How to increase your hospice CAHPS survey response rate

Focusing on techniques to improve your Hospice CAHPS survey response rate is important for accurate survey data that enables you to compare your results with other providers in your area and target efforts on continuous improvement.

How many responses do you need? CMS requires at least 30 complete surveys during an eight-quarter reporting period for reporting on Hospice Compare. Hospices should maximize the opportunity for surveys to be completed and returned. The more responses you receive, the more data you have, and the more valuable the data will be for analysis. This will then allow you to roll out more meaningful improvement initiatives that will ultimately result in higher CAHPS scores.

HEALTHCAREfirst has one of the largest Hospice CAHPS databases in the nation, from which we analyze and report statistics about who is most likely to respond. Here is data from a recent analysis:

Hospice CAHPS Survey Response Rate Data

(Based on HEALTHCAREfirst Hospice CAHPS program data)

• By Region:
  • Midwest = 44.4%
  • Northeast = 40.9%
  • West = 40.4%
  • South = 37.6%
• By Population:
  • Rural = 43.5%
  • Mixed = 39.6%
  • Suburban = 36.8%
  • Urban = 35.5%
• BY ADC Category:
  • 25 or fewer = 42.6%
  • 101-250 = 40.4%
  • 26-50 = 38.9%
  • 51-100 = 37.8%
  • 251-1000 = 37.5%
  • > 1000 = 36.4%
• By Tax Status:
  • Government = 58.8%
  • Not-for-Profit = 42.4%
  • For Profit = 35.3%
• By Respondent:
  • High School graduate or higher = 95%
  • Between 55 and 84 years of age = 78%
  • Female = 72%
  • Child = 47.4%
  • Spouse = 38.9%
• By Patient Gender:
  • Female = 53.6%
  • Male = 46.4%
• By Caregiver Gender:
  • Female = 72.4%
  • Male = 27.63%
• By Relationship to Patient:
  • Child/In-Law = 47.4%
  • Spouse = 38.9%
  • Sibling = 4.7%
  • Other Relative = 3.3%
  • Other = 2.2%
  • Parent = 1.9%
  • Friend = 1.7%
• By Caregiver Age:
  • 65-74 years = 31.3%
  • 55-64 years = 30.0%
  • 75-84 years = 17.7%
  • 45-54 years = 10.8%
  • 85+ years = 6.8%
  • 35-44 years = 2.5%
  • 25-34 years = 0.8%
  • 18-24 years = 0.1%
• By Caregiver’s Highest Level of Education:
  • Some College = 32.4%
  • High School/GED = 26.3%
  • > 4 Year College = 16.7%
  • 4 Year College = 16.7%
  • Some High School = 3.8%
  • 8^th Grade or Less = 1.2%

All of the above information is valuable to know about your own patient population, as well knowing how your population mix can make a difference to your performance scores. CMS includes factors such as these in case mix adjustment calculations to help level the playing field when comparing scores between hospices that are serving different areas with different attributes.

What Can Influence Hospice CAHPS Survey Response Rate?

Survey Awareness

It is important to make caregivers aware that s/he may receive a survey. If they expect to receive the survey, or are at least aware of the possibility of it, they will know why they received it and will be more likely to respond.

Caregivers will also be more likely to respond if they understand how the data will and will not be used. This is definitely a challenge for Hospice CAHPS given CMS regulations and restrictions regarding communicating with caregivers about the Hospice CAHPS survey.

Hospices can inform caregivers that they may receive a survey. They cannot communicate in any way that would present bias into the survey results or attempt to sway participant responses.

Standard protocols and processes are fully outlined by CMS in the Quality Assurance Guidelines (QAG v5.0) available on the Hospice CAHPS website.

Cover Letter & Survey Design

CMS developed the Hospice CAHPS survey and administration protocols specifically to increase the likelihood that caregivers will respond to the survey, and ensure that caregivers’ responses are unbiased and reflect only the decedents’ and caregivers’ experiences of care.

While agencies are very limited on what they can customize what is sent to participants, HEALTHCAREfirst includes the hospice’s logo on the cover letter for our Hospice CAHPS survey customers. This promotes agency recognition and increases the probability of survey completion.

Survey Administration Mode

The Hospice CAHPS survey can be administered in three different modes: mail only, telephone only, and a combination of mail and telephone. In 2015, CMS conducted a mode experiment to identify the effect of administration mode on Hospice CAHPS survey response rate. It found that telephone only mode had a lower return rate and more negative response tendencies than both mail-only and mixed mode. In order to level the playing field for comparisons across agencies, CMS has included mode adjustment as a case-mix variable.

Selecting Survey Recipients

It is important that the hospice selects the appropriate individual to receive the survey – and provides all of the necessary information to ensure the survey is able to be delivered in a timely manner. The individual identified by the hospice agency should be the person who is most knowledgeable about the hospice care the patient received. There isn’t a requirement that individual provided hands on care – it’s possible that they live out of state or are involved in the patient’s care via meetings or other forms of feedback. However, the more involved the caregiver was with the hospice care, the better the quality of the feedback they can provide.

It is also important to identify the appropriate language for the survey. If the caregiver speaks Spanish, you want to make sure to specify in your decedent/caregiver file that the survey should be administered in Spanish. While the survey is available in English, Spanish, Chinese, Russian, Portuguese, Vietnamese, Polish and Korean, survey vendors are not required to administer the survey in all of these languages. It is important to understand which languages are available through your survey vendor.

How many caregivers are sampled depends on the number of survey-eligible recipients during the prior year. If a hospice has fewer than 50 survey-eligible recipients, it can submit for a participation exemption. If it has 50-699 survey-eligible recipients, 100% of survey-eligible recipients are sampled. Lastly, if a hospice has more than 700 survey-eligible recipients during the previous year, you can choose to sample a portion of those people. All records are assumed to be survey-eligible unless documentation indicates ineligibility.

It is important that hospices do not “stack the deck.” You can’t ensure or prevent specific recipients from receiving the Hospice CAHPS survey. The “no publicity” clause is not an “opt-out” clause. It is simply to assure that recipient identity is not known, should they choose that option.

Survey Timing

Hospice CAHPS surveys are initiated two months following the month of patient death within the first seven calendar days. The data collection period is 42 days after initial contact. Although Hospice CAHPS has standard timeframes, scores are adjusted based on lag time prior to public reporting. Lag time is the number of days between death and return of the mailed survey or final disposition of a telephone survey.

Some vendors, such as HEALTHCAREfirst, will still process returned surveys and report the results to the agency after the collection period has ended. While these results are not included in publicly reported data, it can still be used by the hospice for performance improvement measurement and efforts.

Incorrect or Missing Patient Data

Missing or incomplete patient data can negatively impact your response rate. Bad data decreases the likelihood of receiving responses, and it will negatively affect Hospice CAHPS Survey response rate.  You should avoid using placeholders or “notes” entered into address fields. Refrain from using terms like “Unknown,” “None known,” type of relationship, nickname, etc. These terms may end up included in the cover letter and within the mailing address when a survey is mailed, which can discourage recipients and may decrease the chance the survey will be received.

If new or updated information is collected regarding the recipient (mailing information, survey language, etc.), a survey can be resent if it is received before the wave 2 mailing is generated. The 42-day data collection period does NOT reset if new or updated information is provided.

Hospice CAHPS Survey Response Rate Best Practices

Provide Education

It is essential to educate staff about can and cannot be said to patients and caregivers about the Hospice CAHPS survey. You should inform all of your caregivers that they may receive a survey and encourage all of them to participate. Refer to the CAHPS Hospice Survey Quality Assurance Guidelines Version 5.0 (QAG 5.0) for more detailed regulations surrounding communication.

Supplemental Questions

Be careful with supplemental survey questions. While they can provide you with great information, they will add length to the survey and the types of questions themselves may lessen your response rate.

Use of Additional Surveys

Using additional surveys may hinder caregivers from responding to the Hospice CAHPS survey. Carefully consider whether or not those surveys are critical enough to potentially reduce your sample size.

Sampling Percentage

If you are not already sampling 100%, consider your sampling percentage. If you enlarge your sample, you will have a bigger dataset that will allow for more accurate analysis of your hospice performance.

Ensure Correct Data

Confirm that your monthly decedent/caregiver file contains complete, accurate information prior to sending to your Hospice CAHPS vendor. Missing data will not prevent decedents from being sampled, but will very likely inhibit response rate.