New Information Released on the Hospice Quality Reporting Program The Hospice
January 24, 2014 02:41 PM
The hospice Quality Reporting Program (HQRP) was the main focus of the CMS Open Door Forum (ODF) that was held on January 22, 2014. Since the Open Door Forum, CMS has posted the HIS Manual and training slides to the hospice quality webpage.
A summary of information shared on the ODF as well as some information from the HIS Manual is below. NAHC is planning more education on the HIS and HQRP in the near future with information about the education to be disseminated soon.
Hospices should be addressing two HQRP reporting cycles at this time:
Includes the collection of data in calendar year 2013 for two measures – structural measure and pain measure (NQF #0209)
Data is submitted in calendar year 2014 and impacts the payment update for FY2015
Data collection begins July 1, 2014 with the implementation of the Hospice Item Set (HIS)
Data is submitted on a rolling basis and impacts the payment update for FY2016
FY2015 Reporting Cycle
Hospices with a valid CCN (CMS Certification Number) as of March 3, 2014 are required to submit data collected in calendar year 2013 by the April 1, 2014 submission deadline. Hospices collected data for the Structural Measure and the Pain Measure from January 1, 2013 through December 31, 2013. In order to submit this data, hospices must register as a user. Previous registrations made for data submission last year (January 1 – April 1, 2013) are no longer valid.
Hospices can register for this year’s data submission here and clicking the word “Register” in the upper right of the page. More details for registration and submission are available in the Technical User’s Guide for Hospice Quality Reporting Data Entry and Submission, Version 2.02. If hospices have any questions that are not answered here they can direct questions to the QTSO Help Desk at 1-877-201-4721.
Once registered, hospices will be able to enter and submit data. The CCN number is required for registration so be sure to have this information available and verify that it has been entered correctly. If it is not entered correctly it is possible that the hospice will not get credit for submission of the data. Hospices have until 11:59 PM Eastern on April 1, 2014 to complete their submission. Please note that users are able to enter data and not submit it so be sure to select the “Submit” button for each measure. User’s will receive an email confirmation of their submission. We suggest hospices retain a printed copy of this confirmation.
Hospices will only need to answer a single yes/no question for the Structural Measure. The question is: Does your hospice have a Quality Assessment and Performance Improvement (QAPI) program that includes three or more quality indicators related to patient care? No other patient level or facility level data or performance scores will be submitted for the Structural Measure.
For the Pain Measure (NQF #0209) hospices will answer seven questions. The exact questions can be found in the Technical User’s Guide linked above and the questions with data collection details are found in the User’s Guide for Hospice Quality Reporting Data Collection, Version 2.0.
Hospices not reporting data for this cycle are subject to a 2% reduction in the FY2015 annual payment update. Beginning January 1, 2014 hospices are no longer required to collect data for the Structural Measure or Pain Measure.
FY2016 Reporting Cycle
This reporting cycle consists of data collected in calendar year 2014 which impacts the annual payment update for FY2016. For this cycle hospices will submit data on a rolling basis that is collected on the Hospice Item Set (HIS). There are two components to the HIS – a HIS-Admission and a HIS-Discharge. Hospices are to use the HIS beginning with all patients admitted on or after July 1, 2014. This means all patients regardless of payor source, location of care, or age. Each admission after this date is considered a new admission and requires a HIS-Admission even if the person previously was enrolled in hospice care. In order to use the HIS-Discharge there should be a corresponding HIS-Admission so for those patients who are admitted prior to July 1, 2014 but are discharged after this date no HIS is to be completed.
The HIS is a data collection tool only and not an assessment tool. It is not to be administered to hospice patients, families or caregivers. The tool is used to collect patient level data for six National Quality Forum (NQF) endorsed measures and one modified NQF-endorsed measure.
The HIS tool collects demographic and administrative information as well as data for the quality measures. While a HIS-Admission and a HIS-Discharge will be completed and submitted for all patients, data for the quality measures will only be collected for those patients 18 years of age or older.
The HIS-Admission and HIS-Discharge are still in draft form awaiting Office of Management and Budget (OMB) approval. Hospices can find the draft versions here. Significant revisions are not expected.
The HIS tools should be completed based on review of information contained in the medical record. It was suggested that hospices become familiar with the items they will need to collect and match these to the clinical record to ensure the hospice routinely collects the information needed. Hospices can refer to the HIS Fact Sheet for additional information.
Training on data collection, which closely follows the User’s Manual, will be conducted the afternoons of February 4 and 5 in the Baltimore, Maryland offices of CMS. Hospices can participate by attending the training sessions in person or via live streaming. Instructions for live video-streaming access will be provided here.
The training sessions will be recorded and will be available for viewing at a later time as well. Registration is required only for those attending the training in person and this will be limited to one person per hospice with a total number of 150 participants allowed on site. Early registration is suggested for those attending in person. The session on February 5 is not a repeat of the session on February 4.
Hospices should plan to participate in both sessions in order to receive the full training. Training will closely follow the User’s Manual. It is suggested that the User’s Manual and training slides (both linked above) be printed before the training. These sessions will cover data collection only and not technical training.
Technical training will be provided in May 2014. This training will be done via short pre-recorded WebX sessions that will be available for download the first week of May 2014. They will remain available indefinitely. Hospices will be able to access the sessions from the QIES Technical Support Office (QTSO) website. The sessions will walk through the submission details for the HIS.
Hospices will need access to the QIES (Quality Improvement and Evaluation System) Assessment Submission and Processing (ASAP) system for data submission and report retrieval. Each provider must create electronic HIS records and submission files using software that meets the requirements detailed in the currentHIS Data Submission Specifications.
Providers must also establish communication with the QIES ASAP system to submit the files. This is accomplished by using specialized communications software installed on their computer to access the CMS secure wide area network (WAN). Details about how to obtain WAN software and access are available on the QTSO website.
Each hospice will need to create two separate user IDs – one for submitting the HIS data and one for retrieving reports. The instructions for doing this are on the hospice welcome page in the QIES ASAP system. So hospices will need to first establish communication with the CMS WAN in order to access the hospice welcome page and create their two user IDs.
Each provider must decide which software it will use. This can be software from a hospice software vendor, hospices can create their own, or they can use free software offered by CMS. The free software, HEART – Hospice Extraction and Reporting Tool – will be available on or around May 15. Registration for the user IDs, regardless of which software system a hospice uses, can be completed as early as May 19, 2014.
Steps Hospices Should Be Taking Now for the FY2015 and FY2016 Reporting Cycles:
Register for a user account and submit Structural Measure and Pain Measure data no later than 11:59 PM Eastern on April 1, 2014 in order to avoid a 2% reduction in your annual payment update for FY2015.
Carefully review the draft versions of the HIS tools and ensure that the data required is being captured in the medical record and is easily retrievable. Pay special attention to the definitions and timeframes required for each of the measures.
Develop and test processes for completing the HIS
Verify that current computer systems meet the minimum requirements in the technical specifications. Involve the IT department in this project.
Choose a software system for HIS electronic files and submission.
Download and view the technical training videos that will be posted on the CMS website in May.
Obtain the two user IDs necessary for submission of the HIS files and retrieval of submission reports. Access for this will be available May 19, 2014.
Hospice Experience of Care Survey
The hospice survey portion of the HQRP is scheduled to begin in January 2015. On the ODF hospices were reminded of this and told that there will be a website for the hospice experience of care survey related announcements and information. A date for that website launch will be announced by CMS in the future. In the interim, any questions about the hospice survey can be emailed to email@example.com.