased patients between January 1,

2014 and December 31, 2014 qualify for

this exemption and will need to fill out and

submit the proper form no later than

August 12, 2015.

Exemption for Newness Hospices that received their CCN on or

after January 1, 2015 qualify for the

Exemption for Newness for the 2015

performance year.

Served 50 or more deceased patients must

participate in the Dry Run and monthly

starting April 2015.





CAHPS Hospice Survey Timeline

Su

mm

er

20

14 CMS finalizes

the CAHPS Hospice Survey

Win

ter

20

14 Hospices will

need to contract with an approved survey vendor.

Jan

-Ma

r 2

01

5 Hospices will need to participate in a Dry Run for at least one month. A

pri

l 2

01

5 Ongoing monthly survey administration and data collection.





What is the CAHPS® Hospice Survey?

The CAHPS Hospice Survey is a standardized

instrument that consist of 47 questions. The

questions in the survey assess the following

measures of hospice care:

Hospice Team Communication

Getting Timely Care

Treating Family Member with Respect

Providing Emotional Support

Support for Religious and Spiritual Beliefs

Getting Help for Symptoms

Information Continuity

Understanding the Side Effects of Pain

Medication

Getting Hospice Care Training





Hospice Team Communication


Questions CAHPS/FEHC Survey

How often did the hospice team listen carefully to you when you

talked with them about problems with your family member’s

hospice team?

While your family member was in hospice care, how often did

the hospice team listen carefully to you?


the hospice team explain things in a way that was easy to

understand?


the hospice team keep you informed about your family

member’s condition?


the hospice team keep you informed about when they would

arrive to care for your family member?




Getting Timely Care


While your family member was in hospice care, when you or

your family member asked for help from the hospice team how

often did you get help as soon as you needed it?

How often did you get the help you needed from the hospice

team during evenings, weekends, or holidays?





Treating Family Member with Respect



the hospice team treat your family member with dignity and

respect?


you feel that the hospice team really cared about your family

member?





Support for Religious and Spiritual

BeliefsQuestions CAHPS/FEHC Survey

While your family member was in hospice care, how much

Support for religious or spiritual beliefs includes talking, praying,

quiet time, or other ways of meeting your religious or spiritual

needs.





Getting Help for Symptoms



How often did your family member get the help he or she

needed from the hospice team for feelings of anxiety or

sadness?

Did you family member get as much help with pain as he or she

needed?


needed for trouble with constipation?


needed for trouble breathing?




Information Continuity



anyone from the hospice team give you confusing or

contradictory information about your family member’s condition

or care?





Understanding the Side Effects of Pain

MedicationQuestions CAHPS/FEHC Survey

Side effects of pain medicine include things like sleepiness.

Were side effects of pain medicine discussed with any member

of the hospice team?

Did any member of the hospice team discuss side effects of

pain medicine with you or your family member?





Getting Hospice Care Training



Did the hospice team give you the training you needed about

what to do if your family member became restless or agitated?


what side effects to watch for from pain medicine?


how to help your family member if he or she has trouble

breathing?


how to safely move your family member?




Nursing Home Questions




the nursing home staff and hospice team work well together to

care for your family member?

While your family member was in hospice care, how often was

the information you were given about your family member by

the nursing home staff different from the information you were

given by the hospice team?




Global Rating Items



Using any number from 0 to 10, where 0 is the worst hospice

care possible and 10 is the best hospice care possible, what

number would you use to rate your family member’s hospice

care?

Would you recommend this hospice to your friends and family?




Hospice Item Set


There are 7 quality measures – 6 NQF-endorsed measures and 1 modified NQF-

endorsed measure that is used for the Hospice Item Set (HIS).

• NQF #1641 – Treatment Preferences

• Modified NQF #1647 – Beliefs/Values Addressed

• NQF #1634 & #1637 – Pain Screening and Pain Assessment

• NQF #1639 & #1638 – Dyspnea Screening and Dyspnea Treatment

• NQF #1617 – Patients Treated with an Opioid who are Given a Bowel Regimen

These are answered on admission and at discharge.




Beliefs/Values Addressed


Questions

While your family member was in hospice care, how much Support for religious or

spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your

religious or spiritual needs.




Pain Screening and Pain Assessment


Questions

Did family member get as much help with pain as he or she needed?

Did any member of the hospice team discuss side effects of pain medicine with you or

your family member?

Did the hospice team give you the training you needed about what side effects to watch

for from pain medicine?




Dyspnea – Breathing Assessment and

Treatment


Questions

How often did you family member get the help he or she needed for trouble breathing?

Did the hospice team give you the training you needed about how to help your family

member if he or she had trouble breathing?




Patients Treated with an Opioid who are

Given a Bowel Regimen


Questions

How often did your family member get the help he or she needed for trouble with

constipation?




Using the CAHPS

Survey Results to Guide your QAPI





QAPI: What does it mean?

A data-driven, proactive approach to ensuring high quality care

•Combines two approaches

•Quality Assurance

•Performance Improvement

Involves all levels of the organization

Identifies opportunities for improvement

Addresses gaps in systems or processes

Develops and implements improvement plans

Continuously monitors effectiveness of interventions





Principles of Quality Assurance

Measures compliance against standards.

•Retrospective

•Reactive

•Specific to failed standards

•Short term – ends when standard is met





Principles of Performance Improvement

Continuous improvement toward meeting standards:

• Examines gaps between standard and baseline

• Evaluates root cause

• Sets goals/milestones for improvement

• Develops Performance improvement projects

• Provides for continuous review of systems

• Focuses on improving processes

• Improve patient care





Sources of data to guide your QAPI

CAHPS Hospice Survey

Medical records

Complaints

Adverse occurrences

After hour calls

Billing information

Staff input





Example Reports

The Comparison Report compares a hospice’s outcome to

other hospices throughout the United States. This report

helps to identify how your hospice compares to others in your

area so that you can use this information to help guide your

quality assurance and performance outcomes.





Example Dashboard Report

Q9. Providers seemed informed/up-to-date

Q16. Treated as gently as possibleQ19. Treated with

courtesy & respect

Q24. Have any problems

Q2. Inform you of care and services you would

get

Q15. Informed about arrival time

Q17. Explain things in a way that was easy to

understand

Q18. Carefully listen to you

Q22. Get help or advice when you needed

Q3. Talk about home safety

Q4. Discuss prescription medicinesQ5. See prescription

medicines

Q10. Discuss pain

Q12. Discuss new or changed medicine

Q13. Discuss when to take medicines

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

0.20 0.30 0.40 0.50 0.60 0.70 0.80


PE

RF

OR

MA

NC

E (

EX

PLIC

IT M

EA

N)

IMPORTANCE (CORRELATION)

SatMap™ Methodology uses explicit measures of performance, and implicit

measures of importance in order to identify how well your agency is meeting

your patients’ expectation of care.




Example Quality Report

For each Dimension of Care your performance is displayed by the Current

Period, 3-Month Average, 12-Month Average, and Year-to-Date.





Each page in the Quality Report is organized to provide a more in-depth look

into the questions that define that Dimension of Care. The Quality Report will

report and illustrate the Top Box percentage and the response breakout for the

current reporting period, 3-Month Average, 12-Month Average, and Year-to-

Date.





The Executive Summary Page US Health Care Research utilizes its

proprietary quality improvement tool SatMap Analysis to identify areas to focus

your improvement efforts with some suggested actions to improve in that area.




Financial

Investment


Annual Patient Deaths Annual Membership

50 to 250Contact us at 405.689.0444 to

determine your annual membership.251 to 500

501+

US Health Care Research charges on a total project basis, which includes data

collection, data submission, data analysis, and reporting. The costs are scalable

based upon the total number of patients served in a calendar year.

No additional cost for Spanish surveys. Sign-up by September 30, 2014 PAY NO

ANNUAL MEMBERSHIP FEES until April 2015.




For additional information contact:Ryan Nelson

405.689.0444

[email protected]





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CAHPS Hospice Survey - Special Report

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