Reporting Period Nears for Hospice Measures

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)

Time Period for Hospice Reporting Measures Draws NearAre you ready to collect data on the Structural Measure and NQF #0209 (Comfortable Dying) to report to CMS early next year? The data collection period for both measures runs from October through December.

“This quality reporting data will not be made public, but public reporting is closer than you think,” Martha Tecca told attendees of the “Hospice Outcomes Reporting” webinar, sponsored by McKesson. Tecca is founder of M&M Strategies and a noted hospice expert.

Prudent hospice agencies will examine their processes and take steps now both to report the data accurately and to improve performance, Tecca says. These measures have been reported voluntarily on a pilot basis, but this is the first time reporting has been mandated.

The Structural Measure is an updated Quality Assessment and Performance Improvement (QAPI) standard and is fairly straightforward, Tecca says. CMS has defined 10 measurement domains, and some have sub-domains. No performance data is to be reported. Information for the structural measure should be reported by January 31.

The question is: Does your QAPI program include three or more quality indicators related to patient care? If the answer is “yes,” you should consider all quality indicators your agency uses and list the domains they address. During the voluntary reporting period, many hospice agencies stopped at three indicators, but the question is designed to help reveal the prevalence of quality indicators, Tecca says.

The Comfortable Dying Measure (National Quality Forum #0209) data capture and reporting requirements are still being finalized, despite mandatory data collection starting in October. At issue is the timing of the follow-up question: whether a patient’s pain was brought under control within 48 hours.

According to CMS, during the initial assessment (but before a patient describes his/her pain on a scale), a nurse or physician should ask if the patient is uncomfortable because of pain. Reportable data includes number of admissions, number of “yes” and “no” responses, and number of excluded patients.

For those who answer “yes” to the first question, CMS requires that this follow-up question be asked between two and three days after the assessment: “Was your pain brought to a comfortable level within 48 hours of the start of hospice care?” Again, this question should be asked before any pain scale is mentioned. However, it is not necessary that a nurse or physician pose the second question. The reportable data again includes “yes” and “no” responses and excluded patients.

The NHPCO/NQF measure protocol has called for the follow-up question to be asked 48 to 72 hours after the first question, with some flexibility for late responses. The final protocol likely will specify two to three days – removing the requirement to track hours, but disallowing responses after three days.

CMS carves out those patients under 18, but Tecca recommends asking everyone who can respond, as part of consistent pain management practice.  The National Hospice and Palliative Care Organization recommends that hospice agencies explore all “no” responses to the second question as a way to gauge ways to improve their performance.

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This information provides a summary of information publicly available on the NHPCO website or at It is intended to be informational and does not constitute legal advice regarding any specific situation.

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