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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. 

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.

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

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’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

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.

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.

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.

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.

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.

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.

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. 

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.

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.

Frank E. Moss, former U.S. Senator

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

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.

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.

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.

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.

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.

Former President Bill Clinton

IN FOCUS Part 3: The Proposed FY2016 Hospice Payment Rule — HQRP

June 4, 2015 12:14 PM

The National Association for Home Care & Hospice (NAHC) published an initial overview of the proposed FY2016 Hospice Payment Rule in NAHC Report on May 1, 2015.  To provide more in-depth coverage of specific elements of the proposed rule, NAHC is developing a series of “IN FOCUS” articles that will be published over the coming weeks.  Part 3 of the “IN FOCUS” series focuses on CMS proposals for the Hospice Quality Reporting Program (HQRP).

As previously reported, the proposed fiscal year (FY) 2016 hospice payment rule contains proposed changes and updates to the Hospice Quality Reporting Program (HQRP).  The Centers for Medicare & Medicaid Services (CMS) states in its comments that its paramount concern is the successful development of a HQRP that promotes the delivery of high quality healthcare services.  In order to be considered by CMS as part of the rulemaking process, comments must be received by June 29, 2015 and may be submitted here:​dicare-program-fy-2016-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting.

Requirements and Exceptions –Review and Clarification

The HQRP was mandated under Section 3004 of the Affordable Care Act (ACA).  The ACA also requires that beginning with FY 2014 and each subsequent FY, the Secretary of Health and Human Services (HHS) shall reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data submission requirements with respect to that FY.  Reporting compliance is determined by successfully fulfilling both the Hospice CAHPS® Survey requirements and the HIS data submission requirements.  CMS currently notifies hospices of the 2 percentage point reduction via letter of the noncompliance decision.  A hospice may request reconsideration of a noncompliance decision by CMS.  In the FY2016 proposed hospice payment rule, CMS clarifies that any hospice that wishes to submit a reconsideration request must do so by submitting an email to CMS containing all of the requirements listed on the HQRP website at:​-Reporting/Reconsideration-Requests.html . Electronic email sent to is the only form of submission that will be accepted.  Any reconsideration request received through any other channel including U.S. postal service or phone will not be considered as a valid reconsideration request.

HQRP Measures – Review and Proposal

CMS seeks to adopt measures for the HQRP that promote patient-centered, high quality, and safe care.  CMS’ measure selection activities for the HQRP take into consideration input from the Measure Applications Partnership (MAP), convened by the National Quality Forum (NQF). The MAP is a public-private partnership comprised of multi-stakeholder groups convened by the NQF for the primary purpose of providing input to CMS on the selection of certain categories of quality and efficiency measures, as required by section 1890A(a)(3) of the Act. By February 1 of each year, the NQF must provide that input to CMS. Input from the MAP is located at: . CMS also takes into account national priorities, such as those established by the National Priorities Partnership at:; the HHS Strategic Plan at:, the National Strategy for Quality Improvement in Healthcare at:, and the CMS Quality Strategy, at:​y-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html . To the extent practicable, CMS has sought to adopt measures endorsed by member organizations of the National Consensus Project recommended by multi-stakeholder organizations, and developed with the input of providers, purchasers/payers, and other stakeholders.  In addition, CMS takes into consideration vital feedback and input from research published by Abt Associates, the CMS payment reform contractor, as well as from the Institute of Medicine (IOM) report, titled “Dying in America,” released in September 2014. Finally, the current HQRP measure set is also an important consideration for future measure development areas; future measure development areas should complement the current HQRP measure set, which includes HIS measures and CAHPS® Hospice Survey measures.

HIS Measures

To support the standardized collection and calculation of quality measures, a standardized data collection instrument is required.  Therefore, CMS developed and tested a hospice patient- level item set, the HIS (Hospice Item Set).  Hospices are required to submit an HIS-Admission record and an HIS-Discharge record for each patient admission to hospice on or after July 1, 2014.

Electronic submission is required for all HIS records, but   hospices do not need to have an electronic medical record to complete or submit HIS data.  Providers can use either the Hospice Abstraction Reporting Tool (HART) software, which is free to download and use, or a vendor-designed software.  HART provides an alternative option for hospice providers to collect and maintain facility, patient, and HIS Record information for subsequent submission to the QIES ASAP system.  Once HIS records are complete, electronic HIS files must be submitted to CMS via the QIES ASAP system.  Electronic data submission via the QIES ASAP system is required for all HIS submissions; there are no other data submission methods available.   The QIES ASAP system is the same data submission system used by nursing homes, long term care hospitals, home health agencies and inpatient rehab facilities. 

CMS will continue to make HIS completion and submission software available to hospices at no cost.

Proposed Policy for Retention on HQRP Measures Adopted for Previous Payment Determination

CMS proposes the following:

  • Beginning with the FY2018 payment determination, once a quality measure is adopted, it will be retained for use in the subsequent fiscal year payment determination unless otherwise stated, i.e. removed, suspended or replaced.

Quality measures may be considered for removal by CMS if:

  • Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made;
  • Performance or improvement on a measure does not result in better patient outcomes;
  • A measure does not align with current clinical guidelines or practice;
  • A more broadly applicable measure (across settings, populations, or conditions) for the particular topic is available;
  • A measure that is more proximal in time to desired patient outcomes for the particular topic is available;
  • A measure that is more strongly associated with desired patient outcomes for the particular topic is available; or
  • Collection or public reporting of a measure leads to negative unintended consequences.

For any such removal, the public will be given an opportunity to comment through the annual rulemaking process.  However, if there is reason to believe continued collection of a measure raises potential safety concerns, CMS will take immediate action to remove the measure from the HQRP and will not wait for the annual rulemaking cycle.

CMS is not proposing to remove any measures for the FY 2017 reporting cycle nor is it proposing any new measures for FY 2017.  However, CMS is working with the measure development and maintenance contractor to identify measure concepts for future implementation in the HQRP. 

Based on input from stakeholders, CMS has identified several high priority concept areas for future measure development:

  • Patient reported pain outcome measure that incorporates patient and/or proxy report regarding pain management;
  • Claims-based measures focused on care practice patterns including skilled visits in the last days of life, burdensome transitions of care for patients in and out of the hospice benefit, and rates of live discharges from hospice;
  • Responsiveness of hospice to patient and family care needs;
  • Hospice team communication and care coordination

CMS invites public comment on this proposal and about the four high priority concept areas for future measure development.

HIS Form, Manner, and Timing of Quality Data Submission

In the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50488) CMS finalized a policy stating that any hospice that receives its CCN notification letter on or after November 1 of the preceding year involved is excluded from any payment penalty for quality reporting purposes for the following FY.

CMS proposes and invites public comment on proposals to:

  • Modify policies for the timing of new providers to begin reporting to CMS such that, beginning with the FY 2018 payment determination and for each subsequent payment determination, CMS proposes that a new hospice be responsible for HQRP quality data reporting beginning on the date they receive their Certification Number (CCN) (also known as the Medicare Provider Number) notification letter from CMS. Under this proposal, hospices would be responsible for reporting quality data on patient admissions beginning on the date they receive their CCN notification.

Currently, new hospices may experience a lag between Medicare certification and receipt of their actual CCN Number.  Since hospices cannot submit data to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system without a valid CCN Number, CMS proposes new hospices begin collecting HIS quality data beginning on the date they receive their CCN notification letter by CMS.  CMS believes this will provide sufficient time for new hospices to establish appropriate collection and reporting mechanisms to submit the required quality data to CMS.

HIS Proposed Data Submission Timelines and Compliance Threshold Requirements for FY 2018 Payment Determination and Subsequent Years

CMS proposes the following:

  • Beginning with the FY 2018 payment determination, CMS proposes that hospices must submit all HIS records within 30 days of the Event Date.  The Event Date is the patient’s admission date for HIS-Admission records or discharge date for HIS-Discharge records. If finalized as proposed, the requirement that hospices submit all HIS records within 30 days of the Event Date would be in rule and would give CMS and other oversight entities greater latitude for future enforcement efforts (other than the 2 percent financial penalty) should they decide to pursue additional options in the future.  Providers will receive warnings in the QIES ASAP system for any record not submitted timely.  CMS’ reasoning for establishing the timely submission requirement is that the timely submission, coupled with the standardized collection of data, is essential in order to establish a robust quality reporting program and ensure the scientific reliability of the data received.
  • To coincide with this requirement, CMS proposes to establish an incremental threshold for compliance with this timeliness requirement.  The proposed threshold would be implemented over a 3-year period and be effective with all HIS admission and discharge records that occur on or after January 1, 2016, in accordance with the schedule provided below.

CMS stated the ultimate goal is to require all hospices to achieve a timeliness requirement compliance rate of 90 percent or more.

Effective with all HIS admission and discharge records that occur on or after:

Timelines and Thresholds

January 1, 2016 to December 31, 2016

Hospices must submit at least 70 percent for all required HIS records within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2018.

January 1, 2017 to December 31, 2017

Hospices must score at least 80 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2019.

January 1, 2018 to December 31, 2018

Hospices must score at least 90 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2020.


Submission Exception and Extension Requirements

As stated above, hospices currently may request an extension by following the instructions on the CMS Hospice Quality Reporting webpage at:​equests.html.

CMS is proposing to codify at 418.32 exception and extension requirements to:

  • Allow hospices to request and for CMS to grant exemptions/extensions with respect to the reporting of required quality data when there are extraordinary circumstances beyond the control of the provider. When an extension/exception is granted, a hospice will not incur payment reduction penalties for failure to comply with the requirements of the HQRP. For the FY 2016 payment determination and subsequent payment determinations, a hospice may request an extension/exception of the requirement to submit quality data for a specified time period (see below). In the event that a hospice requests an extension/exception for quality reporting purposes, the hospice would submit a written request to CMS. In general, exceptions and extensions will not be granted for hospice vendor issues, fatal error messages preventing record submission, or staff error.
  • In the event that a hospice seeks to request an exception or extension for quality reporting purposes, the hospice must request an exception or extension within 30 days of the date that the extraordinary circumstances occurred by submitting the request to CMS via email to the HQRP mailbox at: Exception or extension requests sent to CMS through any other channel would not be considered as a valid request for an exception or extension from the HQRP’s reporting requirements for any payment determination. In order to be considered, a request for an exception or extension must contain all of the finalized requirements as outlined at: http://www​  .
  • If a provider is granted an exception or extension, timeframes for which an exception or extension is granted will be applied to the new timeliness requirement so providers are not penalized. If a hospice is granted an exception, CMS will not require that the hospice submit any quality data for a given period of time. If CMS grants an extension to a hospice, the hospice will still remain responsible for submitting quality data collected during the timeframe in question, although CMS will specify a revised deadline by which the hospice must submit this quality data.

This process does not preclude CMS from granting extensions/exceptions to hospices that have not requested them when CMS determines that an extraordinary circumstance exists for an entire region or locale.  CMS may grant an extension/exception to a hospice if it determines that a systemic problem with the CMS data collection systems directly affected the ability of the hospice to submit data.  If CMS makes such a determination to grant an extension/exception to hospices in a region or locale, CMS will communicate this decision through routine communication channels to hospices and vendors, including, but not limited to, Open Door Forums, ENews and notices on​y-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Spotlight.html .

CAHPS Hospice – Review and Proposal

The CAHPS® Hospice Survey is the first national hospice experience of care survey that includes standard survey administration protocols that allow for fair comparisons across hospices.

The survey was designed to measure and assess the experiences of patients who died while receiving hospice care as well as the experiences of their informal caregivers.  The goals of the survey are to—

  • Produce comparable data on patients' and caregivers' perspectives of care that allow objective and meaningful comparisons between hospices on domains that are important to consumers;
  • Create incentives for hospices to improve their quality of care through public reporting of survey results; and
  • Hold hospice care providers accountable by informing the public about the providers' quality of care.


Consistent with many other CMS CAHPS® surveys that are publicly reported on CMS Web sites, CMS will publicly report hospice data when at least 12 months of data are available, so that valid comparisons can be made across hospice providers in the United States, to help patients, family and friends choose a hospice program for themselves or their loved ones.

Hospice CAHPS Participation Requirements to Meet Quality Reporting Requirements for the FY 2018 APU

In this proposed rule, CMS outlines what would be required of hospices to meet the FY 2018 Annual Payment Update (APU).  The details are below:

To comply with CMS's quality reporting requirements for the FY 2018 APU, hospices will be required to collect data using the CAHPS® Hospice Survey on an ongoing monthly basis January 1, 2016 through December 31, 2016. Hospices would be able to comply by utilizing only CMS-approved third party vendors that are in compliance with the provisions at §418.312(e).

To meet the HQRP requirements for the FY 2019 payment determination, hospices would collect survey data on a monthly basis for the months of January 1, 2017 through December 31, 2017 to qualify for the full APU. A summary table is below.

CAHPS® Hospice Survey Data Submission Dates FY2017 APU, FY2018 APU, and FY2019 APU

Sample Months
(that is, month of death)1

Quarterly data
submission deadlines2

FY2017 APU

Hospices collect survey data on a monthly basis for the months of April 1, 2015 through December 31, 2015 to qualify for the full FY 2017 APU

Dry Run January-March 2015 (Q1)

August 12, 2015

April-June 2015 (Q2)

November 11, 2015

July-September 2015 (Q3)

February 10, 2016

October-December 2015 (Q4)

May 11, 2016

FY2018 APU

Hospices would collect survey data on a monthly basis for the months of January 1, 2016 through December 31, 2016 to qualify for the full FY 2018 APU.

January-March 2016 (Q1)

August 10, 2016

April-June 2016 (Q2)

November 9, 2016

July-September 2016 (Q3)

February 8, 2017

October-December 2016 (Q4)

May 10, 2017

FY2019 APU

Hospices would collect survey data on a monthly basis for the months of January 1, 2017 through December 31, 2017 to qualify for the full FY 2019 APU.

January-March 2017 (Q1)

August 9, 2017

April-June 2017 (Q2)

November 8, 2017

July-September 2017 (Q3)

February, 14, 2018

October-December 2017 (Q4)

May 9, 2018


1=Data collection for each sample month initiates two months following the month of patient death (for example, in April for deaths occurring in January).
2=Data submission deadlines are the second Wednesday of the submission month.

3=Corrected from the Final Rule published August 22, 2014, 79 FR 50493.


Deadlines are final; no late submissions will be accepted. Hospice providers are responsible for making sure that their vendors are submitting data in a timely manner.  However, in the event of extraordinary circumstances beyond the control of the provider, the provider will be able to request an exemption as previously noted above. 

CMS proposes to continue the exemption for very small hospices from CAHPS® Hospice Survey requirements. Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from January 1, 2015 through December 31, 2015 are exempt from CAHPS® Hospice Survey data collection and reporting requirements for the 2018 APU. To qualify for the survey exemption for the FY 2018 APU, hospices must submit an exemption request form. This form will be available on the CAHPS® Hospice Survey Web site   Hospices are required to submit to CMS their total unique patient count for the period of January 1, 2015 through December 31, 2015. The due date for submitting the exemption request form for the FY 2018 APU is August 10, 2016.

CAHPS® Hospice Survey Oversight Activities - The purpose of the oversight activities is to ensure that hospices and approved survey vendors follow the CAHPS® Hospice Survey technical specifications and thereby ensure the comparability of CAHPS® Hospice Survey data across hospices.

CMS proposes the following:

  • Continue a requirement that vendors and hospice providers participate in CAHPS® Hospice Survey oversight activities to ensure compliance with Hospice CAHPS® technical specifications and survey requirements.
  • Include the reconsiderations and appeals process for hospices failing to meet the Hospice CAHPS® data collection requirements as part of the Reconsideration and Appeals process already developed for the HQRP.
  • Expand communications method regarding annual notification of reporting compliance in the HQRP: In the past, only hospices found to be non-compliant with the reporting requirements set forth for a given payment determination received a notification in the form of a certified United States Postal Service (USPS) letter of this finding along with instructions for requesting reconsideration. In addition to sending a letter via regular USPS mail, beginning with the FY 2017 payment determination and for subsequent fiscal years, CMS proposes to use the Quality Improvement and Evaluation System (QIES) National System for Certification and Survey Provider Enhanced Reports (CASPER).  The electronic APU letters would be accessed using the CASPER Reporting Application. Additional information about how to access the letters would be provided prior to the release of the letters.
  • Disseminate communications regarding the availability of hospice compliance reports in CASPER files through routine channels to hospices and vendors, including (but not limited to) issuing memos, emails, Medicare Learning Network (MLN) announcements, and notices on:
  • Publish a list of hospices that successfully meet the reporting requirements for the applicable payment determination on the HQRP website. CMS further proposes updating the list after reconsideration requests are processed on an annual basis.

CMS invites comment on the proposals to add CASPER Reporting as an additional communication mechanism for the dissemination of compliance notifications and to publish a list of compliant hospices on the HQRP website.

Public Display of Quality Measures and other Hospice Data for the HQRP

CMS made no proposal but did provide comments on the public display of HQRP data.  CMS stated: “We believe it is critical to establish the reliability and validity of the quality measures prior to public reporting in order to demonstrate the ability of the quality measures to distinguish the quality of services provided. To establish reliability and validity of the quality measures, at least four quarters of data will be analyzed.  Data collection began in CY 2014; the data from CY 2014 for Quarter 3 (Q3) will not be used for assessing validity and reliability of the quality measures. We are analyzing data collected by hospices during Quarter 4 (Q4) CY 2014 and Q1–Q3 CY 2015. Decisions about whether to report some or all of the quality measures publicly will be based on the findings of analysis of the CY 2015 data.”

A timeline for posting hospice data publicly has not been determined by CMS. Should a timeline become available prior to the next annual rulemaking cycle, details would be announced via regular HQRP communication channels, including listening sessions, memos, email notification, and Web postings.

CMS did indicate it will develop a CMS Compare Web site for hospice, which will list hospice providers geographically. Like other CMS Compare Web sites, the Hospice Compare Web site will feature a quality rating system that gives each hospice a rating of between one (1) and five (5) stars. Hospices will have prepublication access to their own agency’s quality data, which enables each agency to know how it is performing before public posting of data on the Compare Web site. Decisions regarding how the rating system will determine a provider’s star rating and methods used for calculations, as well as a proposed timeline for implementation will be announced via regular HQRP communication channels, including listening sessions, memos, email notification, provider association calls, Open Door Forums, and Web postings. CMS will announce the timeline for public reporting of quality measure data in future rulemaking.

CMS also plans to make available provider-level feedback reports in the Certification and Survey Provider Enhanced Reports (CASPER) system. These provider-level feedback reports or “quality reports” will be separate from public reporting and will be for provider viewing only, for the purposes of internal provider quality improvement. As is common in other quality reporting programs, quality reports would contain feedback on facility-level performance on quality metrics, as well as benchmarks and thresholds. For the CY 2014 Reporting Cycle, there were no quality reports available in CASPER; however, CMS anticipates that provider-level quality reports will begin to be available sometime in CY 2015. CMS anticipates that providers would use the quality reports as part of their Quality Assessment and Performance Improvement (QAPI) efforts.




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