CMS will host a series of provider trainings for the Hospice Item Set (HIS) in February and May 2014. Click here to read the complete announcement.
What you’ll find on this page:
- a concise overview of the CMS quality reporting program- present and future
- links to quality reporting resources developed by NHPCO
- links to quality reporting resources developed by CMS
The Patient Protection and Affordable Care Act (ACA) mandated the initiation of a quality reporting program for hospices. The Center for Medicare and Medicaid (CMS) determines the quality measures that hospices must utilize and the processes hospices must use to submit data for those measures. Hospices that fail to submit required quality data in a given year will incur a 2 percentage point reduction to the market basket percentage increase for the subsequent fiscal year.
CMS maintains a Hospice Quality Reporting website with information on all aspects of the hospice quality reporting program. Be sure to check the CMS Hospice Quality Reporting website regularly and often for updated information and new resources.
NHPCO Quality Reporting General Resources:
- Quality Reporting Timeline (a schedule and summary of CMS reporting requirements)
- Quality Reporting: Past, Present, and Future - coming soon
January 22, 2013
Quality Reporting Requirements for Today and the Future
July 24, 2012
Implementing Predetermined Quality Measures
CMS Quality Reporting General Resources
What you should be doing now
- Hospices should currently be collecting data for the QAPI Structural Measure and NQF 0209 Measure for all of 2013 (1/1/2013- 12/31/2013).
- The submission period for 2013 data will be January 1, 2014 - April 1, 2014
- The web site for registration, data entry and submission of 2013 quality measure data will not be available until January 1, 2014.
- April 1, 2014 is the submission deadline for both measures.
- Hospices that fail to report quality data in 2014 will have a 2% market basket reduction for FY 2015 (starts October 1, 2014).
NHPCO NQF #0209 Resources:
- Comfortable Dying Measure webpage (includes the Comfortable Dying Manual, Measure Logic Diagram, Comfortable Dying Data Management Workbook, and other related information)
The links below are for materials available on the CMS Quality Reporting website. These materials contain instructions for providers on the current data collection and reporting requirements and processes for the QAPI structural measure and the NQF #0209 pain measure.
- HQRP FY 2015 Reporting Cycle HQRP Training Slides
- HQRP Fiscal Year 2015 Reporting Cycle Requirements Fact Sheet
- User Guide for Hospice Quality Reporting Data Collection Version 2.0
What you need to prepare for
2014: Hospice Item Set (HIS)
The HIS is a patient-level data collection tool that will be used to collect data for 7 process measures:
- NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen
- NQF #1634 Pain Screening
- NQF #1637 Pain Assessment
- NQF #1638 Dyspnea Treatment
- NQF #1639 Dyspnea Screening
- NQF #1641 Treatment Preferences
- Modified NQF #1647 Beliefs/Values Addressed (if desired by the patient)
For each patient admitted on or after July 1, 2014, completion of the HIS will be required on admission and on discharge.
- Data collection period: July 1, 2014 - December 31, 2014.
- Data submission is on a rolling basis. Data submission process -- TBA
- Hospices that fail to report quality data via the HIS system in 2014 will incur a 2% market basket reduction for FY 2016 (starts October 1, 2015).
2015: Hospice Experience of Care Survey
CMS is developing a post-death family caregiver survey that will objectively assess patient and family experiences with hospice care. The hospice experience of care survey will follow the principles used in the development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys and will eventually become part of the CAHPS family of surveys.
- The survey will be administered by vendors on behalf of hospices. Hospices will be required to contract with an approved survey vendor and to provide caregiver contact information to the vendor on a monthly basis.
Different versions of the survey will be administered for each of three hospice care settings based on site of death:
- Nursing home
- Inpatient (freestanding inpatient unit or acute care hospital)
Data Collection and Submission Requirements:
- Mandatory “dry run” for at least 1 month in the first quarter or CY 2015 (January 1, 2015 – March 31, 2015)
- Monthly data collection April 1, 2015 – December 31, 2015.
- Data submission: TBA
- Hospices that fail to report survey data will incur a 2% market basket reduction for FY 2017 (starts October 1, 2016).
CMS is conducting a national field test in the Fall of 2013 using setting specific draft versions of the surveys. Details on the field test are available on the CMS PRA website.
Below are the draft versions of the survey used in the field test. IMPORTANT NOTE: There are more questions in the test surveys than will be used in the final survey. Final versions of the survey will not be available until after the field test is completed.
- Draft Instrument of Hospice Experience of Care Survey – Home Version
- Draft Instrument of Hospice Experience of Care Survey – Nursing Home Version
- Draft Instrument of Hospice Experience of Care Survey – Inpatient Version