Spe­cial re­port: Mea­sur­ing the clin­i­cal per­for­mance of hospices

Hospice-care providers to be­gin re­port­ing on two qual­ity mea­sures, an in­cre­men­tal ap­proach that the in­dus­try sup­ports

Modern Healthcare - - FRONT PAGE - Maureen Mckin­ney

For the more than 5,000 hospices across the coun­try, suc­cess is of­ten mea­sured by hard-to-pin­down met­rics, such as whether a pa­tient feels com­fort­able or is able to help to plan his or her funeral, or whether fam­ily mem­bers feel in­cluded in the end-of-life care process.

Qual­ity in­di­ca­tors that are com­monly used in other set­tings, such as mea­sures of im­proved func­tional sta­tus, are not usu­ally ap­pli­ca­ble, and even if they are, they’re of­ten not part of a hospice’s over­ar­ch­ing goal.

“The dif­fer­ence in hospice is that we’re not fo­cused on a med­i­cal di­ag­no­sis, as in, ‘We treat with these five things and we ex­pect a res­o­lu­tion,’ ” says Pat O’maley-lanphear, a for­mer hospice qual­ity di­rec­tor who now owns an Ar­ling­ton, Wash.-based con­sult­ing com­pany that works with hospice providers. “We’re try­ing to make sure pa­tients’ symp­toms are man­aged and they are as in­formed as pos­si­ble. We’re try­ing to sup­port their de­ci­sions.”

For in­stance, some pa­tients with swal­low­ing dis­or­ders may not want to have a feed­ing tube. In those cases, care might in­clude hy­dra­tion and com­fort mea­sures, O’maley-Lanphear says.

Other pa­tients’ hospice goals may in­clude re­con­nect­ing with loved ones or stay­ing alive un­til a par­tic­u­lar event, says Patty Lup­tak, di­rec­tor of pro­fes­sional ser­vices at Sivitz Jewish Hospice & Pal­lia­tive Care, Pitts­burgh.

“We treat the whole fam­ily,” Lup­tak says. “We con­trol symp­toms, pro­vide spir­i­tual sup­port, help with community re­sources—it’s a whole dif­fer­ent set of dy­nam­ics in hospice.”

Based on per­cep­tion

In­stru­ments that use nu­meric rat­ings, such as pain scales, can be prob­lem­atic, too, be­cause so much of hospice qual­ity is based on pa­tient per­cep­tion, says Carol Spence, vice pres­i­dent for re­search and qual­ity at the Na­tional Hospice and Pal­lia­tive Care Or­ga­ni­za­tion, a mem­ber­ship or­ga­ni­za­tion based in Alexan­dria, Va.

“You can’t have a pain mea­sure that says all pa­tients should be at a three be­cause one per­son’s three is an­other per­son’s six,” Spence, says. “Hospice has to work for each pa­tient.”

Given the in­di­vid­u­al­ized na­ture of hospice care, many providers say it can be dif­fi­cult to use stan­dard­ized qual­ity mea­sures to gauge per­for­mance and fa­cil­i­tate side-by­side com­par­i­son.

In just a few months, though, that’s ex­actly what the CMS will be re­quir­ing hospices to do.

“Yes, hospice is cus­tom­ized to in­di­vid­ual pa­tients and fam­i­lies, but how well they pro­vide care can be stan­dard­ized,” says Robin Dow­ell, a nurse con­sul­tant in the CMS Of­fice of Clin­i­cal Stan­dards and Qual­ity. “There are ex­pec­ta­tions of qual­ity that we can iden­tify.”

Man­dated by the health­care re­form law, the CMS Hospice Qual­ity Re­port­ing Pro­gram will re­quire hospices to gather data and re­port on spe­cific qual­ity mea­sures in or­der to avoid a 2% cut to their an­nual pay­ment up­date.

For fis­cal 2013, hospices have to re­port on two mea­sures—a pain-man­age­ment in­di­ca­tor and a struc­tural mea­sure that eval­u­ates whether hospices have a qual­ity as­sess­ment and per­for­mance im­prove­ment pro­gram in place in the fourth quar­ter of 2012—to avoid a cut in 2014. The pro­gram re­quires hospices to only re­port, and it does not pe­nal­ize them based on their score or the con­tent of their sub­mis­sions.

The data-col­lec­tion pe­riod for the first phase of the pro­gram will run from Oct. 1 un­til Dec. 31. The sub­mis­sion dead­line for the struc­tural mea­sure is Jan. 31, 2013, while the

due date for sub­mit­ting the pain-man­age­ment mea­sure data is April 1.

Hospice groups mostly praised the CMS for tak­ing what they called a care­ful, in­cre­men­tal ap­proach to in­tro­duc­ing qual­ity re­port­ing to a field that has lit­tle, if any, ex­pe­ri­ence with it.

“We be­lieve they have been very cau­tious in try­ing not to over­load hospices with too much at one time while also get­ting them ready for broader-scale re­port­ing,” says Theresa Forster, ex­ec­u­tive vice pres­i­dent of hospice pro­grams for the Na­tional As­so­ci­a­tion for Home Care & Hospice, a Wash­ing­ton-based trade as­so­ci­a­tion. “We think it’s been done in a ju­di­cious way.”

O’Maley-Lanphear says the pro­gram will give hospices an op­por­tu­nity to demon­strate the value of their ser­vices while also pro­vid­ing a way to iden­tify and share best prac­tices. “When you look at hospices that have each de­vel­oped their own in­ter­nal qual­ity mea­sures, you’re com­par­ing ap­ples to or­anges,” she says. “By com­ing up with some clear guide­lines, we can start to com­pare ap­ples to ap­ples.”

As­sess­ing pain man­age­ment

The two mea­sures cho­sen for the first year of the hospice qual­ity pro­gram were fi­nal­ized in the Hospice Wage In­dex for 2012, pub­lished Aug. 4, 2011.

The first, de­vel­oped by the Na­tional Hospice and Pal­lia­tive Care Or­ga­ni­za­tion, mea­sures how many pa­tients who were in pain at their ini­tial as­sess­ment af­ter ad­mis­sion to hospice had their pain brought to a com­fort­able level within 48 hours.

That mea­sure, en­dorsed by the Na­tional Qual­ity Forum in Au­gust 2009 and reap­proved on Feb. 14, is a source of con­cern for some hospice providers. Lin Si­mon, di­rec­tor of qual­ity for Gilchrist Hospice Care, Hunt Val­ley, Md., con­tends that the pain-man­age­ment mea­sure ap­plies only to a very small per­cent­age of hospices’ pa­tient pop­u­la­tions.

More than a decade ago, when the mea­sure was de­vel­oped, hospices served a much larger per­cent­age of can­cer pa­tients, Si­mon says.

“Back then, many of them ar­rived in hospice in ter­ri­ble pain, com­ing from set­tings that didn’t treat pain well,” Si­mon says. “Things have re­ally changed and now we have many more pa­tients with de­men­tia, (chronic ob­struc­tive pul­monary dis­ease) and heart fail­ure. And peo­ple are com­ing to us from set­tings that are much bet­ter at ad­dress­ing pa­tients’ pain.”

Based on data from Gilchrist’s in­ter­nal qual­ity pro­gram, less than 10% of the hospice’s pa­tients are ad­mit­ted in pain, she adds. “This rep­re­sents only a tiny, tiny sub­set of who we serve.”

An­other is­sue with the mea­sure, Si­mon says, is that it re­quires pa­tients to state ver­bally af­ter 48 hours that their pain has been brought to a com­fort­able level. Some pa­tients who were in the orig­i­nal de­nom­i­na­tor—those who were in pain at the ini­tial as­sess­ment—may die dur­ing the 48-hour time pe­riod. Oth­ers may be un­con­scious and un­able to re­spond, she says.

“What ef­fect will those pa­tients who can’t re­spond have on the nu­mer­a­tor?” Si­mon says. “We don’t know.”

Vir­ginia White, di­rec­tor of qual­ity and per-

“We treat the whole fam­ily. We con­trol symp­toms, pro­vide spir­i­tual sup­port, help with community re­sources—it’s a whole dif­fer­ent set of dy­nam­ics in hospice.”

—Patty Lup­tak Sivitz Jewish Hospice & Pal­lia­tive Care, Pitts­burgh

for­mance im­prove­ment for Home & Hospice Care of Rhode Is­land, Prov­i­dence, shares some of Si­mon’s con­cerns about pa­tients who can­not re­spond at the 48-hour mark. “To the pub­lic who have not read the specifics of this mea­sure, they may see scores that seem re­ally low,” she says.

The CMS, how­ever, says it will gather data specif­i­cally on pa­tients who are un­able to sel­f­re­port their pain level at the 48-hour fol­lowup mark.

“The good thing is that CMS is say­ing to us, ‘Don’t do the math,’ ” Si­mon says. “They just want us to give them all of the num­bers. Hope­fully, they’ll take out the peo­ple who, for what­ever rea­son, could not re­spond.”

The sec­ond mea­sure for 2013’s qual­ity re­port­ing pro­gram was con­ceived as a way for the CMS to col­lect data about how hospices are cur­rently mea­sur­ing qual­ity in their orga- niza­tions, says Dow­ell of the CMS.

“The ACA re­quires that we use en­dorsed mea­sures in re­port­ing pro­grams un­less there are none avail­able and at the time, there were only two,” Dow­ell says, re­fer­ring to two NQF mea­sures, the pain man­age­ment in­di­ca­tor and an­other that mea­sures pa­tient ex­pe­ri­ence.

In Fe­bru­ary, the NQF en­dorsed 14 mea­sures for pal­lia­tive and end-of-life care, ad­dress­ing top­ics such as pain, short­ness of breath and care-pref­er­ence doc­u­men­ta­tion, which the CMS has in­di­cated it will likely choose among for fu­ture ver­sions of the hospice re­port­ing pro­gram.

In or­der to ful­fill the re­quire­ments of the struc­tural mea­sure, hospices will sim­ply have to con­firm that they have a qual­ity as­sess­ment and per­for­mance im­prove­ment, or QAPI, pro­gram that in­cludes at least three qual­ity in­di­ca­tors re­lated to pa­tient care. Then they will in­di­cate what ar­eas their mea­sures cover by check­ing boxes next to var­i­ous qual­ity do­mains and sub-do­mains.

“The struc­tural mea­sure gath­ers in­for­ma­tion on what hospices are al­ready col­lect­ing and what they think are im­por­tant in­di­ca­tors,” Dow­ell says.

To help hospices pre­pare for qual­ity re­port­ing, the CMS ar­ranged a three-month vol­un­tary re­port­ing pe­riod when hospices could sub­mit data about their QAPIs. Dur­ing the vol­un­tary re­port­ing pe­riod, which ran from Oct. 1, 2011, un­til Dec. 31, the CMS re­ceived re­sponses from 911 hospices, ac­cord­ing to a re­port from RTI In­ter­na­tional, a CMS con­trac­tor. Of those re­spon­dents, more than 95% said they had a QAPI pro­gram in place that

in­cluded more than three in­di­ca­tors.

The re­sults of that re­port re­vealed just how widely var­ied hospices’ in­ter­nal qual­ity pro­grams are and how com­plex ef­forts to stan­dard­ize them may prove to be.

In to­tal, par­tic­i­pat­ing hospices sub­mit­ted 6,712 qual­ity in­di­ca­tors dur­ing vol­un­tary re­port­ing. Pain as­sess­ment and man­age­ment ac­counted for more than 1,200 of those mea­sures, while an­other 812 ad­dressed com- mu­ni­ca­tion with pa­tients and their fam­i­lies. Other com­mon mea­sure­ment ar­eas in­cluded anx­i­ety, short­ness of breath, care co­or­di­na­tion, nausea, fall preven­tion and med­i­ca­tion man­age­ment.

“This is an in­dus­try that has for years col­lected in­for­ma­tion that is dis­crete to the hospice and to the re­gion, and that data is not nec­es­sar­ily trans­ferrable,” says O’Maley-Lanphear, who em­pha­sized the need for com- mon met­rics. “CMS’ first bite—the vol­un­tary re­port­ing cy­cle—pro­duced thou­sands of mea­sures.”

Not all mea­sures are cre­ated equal, of course. Ac­cord­ing to RTI In­ter­na­tional’s re­port, some hospices are us­ing high-qual­ity in­di­ca­tors that mea­sured “im­por­tant and ac­tion­able ar­eas of qual­ity re­lated to pa­tient care, with ap­pro­pri­ate spec­i­fi­ca­tions and pre­cise de­scrip­tions of the nu­mer­a­tor and the de­nom­i­na­tor.”

On the other end of the spec­trum, many hospices’ mea­sures lacked pre­ci­sion, ac­cord­ing to the re­port. Some even sub­mit­ted in­di­ca­tors that were more like qual­ity-re­lated goals—such as “All pa­tients will be free of pain” —which lacked nu­mer­a­tors and de­nom­i­na­tors al­to­gether.

‘Ap­pro­pri­ate and pos­i­tive’

Ron Fried, se­nior vice pres­i­dent of pub­lic af­fairs for Vi­tas, a for-profit hospice provider based in Miami, says hospices are well aware of the need for across-the-board guide­lines and mea­sures. Vi­tas is cur­rently par­tic­i­pat­ing in a qual­ity re­port­ing ini­tia­tive in­volv­ing more than 40 Florida hospice providers. Us­ing se­lected mea­sures from the Fam­ily Eval­u­a­tion of Hospice Care sat­is­fac­tion sur­vey tool, a com­monly used per­for­mance eval­u­a­tion tool main­tained by the Na­tional Hospice and Pal­lia­tive Care Or­ga­ni­za­tion, the hospices are com­par­ing qual­ity data with one an­other.

“We wel­come the CMS pro­gram and we think these first two mea­sures are ap­pro­pri­ate and pos­i­tive,” Fried says. “But we do want to make sure the process is as in­cre­men­tal as pos­si­ble and any im­ple­men­ta­tion chal­lenges are worked out be­fore new mea­sures are in­tro­duced. It seems like CMS is sen­si­tive to that.”

For now, the CMS is tak­ing it slowly. For 2014’s pro­gram, which will af­fect 2015’s pay­ment up­date, the agency is lim­it­ing the pro­gram to the same two in­di­ca­tors, ac­cord­ing to pro­posed changes pub­lished in the Fed­eral Reg­is­ter on July 13.

In fu­ture years, the CMS says it would con­sider ex­pand­ing the pro­gram “to in­clude some ad­di­tional mea­sures en­dorsed by NQF.”

“The hospice community has given feed­back and told us that they are will­ing and in­ter­ested in pro­vid­ing qual­ity data for us,” Dow­ell says. “I have no rea­son to be­lieve they are not ready to start col­lect­ing data in Oc­to­ber.”

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