Rural Hospice Demonstration: Quality Assurance Metrics Implementation Support

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Title
Rural Hospice Demonstration: Quality Assurance Metrics Implementation Support
Project Officer(s)
Cindy Massuda
Start Date
End Date
Award
Contract
Description
Section 409 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) authorized a five-year demonstration for rural Medicare beneficiaries who are unable to receive hospice care at home for lack of an appropriate caregiver. These demonstration patients were provided such care in a rural facility of 20 or fewer beds that provides, within its walls, the full range of hospice services. The demonstration tested whether hospice services provided by a rural hospice that does not need to meet the cap on inpatient care days or provide hospice services outside of the facility results in wider access, improved hospice services, benefits to the rural community, and a sustainable pattern of care. The demonstration was awarded to the Sanctuary Hospice House (SHH) located in Tupelo, Mississippi and Haven Hospice (formerly Hospice of North Central Florida) headquartered in Gainesville, Florida. The demonstration also implemented a Quality Assessment and Performance Improvement (QAPI) Program following the CMS proposed Conditions of Participation (CoP's) for hospice with CMS receiving aggregated metrics electronically. QAPI means that the demonstration sites collect quality data, analyzes their data, and then develop performance improvement projects based on a review of its quality data. Metrics collections began July 2006 and in total 16 quarters of data were collected. The hospices report aggregated data using an electronic tool developed for the demonstration and in conjunction with the hospices using their work processes. The data are viewed in tables and graphs. This demonstration was the first time CMS collected quality data in the hospice industry. It resulted in the largest CMS database of aggregated quality measures since they were reported on all patients and the Average Daily Census (ADC) was at least 600 throughout the demonstration. Additionally the sites took on a project to increase awareness of hospice and use of hospice services to underserved populations. The demonstration started on October 1, 2005 and ended on September 30, 2010.
Funding
$472,444.00
Principal Investigator(s)
Susan Lorentz
Project Number
HHSM-500-2005-00034C
Status
The Rural Hospice Demonstration ended September 28, 2010. It had significant lessons learned. The demonstration showed that the hospices were able to care for all patients appropriately under the traditional Medicare Hospice Program and that this provided a more sound business model. Effectively the waivers in the demonstration were ultimately not needed. One site never had any waivers. The other site became a traditional Medicare Hospice by becoming certified for and servicing patients in the community and not using the 20-inpatient cap. The demonstration learned much from the implementation of the quality measures, which was implemented using rapid response learning. Also, each site took on a project to increase awareness of and use of hospice services to underserved populations. The demonstration was designed to provide lessons learned for future planning of hospice quality measures since this demonstration was the first time Medicare required hospice providers to collect and report on quality measures. The quality measures were collected and reported using a secure web portal that provided the data in both tables and graphs such that trends could easily be viewed. The eight metrics were designed to cover hospice operations and to be: - Patient-focused and outcome oriented; - Valid, reliable, and feasible to use in hospice settings; and - Meaningful to participating hospices. These measures are: 1. Average pain severity on admission and after 1 day and 2 days of care for patients who: Report on admission that they are not satisfied with pain management; and/or Report (or have assessed) pain > 6 on admission (whether satisfied or not); and/or have a medication change for pain due to admission assessment. 2. Quarterly number of selected occurrences per 100 patient-days - aggregated for: All patients, Care centers, and Demo and Non-demo patients. 3. Quarterly LOS % patients with LOS < 3 days and > 180 days 4. Percentage of patients for whom the time from admission to completion of the comprehensive assessment is < 5 days (Will also calculate frequencies for 1, 2, 3, 4, 5 and >5 days; and mean # days) 5. Percentage of "families" reporting "Always" on item D2 of the FEHC: how often the family was kept informed about the patient's condition 6. Quarterly turnover rates (FT/PT) include volunteers in core patient care positions 7. Quarterly vacancy rates; include volunteers in core patient care positions 8. Volunteer hours (patient care) To learn about issues in implementing aggregated quality measures, we used rapid response learning. CMS' contractor provided technical support on how to implement these quality measures within their current business processes. The sites met via conference calls to discuss with the contractor and various CMS components issues with implementation, staff training, and other aspects of readying a hospice organization for collecting and reporting on aggregated quality measures. These calls resulted in identifying issues, such as the need to clarify some definitions or targeted staff training, and reconvening after revisions were made. Conference calls were also held between the sites and various CMS components after about each quarter or two of quality data was reported. This provided timely feedback to CMS and the sites about the process for data collection, team dissemination of information, analysis of the data, and usefulness of the data collection. These interactive calls with the feedback loop resulted ultimately in the sites' ability to report data consistently and accurately. CMS components received useful information for use in other hospice quality projects. A key to success in fostering the candid discussions that allowed the sites to share and act on their insights was trust and mutual respect between all parties. This strong relationship took time to develop. The sites reported that the aggregated metrics are a useful set of core measures, but that the occurrences should be based on 1000 patient days for easier analysis and review. This revision was included in CMS' future quality projects. The sites reported that the ability to access the measures online enabled each hospice to review its data by any of its staff and managers. This has improved awareness of the quality program and support at all levels of the hospices. The sites reported that the ability to view the measures graphically and tabularly has made it easier for them to understand, analyze, and discuss their data. Both sites identified opportunities for improvement and took action to improve performance. Verification and validation of the measures provided further insight that showed the importance for continued staff training for all aspects of quality reporting.
Awardee Address

4390 Parliament Place
Lanham, MD 20706-1808
Estados Unidos

Awardee Name
HDC International, Inc.