Quality-Data-Reporting

Hospice Blog Series Part 4 | Quality Data Reporting

Hospice Quality Data Reporting Timeline.

Quality Data Reporting: The final blog in our CMS 1355-F blog series. In my humble opinion, this is the one that will have the most significant impact on hospice agencies in the coming years.

What is the Quality Data reporting program? CMS, NHPCO, NAHC and many other organizations have all defined the program. In short the Quality Data Reporting program is a program that CMS is implementing to collect information on the care provided to patients and family members participating in the hospice program.  A result of the program will be that reimbursements will be impacted by the data submitted.  Full details on what’s to be reported, how it will be reported, etc. are still being defined.

This is something I think we can all agree we knew would come eventually.  CMS has been hinting, not too subtly, at a data collection model for hospice for a while now. The question had been “when will it get here?”  We now have the answer, at least in part.  The first (voluntary) deadline for program is January 31, 2012.

In an effort to try to wrap my head around what’s going to happen when, and what’s required versus an important date that I need to know, I needed a timeline. I needed a timeline that could be printed on one page that I could hang in my office and reference.  Using multiple flip charts, 4 colors of sticky note pads, markers and pens I arrived at something that I hope will be helpful for you, and me, as we progress through the next 12-18 months.

DataTimeline

What exactly should you be doing on each of the dates?  Below is some additional information on each of the timeline dates and where applicable what you can to do to begin preparing.

January 31, 2012
CMS is looking for agencies to voluntarily submit information on their QAPI program indicators that relate to patient care.  This section of the Hospice Quality Reporting program is referred to as the Structural Measure Reporting. Information that CMS is requesting agencies submit includes:

  • What is the name of the indicator?
  • What is the domain of care?
  • Provide a description of the numerator and denominator, if applicable.
  • Where is the data source stored? (EMR, paper medical record or adverse events log)

CMS has indicated that they will post a collection tool to their website by December 31, 2011.  As of December 28, 2011 that tool had not yet been posted.

October 2012 (Anticipated Requirement)
In the FY2012 Wage Index Final Rule CMS indicated that they were considering implementing, as a requirement, the FEHC Survey in the FY2013 Hospice Wage Index.  This tool measures the patient and family experience with hospice care. Ensuring patient and family centered care is a priority for CMS and measurement of this is being considered through use of the survey.

CMS has noted that approximately 1/3 of hospice agencies are currently using this tool. We recommend agencies that are not utilizing the tool become familiar with it to assist with change management come Fall 2012.

October 1, 2012 – December 31, 2012
Patient Care Related QAPI indicators utilized during this period will be required to be submitted to CMS. This data is known as the Structural Measure.  The indicators should include:

  • What is the name of the indicator?
  • What is the domain of care?
  • Provide a description of the numerator and denominator, if applicable.
  • Where is the data source stored? (EMR, paper medical record or adverse events log)

October 1, 2012 – December 31, 2012
CMS will begin requiring the collection of NQF #0209 (Patient Pain Measurement).  This measure identifies the percentage of patients who were uncomfortable due to pain on admission to hospice whose pain was brought to a comfortable level within 48 hours of their admission. The patient-level data will be aggregated and submitted on a template prepared by CMS.

January 1, 2013
CMS will be changing to a Calendar Year adoption for Quality Reporting purposes.  Prior to this the reporting structure began on an October 1 calendar.  i.e. FY2015 data collection will be January 1, 2013 through December 31, 2013.  The dates associated with reporting the data collected during the year are not yet known.

January 31, 2013
CMS has required the submission of the Structural Measure indicators by January 31, 2013.  The tool and method for submission will be provided by CMS at a later date.

April 1, 2013
CMS will require submission of NQF #0209 (Pain Management Measurement) by April 1, 2013. The tool and method for submission will be provided by CMS at a later date.

At this point, there is more to be defined than has been defined.  There is an opportunity ahead of us that feels pretty unique.  This being the opportunity to submit information that agencies are collecting today and feel would be important to consider in the long-term design and implementation of the Hospice Quality Reporting Program.  I hope that you’ll consider submitting the QAPI patient care indicators that you’re using today. You may think, “Everyone else will be submitting these indicators.  CMS does not need my submission too.”  Maybe.  Maybe not.  Perhaps the more agencies that are using a measure the more they will consider implementing it.or perhaps you are capturing a gem of information that others haven’t considered collecting.

Based on what you know, do you plan to submit in the voluntary reporting period come January? We’ll keep you updated as we hear information and hope you will share with us as well.

Click here to download a copy of the timeline graph above.

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December 29, 2011
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