Arm Yourself with the Know-How to Ace Your Hospice Quality Measures

Make sure you’re visiting patients in the last days of life

Thanks to the launch of the new Hospice Compare website, your agency’s quality scores are on display for the whole world to see. Plus, you have a variety of new quality reporting items to contend with. From the Hospice Item Set (HIS) to the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS), your quality reporting duties can seem never-ending.

In addition to HIS and CAHPS, 2018 will also include other quality reporting requirements, such as Edmonton Symptom Assessment Scale (ESAS), visits at end of life, and more—that’s according to Michelle Crowell, BSN, RN who hosts an educational session for AudioEducator on hospice quality reporting. Not only do you need to understand this year’s requirements, but you also must prepare your agency and staff for meeting the quality goals set out by the Centers for Medicare & Medicaid Services (CMS).

Report HIS Data—or Face the Penalty

The CAHPS survey and the HIS are the two reporting requirements under the CMS Hospice Quality Reporting Program (HQRP), and both are reported on the Hospice Compare website. After a few technical hiccups, Hospice Compare seems to be running more smoothly and has started displaying CAHPS survey data from all Medicare-certified hospices that had at least 30 surveys from April 1, 2015 to March 31, 2017.

Beware: All Medicare-certified hospice providers must report HIS data, regardless of their size or average daily census, or else face a 2-percent payment penalty.

The quality measures that CMS calculates using the HIS include:

  • Patients Treated with an Opioid Who are Given a Bowel Regimen (NQF #1617);
  • Pain Screening (NQF #1634);
  • Pain Assessment (NQF #1637);
  • Dyspnea Screening (NQF #1639);
  • Dyspnea Treatment (NQF #1638);
  • Treatment Preferences (NQF #1641);
  • Beliefs/Values Addressed (if desired by the patient) (NQF #1647);
  • Hospice Visits when Death is Imminent; and
  • Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment at Admission (NQF #3235).


CMS has categorized the CAHPS survey itself as a single NQF measure (NQF #2651). The survey includes the following quality items:

  • Communication with family;
  • Getting timely help;
  • Treating patient with respect;
  • Emotional and spiritual support;
  • Help for pain and symptoms;
  • Training family to care for patient;
  • Rating of this hospice; and
  • Willing to recommend this hospice.


Good news: Since the first release of national averages of the family caregiver’s survey results, the “treating patient with respect” and “training family to care for patient” quality measures from the CAHPS survey improved, according to a recent analysis by Fazzi Associates. The “willingness to recommend” indicator worsened slightly.

Are Your Patients Getting These Visits?

Pay attention: A new HIS quality indicator is “Hospice Visits when Death is Imminent,” which is actually two measures rolled into one. CMS calls this a “measure pair” that assesses hospice staff visits to patients at the end of life.

One aspect of this measure examines the percentage of patients who received at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last three days of life. CMS has excluded from this measure any patients who did not expire in hospice care, as well as patients who received any continuous home care, respite care, or general inpatient care in the last three days of life.

The second measure examines the percentage of patients who received at least two visits from medical social workers, chaplains, or spiritual counselors, licensed practical nurses, or hospice aides in the last seven days of life. Patients excluded from this measure are those who did not expire in hospice care, or those who received any continuous home care, respite care, or general inpatient care in the last seven days of life, or who had a length of stay of one day.

Put Your Best Foot Forward

CMS will use the HIS and CAHPS survey data to calculate your hospice’s performance on the key quality measures, and the public will be able to see how your hospice ranks on the new Hospice Compare website.

Bottom line: When it comes to the new Hospice Compare and your 2018 quality reporting challenges, knowledge is power. Make sure your staff has a solid understanding of all the quality reporting items and requirements, as well as the ESAS measures and requirements for visits at the end of life, Crowell stresses.

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