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Testimonials

In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

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VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

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President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

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U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human element...it’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

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Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

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Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

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U.S. Senator John McCain (R-AZ)

 

Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

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Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

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Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

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Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

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Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

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Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

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Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

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Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

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Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

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Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

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Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

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Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

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National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

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Former President Bill Clinton

Hospice FY2014 Payment, Wage Index Final Rule Issued: Debility, AFTT Prohibited as Principal Diagnoses Starting October 1, 2014 (PART TWO)

August 6, 2013 10:26 AM

PART TWO

Hospice Quality Reporting Program

As part of the Final Rule, CMS provided an update on the Hospice Quality Reporting Program (HQRP) and some details of two components of the HQRP:  (1) the Hospice Item Set (HIS) and (2) the Hospice Experience of Care Survey. 

Hospices were mandated to participate in reporting of two quality measures at the beginning of 2013 – the structural measure and the pain measure (NQF #0209).  The reporting deadlines were January 31, 2013 and April 1, 2013, respectively.  Hospices not meeting the January 31, 2013 structural measure reporting deadline and/or the April 1, 2013 pain measure reporting deadline are scheduled to have their market basket update reduced by 2 percent for FY2014. 

The market basket update is a component of the hospice payment formula, so depending on other factors, hospices having their market basket update reduced by 2 percent could actually see a negative payment update percentage.  CMS implemented a reconsideration process for hospices that did not meet the HQRP reporting deadlines.  More information about the reconsideration process is available here

In the proposed FY2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform released at the end of April of this year, CMS proposed the following in respect to the HQRP:

  1. The structural measure related to QAPI indicators and the NQF #0209 pain measure would not be required for the HQRP beyond data submission for the FY 2015 payment determination (submission in April 2014)
  2. Implementation of a Hospice Item Set (HIS) in July 2014 (affects payments beginning in FY2016) with reporting continuing regularly for each patient admitted to hospice on or after July 1, 2014 regardless of payor source, and,
  3. Implement a Hospice Experience of Care Survey in July 2015

Deletion of the Structural and Pain Measure

This is based on the fact that data collections of the structural measure to date (voluntary reporting period in 2012 and first mandatory reporting period) have provided adequate information on hospices’ patient care-related indicators making further reporting on the structural measure unnecessary and the fact that CMS has determined that the NQF # 0209 measure as it is currently collected and reported by hospices is not suitable for long-term use as part of HQRP. 

The measure results show too much variance in what hospices collect, aggregate, and report, and there is a high rate of patient exclusion due to patient ineligibility for the measure and patients’ denying pain at the initial assessment. 

In the Final Rule, CMS finalized the proposal to remove the structural measure requirement and the NQF #0209 pain measure beyond data submission for the FY2015 payment determination. Instead of NQF #0209, hospices will collect data on two other measures that address pain -- Pain Screening and Pain Assessment (see Hospice Item Set). 

Like commenters on the proposed rule, CMS recognizes that the Pain Screening and Pain Assessment measures do not reveal the level of improvement of a patient’s pain.  In the proposed rule, an alternative proposal was made to retain NQF #0209 until a more suitable outcome measure was available for use in the HQRP, to maintain a focus on achieving patient comfort. CMS intends to work toward the HQRP’s future inclusion of an improved pain outcome measure.

CMS also reiterated that the requirements regarding QAPI in the Conditions of Participation remain intact.

Hospice Item Set (HIS)

CMS has developed a hospice-specific data item set that contains seven quality measures endorsed by the National Quality Forum (NQF) for hospice.  The HIS was available for hospice review and comment.  It is a standardized, patient-level data collection vehicle.  CMS stresses that it is not a hospice assessment tool and it will not be administered to the patient and/or family or caregivers during the initial assessment visit. The HIS is not intended to replace a hospice’s current initial patient assessment.  The HIS was finalized as proposed.

Hospices will complete and submit an HIS upon a patient’s admission and at discharge - the Admission HIS and the Discharge HIS, respectively. The following are the seven proposed quality measures:

  1. NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen
  2. NQF #1634  Pain Screening
  3. NQF #1637  Pain Assessment
  4. NQF #1638  Dyspnea Treatment
  5. NQF #1639  Dyspnea Screening
  6. NQF #1641  Treatment Preferences
  7. NQF #1647  Beliefs/Values Addressed (if desired by the patient)

CMS finalized implementation of the HIS for July 1, 2014 - affecting payments beginning in FY2016 - with reporting continuing regularly for each patient admitted to hospice on or after July 1, 2014, regardless of payor source.

Hospices failing to report quality data via the HIS for the last six months of 2014 (July through December) will have their market basket update reduced by 2 percentage points in FY2016. Hospice programs will be evaluated for purposes of the quality reporting program based on whether or not they submit data, not on their performance level on required measures. 

Data submission will be electronic through software vendor program or through submission software CMS will develop and make available to hospices at no charge.  On July 16, 2013, CMS held a call specifically for software developers and vendors regarding the HIS technical data specifications.

CMS will hold additional vendor calls as needed to ensure that software vendors have the appropriate information to develop their own products for HIS. CMS stated that software vendors should not be waiting for final technical data specifications to be posted to begin development of their own products.

A beta version of free CMS HIS software will be made available in May 2014 and the final version in June 2014. CMS believes that providing a beta version in May 2014 is ample time for hospice staff to be ready for a July 1, 2014 implementation date. CMS will provide training on the free CMS HIS software and the submission process. The training is expected to occur in the spring of 2014.  

In cases where a hospice has purchased vendor software and the product is not available by July 1, 2014, the hospice may download the CMS software and submit records to the Quality Improvement and Evaluation System (QIES) Assessment and Submission Processing (ASAP) system as required. Thus, hospices will be able to comply with the July 1, 2014 implementation date of the HIS.

In the comments to the Final Rule, CMS acknowledged that the Admission HIS and Discharge HIS do not allow for calculation of all the NQF measures - specifically measures #1641 and #1647 - exactly as defined by the NQF. 

Measure #1641 does not have a specific time associated with the numerator and measure #1647 has a timeframe of the entire course of the patient’s hospice care.  CMS will use a modified version of measure #1647 still complying with the intent of the measure. 

CMS stated:

“We recognize that the discussion can take place at any time in the course of a patient’s hospice care but believe the patient should be offered the opportunity to address these concerns in the early days of care when they are more likely to be able to do so. We consider it best practice. We have chosen this approach also because it allows the gathering of the data for the measure closer to “real time” in terms of usual hospice assessment and workflow and because this approach will likely improve accuracy and reduce burden to the provider…We will monitor the performance over time to inform future evaluation for maintenance of the measure’s endorsement. We will proceed with the collection of the NQF #1641 measure and the modified NQF #1647 measure as part of the Admission HIS.”

CMS received comments from hospice providers and other interested parties specific to the NQF measures such as when the bowel regimen question should be answered, and that the dyspnea measure should include a measure of dyspnea upon exertion, etc.  Nearly all of the commenters’ questions are answered in the measure details from the NQF. 

Providers can link to a NAHC summary of the measures, including the modified NQF#1647, here.  If they’ve not already done so, providers should begin using these measures now and should implement the HIS tools now in order to prepare staff for implementation. 

Hospices are reminded that this is not a pay for performance system at this time and hospices will only be penalized if they do not participate in the submission of HIS data to CMS by the timeframes requested. CMS will provide reports to individual hospices on their performance on the measures calculated from data submitted via the HIS. The specifics of the reporting system and precisely when specific measures will be made available have not yet been determined.

 CMS did determine in 2012 that all hospice quality reporting periods subsequent to that for Payment Year FY2014 will be based on a calendar year instead of a calendar quarter and for FY 2015 and beyond, the data submission deadline will be April 1of each year. The implementation of the HIS in July 2014 will negate the calendar year data collection requirement and the April 1 data submission deadline. CMS will provide details on data collection and submission timing prior to implementation of the HIS.  CMS will also provide guidance and training materials, including a detailed user guide, to hospices prior to implementation of the HIS.

Summary Tables – HQRP Annual Payment Update (APU) Calculations

Finalized in the CY 2013 HH PPS Final Rule

Data Collection

Data Submission

APU Impact

Measure

1/1/2013 – 12/31/2013

4/1/2014

FY 2015

(October 1, 2014)

Structural/QAPI Measure

NQF # 0209

 

Finalized in this Final Rule

Data Collection

Data Submission

APU Impact

Measure

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Hospice and Palliative Care – Pain Screening, NQF

#1634

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Hospice and Palliative Care – Pain Assessment, NQF

#1637

 

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Hospice and Palliative Care – Dyspnea Screening,

NQF #1639

 

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Hospice and Palliative Care – Dyspnea Treatment,

NQF #1638

 

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Patients Treated with an Opioid who are Given a Bowel

Regimen, NQF #1617

 

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Hospice and Palliative Care

– Treatment Preferences,

NQF #1641

 

7/1/2014 – 12/31/2014

Rolling

FY 2016

(October 1, 2015)

Beliefs/Values Addressed (if desired by patient),

modified NQF #1647

 

 

Family Experience of Care Survey

CMS developed a draft Hospice Experience of Care Survey modeled closely after other CMS Consumer Assessment and Healthcare Providers and Systems (CAHPS) surveys and including questions from existing hospice survey tool, Family Evaluation of Hospice Care (FEHC).  The goals of the Hospice Experience of Care Survey are the same as the goals of our other CAHPS surveys: (1) to produce comparable data on the caregiver’s or loved one’s perspectives on care that allow objective and meaningful comparisons between hospices on domains that are important to consumers; (2) to create incentives for hospices to improve their quality of care through public reporting of survey results; and (3) to enhance public accountability in health care by increasing the transparency of the quality of the care provided in return for the public investments.

This family experience of care survey is part of the HQRP and its results will be publicly reported at a yet to be determined future date and hospice participation in the Survey will be part of the Annual Payment Update (APU) determination beginning in FY2017. 

The Survey captures such topics as hospice provider communications with patients and family members, hospice provider care, and patient and family member characteristics. The Hospice Experience of Care Survey will treat the dying patient and his or her informal caregivers (family members or friends) as the unit of care. The survey would allow the informal caregiver (family member or friend) to provide an overall rating of the hospice care their patient received, and would ask if they would recommend “this hospice” to others. 

Only the caregivers of patients who died in the program would be eligible to complete the tool.  Fielding timelines will be established to give the respondent some recovery time (two to three months), while simultaneously not delaying so long that the respondent is likely to forget details of the hospice experience. Caregivers will be presented with a set of standardized questions about their own experiences and the experiences of the patient in hospice care.

The Survey would allow for comparisons across hospices.  Part of the Survey includes demographic characteristics of the patients and their caregivers that can be used to feed into case mix adjustments of the publicly reported data from the HQRP.  During national implementation of this survey, hospices would be required to offer the survey, but individual caregivers would respond only if they voluntarily chose to do so.  Hospices would be required to contract with an approved survey vendor.  The draft experience of care survey is being field tested nationally in Fall 2013. 

As stated above, The Hospice Experience of Care Survey, as well as the CAHPS family of surveys, focuses on patient perspectives on the experience of care, rather than on patient satisfaction. CAHPS data complements other data, including clinical measures. CAHPS surveys are specifically intended to focus on issues where the patient (or in this case the caregiver) is the best source of information. CMS intends the Hospice Experience of Care Survey to have a similar focus. Once the survey is final, it will be submitted for CAHPS endorsement and National Quality Forum endorsement.

Like the Hospital and Home Health CAHPS surveys, CMS plans to move forward with a model of survey administration in which it will approve and train survey vendors to administer the survey on behalf of hospices. Hospices will be required to contract with an approved survey vendor and to provide the sampling frame to the approved vendor on a monthly basis. Small hospices serving 50 or fewer patients in an annual period will complete (annually) a Participation Exemption Request Form so that they will not incur survey costs.

In response to a significant number of comments to CMS that the draft Survey is too long, CMS indicated that there are more questions on the draft of the tool than are expected to be on the final Survey.  The results of the field testing will help to pare this down. 

It is anticipated that the final Survey tool will be significantly shorter than the FEHC, which has 54 questions.  CMS cited the example of the Home Health CAHPS survey that had 54 questions for the field test and was finalized with 34.  The Survey must be available from vendors in at least Spanish and English. Providers/vendors cannot translate the tool into other languages unless using the CMS translations. 

Providers will not be evaluated on the response rate for the surveys or on the actual responses to the survey questions at this time.  Hospices will be evaluated, though, on whether or not they participate in the process.  Like the HIS, CMS will notify hospices if there is no record of their participation and the hospice will have an opportunity to request reconsideration.  Those hospices found not to be participating will receive a 2 percent reduction to their annual payment update for the next payment year.

The following are key dates for the national implementation of the Hospice Experience of Care Survey:

  1. Hospices would contract with a CMS-approved survey vendor to conduct a “dry run” of the survey for at least one month in the first quarter of CY 2015 (January, February or March 2015)
  2. Vendors would submit data on the hospice’s behalf to the CMS hospice patient experience data center. The deadline for data submission has not yet been finalized
  3. “Dry run” data would not be publicly reported
  4. Hospices would contract with CMS-approved vendors to begin continuous monthly data collection starting April 1, 2015.
  5. The FY 2017 Annual Payment Update (APU) determination, based in part on the Hospice Experience of Care Survey, would include a dry run for at least one month in the first quarter of CY 2015 (Jan. 2015, Feb. 2015, and/or March 2015) plus three quarters of continuous monthly participation (April 1, 2015 through December 31, 2015).
  6. Subsequent APU determinations would be based upon four quarters of continuous monthly participation from Jan/ 1 through Dec. 31 of the relevant CY.
  7. Hospices that had fewer than 50 unduplicated or unique deceased patients in the period from Jan. 1, 2014 through Dec. 31, 2014 would be exempt from the Hospice Experience of Care Survey data collection and reporting requirements for the FY 2017 payment determination.  Hospices will be required to report the number of unique deceased patients for this period.

In summary, CMS will implement the HQRP requirement of a Hospice Experience of Care Survey with a test run for at least 1 month in the first quarter of CY 2015 with continuous monthly data collection beginning April 1, 2015 through December 31, 2015, to meet the annual payment update requirements for FY 2017.

Update on Hospice Payment Reform

As part of the final rule, CMS provides a summary of the information provided in the proposed rule on progress made thus far toward development of a refined hospice payment system.  Included as part of the summary are discussion of options for payment reform, including a U-shaped model, a tiered payment model, a low-utilization payment adjustment (LUPA) add-on as used under home health that would be provided for patients with short stays in hospice, and a case-mix based system.  CMS also discusses the potential for rebasing of routine home care (RHC) which would reduce daily rates for RHC by approximately 10.1 percent, and a site-of-service adjustment under which payments for patients in nursing facilities would be reduced.  An article describing these options in greater depth that was previously published in NAHC Report is available here.

 

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