Rural Hospice Demonstration: Quality Assurance Metrics Implementation Support

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.