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Current Measures

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The Hospice Quality Reporting Program (HQRP) currently consists of two reporting requirements: the Hospice Item Set (HIS) and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey. HIS and Hospice CAHPS® data are used to calculated performance on quality measures.

HIS data can be used to calculate eight National Quality Forum (NQF)-endorsed measures and one non-NQF-endorsed measure. Descriptions of the nine HIS-based measures are provided below. Additional details about the measures can be found in the QM User’s Manual located in the Downloads section at the bottom this web page.

The CAHPS® Hospice Survey was considered as a single measure by NQF and endorsed as NQF #2651; CAHPS® data can be used to calculate eight patient experience measures. Additional details about the CAHPS® quality measures can be found below, and on the CAHPS® survey webpage at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps/scoring-and-analysis/steps-for-scoring-cahps-hospice-survey-measures--2017q1-_nov-2017.pdf.

Information on this webpage is specific to the quality measures that are calculated using HIS and CAHPS® data. For item-level information on the HIS (e.g., coding instructions, HIS Manual), please visit the Hospice Item Set (HIS) portion of this webpage. For information on the CAHPS® survey itself (e.g., survey questions, data collection timelines), please see the Hospice CAHPS® portion of this webpage. 

Quality Measures Calculated using the HIS

NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen

Measure Description: Percentage of patient stays treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed.
Numerator Statement: Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed.
Denominator Statement: Patient stays, except for those with an exclusion, where a scheduled opioid that is initiated or continued.
Denominator Exclusions:    Patients are excluded from the denominator if they are under 18 years of age.
Measure Type:                 Process.

NQF #1634 Pain Screening

Measure Description: Percentage of patient stays during which the patient was screened for pain during the initial nursing assessment.
Numerator Statement: Patient stays from the denominator who are screened for the presence or absence of pain and, if present, rating of its severity using a standardized tool within 2 days of admission to hospice.
Denominator Statement: All patient stays except for those with exclusions.
Denominator Exclusions:   Patients are excluded from the denominator if they are under 18 years of age.
Measure Type:                 Process.

NQF #1637 Pain Assessment

Measure Description: Percentage of patient stays during which the patient screened positive for pain and received a comprehensive assessment of pain within 1 day of the screening.
Numerator Statement: Patient stays from the denominator who received a comprehensive pain assessment within 1 day of the pain screening and the pain assessment included at least 5 of the following characteristics: location, severity, character, duration, frequency, what relieves or worsens that pain, and the effect on function or quality of life.
Denominator Statement: Patients stays, except for those with exclusions, where the patient’s pain severity at the pain screening was rated mild, moderate, or severe.
Denominator Exclusions:   Patient stays are excluded from the denominator if they are under 18 years of age.
Measure Type:                 Process.

NQF #1639 Dyspnea Screening

Measure Description: Percentage of patient stays during which the patient was screened for dyspnea during the initial nursing assessment.
Numerator Statement: Percentage of patient stays during which the patient was screened for dyspnea during the initial nursing assessment.
Denominator Statement: All Patient stays, except for those with exclusions.
Denominator Exclusions:   Patient stays are excluded from the denominator if they are under 18 years of age.
Measure Type:                 Process.

NQF #1638 Dyspnea Treatment

Measure Description: Percentage of patient stays during which the patient screened positive for dyspnea and received treatment within 1 day of the screening.
Numerator Statement: Patient stays from the denominator who received treatment within 1 day of screening positive for dyspnea.
Denominator Statement: Patient stays, except those with exclusions, where the patient screened positive for dyspnea at the initial screening encounter.
Denominator Exclusions:   Patient stays are excluded from the denominator if they are under 18 years of age
Measure Type:                 Process.

NQF #1641 Treatment Preferences

Measure Description: Percentage of patient stays with chart documentation that the hospice discussed (or attempted to discuss) preferences for life sustaining treatments.
Numerator Statement: Patient stays from the denominator where the patient/responsible party was asked about preference regarding use of cardiopulmonary resuscitation, or hospitalization, or other life-sustaining treatments no more than 7 days prior to admission or within 5 days of the admission date
Denominator Statement: All patient stays, except those with exclusions.
Denominator Exclusions:   Patients are excluded from the denominator if they are under 18 years of age.
Measure Type:                 Process.

NQF #1647 Beliefs/Values Addressed (if desired by the patient)

Measure Description: Percentage of patient stays with documentation of a discussion of spiritual/religious concerns or documentation that the patient and/or caregiver did not want to discuss spiritual/religious concerns.
Numerator Statement: Number of patient stays from the denominator where the patient and/or caregiver was asked about spiritual/existential concerns no more than 7 days prior to admission or within 5 days of the admission date.
Denominator Statement: All patient stays, except for those with exclusions.
Denominator Exclusions:   Patient stays are excluded from the denominator if they are under 18 years of age
Measure Type:                 Process.

Hospice Visits when Death is Imminent

Measure Description:

This measure is a measure pair assessing hospice staff visits to patients at the end of life.

Measure 1: Percentage of patients receiving at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life.

Measure 2: Percentage of patients receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides in the last 7 days of life.

Numerator Statement:

Measure 1: Number of patients from the denominator receiving at least one visit from registered nurses, physicians, nurse practitioners or physician assistants in the last 3 days of life.

Measure 2: Number of patients from the denominator receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides in the last 7 days of life.

Denominator Statement:

Measure 1: All patients, except for those with exclusions.

Measure 2: All patients, except for those with exclusions.

Denominator Exclusions:  

Measure 1: Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 3 days of life.

Measure 2: Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 7 days of life, or had a length of stay of one day.

Measure Type:                

Process.

NQF #3235 Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment at Admission

Measure Description:

Percentage of patient stays during which the patient received all care processes captured by quality measures NQF #1617, NQF #1634, NQF #1637, NQF #1638, NQF #1639, NQF #1647, NQF #1641, as applicable.

Numerator Statement:

All patient stays from the denominator who meet the numerator criteria for the individual component QMs applicable to the patient.

Denominator Statement:

All patient stays, except for those with exclusions.

Denominator Exclusions:  

Patient stays are excluded from the denominator if they are under 18 years of age.

Measure Type:                

Process.

 

Measures calculated from the CAHPS® Hospice Survey

The CAHPS® Hospice Survey was considered as a single measure by NQF and endorsed as NQF #2651.

 Communication with family

Measure Description:

Multi-item measure. "While your family member was in hospice care..."   P1: “How often did the hospice team keep you informed about when they would arrive to care for your family member?”   P2: “How often did the hospice team explain things in a way that was easy to understand?” P3: “How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?” P4: “How often did the hospice team keep you informed about your family member’s condition?” P5: “How often did the hospice team listen carefully to you? P6: "How often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?"

Numerator Statement:

CAHPS Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. For questions P1 through P5 in this measure, the top box numerator is the number of respondents who answer “Always.” For question P6, the top box numerator is the number of respondents who answer “Never.” Top box scores for each survey question within the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator:

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of P1 through P6).

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Outcome

 

Getting timely help

Measure Description:

Multi-item measure   P1: “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?” P2: “How often did you get the help you needed from the hospice team during evenings, weekends, or holidays?”

Numerator Statement:

CAHPS Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. The top box numerator is the number of respondents who answer “Always.” Top box scores for each survey question within the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of P1 or P2).

Exclusions:

Exclusions from the denominator: -The hospice patient is still alive -The decedent’s age at death was less than 18 -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian   -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Outcome

 


Treating patient with respect

Measure Description:

Multi-item measure   P1: “While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?” P2: “While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?

Numerator Statement:

CAHPS Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. For both questions in this measure, the top box numerator is the number of respondents who answer “Always.” Top box scores for each survey question within the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of P1 or P2).

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Outcome

 

Emotional and spiritual support

Measure Description:

Multi-item measure   P1: “While your family member was in hospice care, how much emotional support did you get from the hospice team?”   P2: “In the weeks after your family member died, how much emotional support did you get from the hospice team?”   P3: “Support for religious or spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your religious or spiritual needs. While your family member was in hospice care, how much support for your religious and spiritual beliefs did you get from the hospice team?”

Numerator Statement:

CAHPS Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. For all questions in this measure, the top box numerator is the number of respondents who answer “Right amount.” Top box scores for each survey question within the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of P1 through P3).

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Patient Reported Outcome

 

Help for pain and symptoms

Measure Description:

Multi-item measure   P1: “Did your family member get as much help with pain as he or she needed?” P2: “How often did your family member get the help he or she needed for trouble breathing?” P3: “How often did your family member get the help he or she needed for trouble with constipation?” P4: “How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?”

Numerator Statement:

CAHPS Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. For question P1, the top box numerator is the number of respondents who answer “Yes, definitely.” For questions P2, P3 and P4, the top box numerator is the number of respondents who answer “Always.” Top box scores for each survey question within the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of P1 through P4).

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Patient Reported Outcome

 


Training family to care for patient

Measure Description:

Multi-item measure   P1: Did the hospice team give you the training you needed about what side effects to watch for from pain medication? P2: Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member? P3: Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing? P4: Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? P5: Side effects of pain medicine include things like sleepiness. Did any member of the hospice team discuss side effects of pain medicine with your or your family member?

Numerator Statement:

CAHPS Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. For all questions in this measure, the top box numerator is the number of respondents who answer “Yes, definitely.” Top box scores for each survey question within the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of P1 through P5).

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Patient Reported Outcome

 

Rating of this hospice

Measure Description

Individual survey item asking respondents: "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?" 0-10 rating scale with 0=Worst hospice care possible and 10=Best hospice care possible

Numerator Statement:

The top box numerator is the number of respondents in the hospice who answer “9” or “10.” Top box scores for the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level) to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the total number of respondents in the hospice who answered the item.

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Patient Reported Outcome

 


Willing to recommend this hospice

Measure Description:

Individual survey item asking respondents: “Would you recommend this hospice to your friends and family?”

Numerator Statement:

The top box numerator is the number of respondents in a hospice program who responded “Definitely yes.” Top box scores for the measure are adjusted for mode of survey administration (at the individual respondent level) and case mix (at the hospice level) to calculate the overall hospice-level measure score.

Denominator Statement:

The top box denominator is the total number of respondents in the hospice that answered the item.

Exclusions:

The hospice patient is still alive -The decedent’s age at death was less than 18   -The decedent died within 48 hours of his/her last admission to hospice care -The decedent had no caregiver of record -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address -The decedent had no caregiver other than a nonfamilial legal guardian -The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted) -The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased -The caregiver reports on the survey that he or she “never” oversaw or took part in decedent’s hospice care

Measure Type:

Patient Reported Outcome

 Updates

January 19, 2018

New Version of HQRP QM User’s Manual now available for Download

Version 2.00 of the HQRP QM User’s Manual is now available for download in PDF format. The measure specifications for the Hospice and Palliative Care Composite Process Measure: Comprehensive Assessment at Admission (NQF #3235) are included in this new version. Please refer to the “HQRP QM Users Manual v2.00_January 2018” document in the Downloads section of this page to download the QM User’s Manual v2.00 for your reference. 

December 22, 2017

Current Measures Description Tables now available for Download

The above description tables of the current HQRP measures, for both the Hospice Item Set (HIS) and Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®), are now available for download in PDF format. Please refer to the “Current Measures_12.11.17” document in the Downloads section of this page, to download and print these measure descriptions for your reference.

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