CAHPS Hospice Survey - Special Report

Preparation of the
CAHPS Hospice Survey
A SPECIAL REPORT PREPARED BY US HEALTH CARE RESEARCH
1319 Classen Drive
Oklahoma City, OK 73103
405.689.0444
www.ushcrc.com
©2014 US Health Care Research LLC
Reproduction not permitted.

An Overview of the CAHPS® Hospice Survey
Beginning in the first quarter of 2015, Hospice CAHPS (also known as the Hospice Experience of Care Survey) will be a mandatory component of the Hospice Quality Reporting Program (HQRP).As a pay-for-reporting requirement, hospices that fail to comply with the rule will receive a two percent reduction in their annual payment update for the fiscal year.
There are two tidbits of good news:
1.While this is another box for hospices to check off their already long laundry list of things to do, it won’t add much to their everyday workload. In fact, the majority of the work will be in the hands of a vendor—in this case, US Health Care Research.
2.The CAHPS Hospice Survey is an opportunity to improve care and services. The CAHPS Hospice Survey can be used to guide your QAPI.

Participation Requirements
 All Medicare-certified hospices are required to participate in the CAHPS
Hospice Survey
 Two Exemptions
 Participation Exemption for Size
 Exemption for Newness
 Served 50 or more deceased patients must participate in the Dry Run
 Hospices that served 50 or more deceased patients from January
1, 2014 and December 31, 2014 will need to partner with a survey
vendor to sample and collect survey responses from caregivers for
at least one of the following months – January, February, or March
2015.
 Ongoing surveying beginning April 2015
2% reduction in the hospice’s APU for
failure to participate.
405.689.0444 | www.ushcrc.com | rnelson@ushcrc.com

CMS Goals for Annual Returns
Hospice Size Annual Survey Return Goal
700+ annual decedents n=300
50-699 annual decedents n=21-300
<50 annual decedents
Can apply for Participation for Size Exemption. Form
must be submitted by August 15, 2015.

What can you do to receive your full APU?
 Do you quality for survey participation
exemption?
 Participation Exemption for Size
 Hospices that served fewer than 50
deceased patients between January 1,
2014 and December 31, 2014 qualify for
this exemption and will need to fill out and
submit the proper form no later than
August 12, 2015.
 Exemption for Newness
 Hospices that received their CCN on or
after January 1, 2015 qualify for the
Exemption for Newness for the 2015
performance year.
 Served 50 or more deceased patients must
participate in the Dry Run and monthly
starting April 2015.

CAHPS Hospice Survey Timeline
Summer 2014
CMS finalizes
the CAHPS
Hospice Survey
Winter 2014
Hospices will
need to
contract with
an approved
survey vendor.
Jan-Mar 2015
Hospices will
need to
participate in a
Dry Run for at
least one
month.
April 2015
Ongoing
monthly survey
administration
and data
collection.

What is the CAHPS® Hospice Survey?
The CAHPS Hospice Survey is a standardized
instrument that consist of 47 questions. The
questions in the survey assess the following
measures of hospice care:
 Hospice Team Communication
 Getting Timely Care
 Treating Family Member with Respect
 Providing Emotional Support
 Support for Religious and Spiritual Beliefs
 Getting Help for Symptoms
 Information Continuity
 Understanding the Side Effects of Pain
Medication
 Getting Hospice Care Training

Hospice Team Communication
Questions CAHPS/FEHC Survey
How often did the hospice team listen carefully to you when you
talked with them about problems with your family member’s
hospice team?
While your family member was in hospice care, how often did
the hospice team listen carefully to you?
the hospice team explain things in a way that was easy to
understand?
the hospice team keep you informed about your family
member’s condition?
the hospice team keep you informed about when they would
arrive to care for your family member?

Getting Timely Care
While your family member was in hospice care, when you or
your family member asked for help from the hospice team how
often did you get help as soon as you needed it?
How often did you get the help you needed from the hospice
team during evenings, weekends, or holidays?

Treating Family Member with Respect
the hospice team treat your family member with dignity and
respect?
you feel that the hospice team really cared about your family
member?

Support for Religious and Spiritual
Beliefs
While your family member was in hospice care, how much
Support for religious or spiritual beliefs includes talking, praying,
quiet time, or other ways of meeting your religious or spiritual
needs.

Getting Help for Symptoms
How often did your family member get the help he or she
needed from the hospice team for feelings of anxiety or
sadness?
Did you family member get as much help with pain as he or she
needed?
needed for trouble with constipation?
needed for trouble breathing?

Information Continuity
anyone from the hospice team give you confusing or
contradictory information about your family member’s condition
or care?

Understanding the Side Effects of Pain
Medication
Side effects of pain medicine include things like sleepiness.
Were side effects of pain medicine discussed with any member
of the hospice team?
Did any member of the hospice team discuss side effects of
pain medicine with you or your family member?

Getting Hospice Care Training
Did the hospice team give you the training you needed about
what to do if your family member became restless or agitated?
what side effects to watch for from pain medicine?
how to help your family member if he or she has trouble
breathing?
how to safely move your family member?

Nursing Home Questions
the nursing home staff and hospice team work well together to
care for your family member?
While your family member was in hospice care, how often was
the information you were given about your family member by
the nursing home staff different from the information you were
given by the hospice team?

Global Rating Items
Using any number from 0 to 10, where 0 is the worst hospice
care possible and 10 is the best hospice care possible, what
number would you use to rate your family member’s hospice
care?
Would you recommend this hospice to your friends and family?

Hospice Item Set
There are 7 quality measures – 6 NQF-endorsed measures and 1 modified NQF-endorsed
measure that is used for the Hospice Item Set (HIS).
• NQF #1641 – Treatment Preferences
• Modified NQF #1647 – Beliefs/Values Addressed
• NQF #1634 & #1637 – Pain Screening and Pain Assessment
• NQF #1639 & #1638 – Dyspnea Screening and Dyspnea Treatment
• NQF #1617 – Patients Treated with an Opioid who are Given a Bowel Regimen
These are answered on admission and at discharge.

Beliefs/Values Addressed
Questions
While your family member was in hospice care, how much Support for religious or
spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your
religious or spiritual needs.

Pain Screening and Pain Assessment
Questions
Did family member get as much help with pain as he or she needed?
Did any member of the hospice team discuss side effects of pain medicine with you or
your family member?
Did the hospice team give you the training you needed about what side effects to watch
for from pain medicine?

Dyspnea – Breathing Assessment and
Treatment
Questions
How often did you family member get the help he or she needed for trouble breathing?
Did the hospice team give you the training you needed about how to help your family
member if he or she had trouble breathing?

Patients Treated with an Opioid who are
Given a Bowel Regimen
Questions
How often did your family member get the help he or she needed for trouble with
constipation?

Using the CAHPS
Survey Results to
Guide your QAPI

QAPI: What does it mean?
A data-driven, proactive approach to ensuring high quality care
•Combines two approaches
•Quality Assurance
•Performance Improvement
Involves all levels of the organization
Identifies opportunities for improvement
Addresses gaps in systems or processes
Develops and implements improvement plans
Continuously monitors effectiveness of interventions

Principles of Quality Assurance
Measures compliance
against standards.
•Retrospective
•Reactive
•Specific to failed standards
•Short term – ends when standard
is met

Principles of Performance Improvement
Continuous improvement toward
meeting standards:
• Examines gaps between standard and baseline
• Evaluates root cause
• Sets goals/milestones for improvement
•Develops Performance improvement projects
• Provides for continuous review of systems
• Focuses on improving processes
• Improve patient care

Sources of data to guide your QAPI
CAHPS Hospice Survey
Medical records
Complaints
Adverse occurrences
After hour calls
Billing information
Staff input

Example Reports
The Comparison Report compares a hospice’s outcome to
other hospices throughout the United States. This report
helps to identify how your hospice compares to others in your
area so that you can use this information to help guide your
quality assurance and performance outcomes.

Example Dashboard Report
Q9. Providers seemed
informed/up-to-date
Q16. Treated as gently
Q19. Treated with as possible
courtesy & respect
Q24. Have any
problems
Q2. Inform you of care
and services you would
get
Q15. Informed about
arrival time
Q17. Explain things in a
way that was easy to
understand
Q18. Carefully listen to
you
Q22. Get help or advice
when you needed
Q3. Talk about home
safety
Q4. Discuss
Q5. See prescription prescription medicines
medicines
Q10. Discuss pain
Q12. Discuss new or
changed medicine
Q13. Discuss when to
take medicines
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0.20 0.30 0.40 0.50 0.60 0.70 0.80
PERFORMANCE (EXPLICIT MEAN)
IMPORTANCE (CORRELATION)
SatMap™ Methodology uses explicit measures of performance, and implicit
measures of importance in order to identify how well your agency is meeting
your patients’ expectation of care.

Example Quality Report
For each Dimension of Care your performance is displayed by the Current
Period, 3-Month Average, 12-Month Average, and Year-to-Date.

Each page in the Quality Report is organized to provide a more in-depth look
into the questions that define that Dimension of Care. The Quality Report will
report and illustrate the Top Box percentage and the response breakout for the
current reporting period, 3-Month Average, 12-Month Average, and Year-to-
Date.

The Executive Summary Page US Health Care Research utilizes its
proprietary quality improvement tool SatMap Analysis to identify areas to focus
your improvement efforts with some suggested actions to improve in that area.

Financial
Investment
Annual Patient Deaths Annual Membership
50 to 250
Contact us at 405.689.0444 to
determine your annual membership.
251 to 500
501+
US Health Care Research charges on a total project basis, which includes data
collection, data submission, data analysis, and reporting. The costs are scalable
based upon the total number of patients served in a calendar year.
No additional cost for Spanish surveys. Sign-up by September 30, 2014 PAY NO
ANNUAL MEMBERSHIP FEES until April 2015.

For additional information contact:
Ryan Nelson
405.689.0444
rnelson@ushcrc.com

CAHPS Hospice Survey - Special Report

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