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Hospice Quality Public Reporting

Hospice Compare – Now Live!

On August 16, 2017 CMS unveiled the new Hospice Compare website. The goal of Hospice Compare is to help consumers compare hospice providers on their performance and assist consumers in making decisions that are right for them. Providers can start a conversation with their patients and family members about how the new Hospice Compare website impacts them by:

  • Explaining that the compare website provides a snapshot of the quality of care a hospice offers;
  • Encouraging patients and their family members to review quality ratings; and
  • Helping to strengthen patients and family members’ ability to make the best decisions for their care.

Background:

The Hospice Quality Reporting Program (HQRP) was established under section 1814(i)(5) of the Social Security Act. The Act also requires the Secretary to publicly report, on a CMS website, quality measures that relate to the care provided by hospice programs across the country. 

The seven (7) National Quality Forum (NQF) - endorsed Hospice Item Set (HIS) quality measures initially displayed on Hospice Compare are:

  • Hospice and Palliative Care- Treatment Preferences - NQF #1641
  • Hospice and Palliative Care- Beliefs/Values Addressed- NQF #1647
  • Hospice and Palliative Care- Pain Screening- NQF #1634
  • Hospice and Palliative Care- Pain Assessment- NQF #1637
  • Hospice and Palliative Care- Dyspnea Screening- NQF #1639
  • Hospice and Palliative Care- Dyspnea Treatment- NQF #1638
  • Hospice and Palliative Care- Patients treated with opioids who are given a bowel regimen- NQF #1617 

The Consumer Assessment of Healthcare Providers & Systems (CAHPS®) Hospice survey information will be displayed during a subsequent quarterly data update in winter 2018.

Hospice Public Reporting Key Dates for Providers

CMS encourages providers to be familiar with the important dates outlined in the table below, which is also available in PDF format in the Downloads section of this webpage. Providers will need to submit all Hospice Item Set (HIS) modification or inactivation records prior to the “freeze date” for the modifications to be reflected in the corresponding Provider Preview Report and Hospice Compare refreshes.

*Note: The “freeze date” is always before the Hospice Provider Preview Report becomes available in the CASPER folder. Once you review your preview report, it is too late to modify the underlying HIS data included in the report and the corresponding Hospice Compare refresh. If a Hospice disagrees with their quality measure results (denominator or quality metric) contained within their Hospice Provider Preview Report, they will have an opportunity to request review of the calculations by CMS.

Inaccurate data related to provider submission errors will not be considered a reason for CMS review. CMS does not consider data to be “inaccurate” because a provider did not make necessary corrections to the data prior to a specific “freeze date”, as the measure score is accurate based on the data that was in our system at the time the quality measure was calculated. Procedures for Requesting CMS’ Review during Preview Period are outlined below.

Hospice Compare Refresh Date 11/21/2017 2/20/2018 5/24/2018 8/TBD/2018
Hospice Compare Refresh Reflects Patient Stays Discharged for Quarters Quarter 1 2016-Quarter 4 2016

Quarter 2 2016-

Quarter 1 2017
Quarter 3 2016–Quarter 2 2017 Quarter 4 2016–Quarter 3 2017

Freeze Date

Hospice Providers to submit HIS Modification and Inactivation Records (all HIS records, including modifications/corrections and inactivation’s) to be reflected in the next Hospice Provider Preview Reports Hospice Compare Refresh

 

(Records to be submitted and accepted into the QIES ASAP system by 11:59:59 p.m. E.D.T.)
8/15/2017 11/15/2017 2/15/2018 5/15/2018
HIS Provider Preview Reports Available in CASPER Folder 8/29/2017 12/01/2017 03/01/2018 06/01/2018

30-Day HIS Provider Preview Period

Requests for CMS review of HIS data must be submitted by 11:59:59 p.m. PST on day 30 of the preview period

8/29/2017-

9/28/2017

12/01/2017-

12/30/2017

03/01/2018-

03/30/2018

06/01/2018-

06/30/2018

Hospice Provider Preview Reports

Prior to each quarterly release of data on Hospice Compare, hospice providers are given the opportunity to review their quality measure results during a 30-day preview period using a Hospice Provider Preview Report. The purpose of these reports is to give providers the opportunity to preview their quality measure results on each quality measure prior to public display on Hospice Compare. Hospice Provider Preview Reports can be accessed via Certification and Survey Provider Enhanced Reports (CASPER) application, which is accessible from a Hospice’s “Welcome to the CMS QIES Systems for Providers” page.

Please note: Providers will not be able to access their preview reports after 60 days from the report release date. CMS encourages providers to download and save their Hospice Provider Preview Reports for future reference as they will no longer be available in CASPER after this 60-day period. 

Instructions on how to access the reports are available in the Download section below.

Thirty Day Preview Period

Hospices will have 30 days to preview their quality measure results beginning on the date the reports are made available by CMS. Should the hospice provider believe the denominator or other quality metric to be inaccurate, a provider may request CMS review of the calculations contained within the Hospice Provider Preview Report.

Please note that inaccurate data related to provider submission errors will not be considered a reason for CMS review. CMS does not consider data to be “inaccurate” because a provider did not make necessary corrections to the data prior to a specific “freeze date”, as the measure score is accurate based on the data that was in our system at the time the quality measure was calculated. All requests for CMS review must be made during the 30-day preview period. All requests for CMS review of the calculations must be submitted to HospicePRquestions@cms.hhs.gov, and must contain all required information, as listed below.

All questions related to HIS public reporting, other than requests for CMS review should be directed to the Hospice Quality Help Desk at HospiceQualityQuestions@cms.hhs.gov.

Although Hospice providers, per the CMS Hospice QRP policy, can continue to make changes to their patient-level HIS data for up to 36 months beyond the target date on any given HIS assessment, any modifications that are made to underlying HIS data on or after the Hospice Provider Preview Report freeze date, will not affect the current Hospice Provider Preview Report or the related Hospice Compare Refresh and only be reflected in subsequent preview reports and Compare refreshes. CMS encourages providers to the review the Hospice Public Reporting Key Dates table.

Procedures for Requesting CMS’ Review during Preview Period:

We encourage Hospice Providers to review their data as provided in the Hospice Provider Preview Reports. If a provider disagrees with their quality measure results (denominator or quality metric) contained within their Hospice Provider Preview Report, they will have an opportunity to request review of the calculations by CMS. In order to make such a request, providers must adhere to the process outlined below:

  • Requests for CMS review of measure results be submitted to CMS beginning on the day the Hospice Provider Preview Reports are available in Hospice CASPER folders, and may be submitted through 11:59:59 p.m. PST on day 30 of the preview period.
  • CMS will not accept any requests for review of measure results that are submitted after the posted deadline, which falls on the last day of the preview period.
  • Hospices are required to submit their request to CMS via email with the subject line: “[Provider Name] Hospice Public Reporting Request for Review of Measure Results” and include the Hospice CMS Certification Number (CCN) (e.g., St. Mary’s Hospice and Home Care, Hospice Public Reporting Request for Review of Measure Results, XXXXXX). The request must be sent to the following email address: HospicePRquestions@cms.hhs.gov.
  • The email request must include the following information:
    • Hospice CMS Certification Number (CCN)
    • Hospice Agency Name and Mailing Address
      • CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
      • Information supporting the Hospice’s belief that the data contained within their Preview Report is erroneous, including, but not limited to, all quality measures affected, and aspects of quality measures affected (denominator or quality metric)
  • Hospices will receive an email confirming receipt of their request and may be asked to provide additional information to allow CMS to fully evaluate the request. Such requests from CMS will be sent to the contact person named above.
  • CMS will review all requests and provide responses outlining our decisions via email. Please note that any corrections to underlying data that are made on or after the Hospice Provider Preview Report freeze date, will not affect the current Hospice Provider Preview Report or the related Hospice Compare Refresh and only be reflected in subsequent quarterly Preview Report and Hospice Compare refresh.
  • The data used to generate the Hospice Provider Preview Reports are frozen for the upcoming Hospice Compare refresh, and corrections submitted after Hospice Provider Preview Report freeze date (see Hospice Public Reporting Key Dates table) will not be reflected until the next Preview Report is generated (next quarter). However, Hospices can still submit HIS modification and inactivation records for up to 36 months after the target date.

Please note: The only method for submitting a request to CMS for review of your Preview Report data is via email (HospicePRquestions@cms.hhs.gov). Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) or other Health Insurance Portability and Accountability Act (HIPAA) violations in the request being submitted to CMS for review.

Resources:

Hospice Quality Help Desk: HospiceQualityQuestions@cms.hhs.gov - All questions related to hospice quality measures including hospice quality reporting questions, Hospice Compare, and Hospice Compare Preview Reports.

Requests for CMS Review of HIS Data: HospicePRquestions@cms.hhs.gov  - All requests for CMS to review Hospice Provider Preview Report data can only be submitted here during the 30-day preview period. For more information, visit the Hospice Quality Public Reporting webpage.

Sign up for Hospice QRP updates today!

Updates:

November 28, 2017

Hospice Compare Search Function Alert

CMS is aware that the location search on Hospice Compare may return incorrect results.  As a result, we have provided a message on the home page of Hospice Compare informing users that when searching by location, the list of agencies provided may not serve the zip code, city, or state they entered. The message also recommends that consumers call hospice providers to confirm their service areas.  We are currently working to improve the search functionality and will update the website as soon as possible. We appreciate your patience while we work to enhance the end users’ experience with Hospice Compare. Please continue to monitor this webpage for updates.

November 15, 2017

Updated Guidance on How to Update Demographic Data within ASPEN

The demographic data displayed on Hospice Compare is generated from the information stored in the Automated Survey Processing Environment (ASPEN) system. Guidance on how to update a provider’s demographic information such as address, telephone number, and ownership with their state ASPEN coordinator is now available. View the How to Update Demographic Data 11.14.17  PDF for further information as well as more details on the cutoff dates for changes to demographic information in the ASPEN system.

Please note: When requesting updates to your demographic data, it is important to ask for updates to your data within the ASPEN system, and not your data on the Hospice Compare site. 

November 15, 2017

Hospice Compare Refresh Delayed

The Hospice Compare Refresh scheduled for November 21, 2017 has been delayed.  CMS will inform the provider community when the new refresh date is determined. 

Please note that this refresh delay will not impact the HIS Freeze date of November 15, 2017 and HIS Provider Preview Reports that will be available on December 1, 2017.  

October 03, 2017

Hospice Compare Fact Sheet Now Available

A new Hospice Compare fact sheet is now available in the downloads section below. This fact sheet contains information related to Hospice Compare and how the site can serve as a resource to providers in understanding their current quality ratings. The fact sheet also suggest approaches to communicating with patients and family members about how the Compare site can inform their decision making process.

September 13, 2017 

Incorrect Footnote “E” on Provider Preview Report 

Please note that hospice providers may have incorrectly received footnote “e: Results are based on a shorter time period than required” on the Hospice Provider Preview Report for the reporting period Quarter 1- 2016 to Quarter 4- 2016, which CMS distributed via CASPER on August 29, 2017. 

If your hospice received this footnote in error, your data will be shown correctly on Hospice Compare, without this footnote, when this data is publicly reported in November 2017. Additionally, this issue will be corrected for the next quarterly Hospice Provider Preview Report, which is due to be released on December 1, 2017. 

If you have questions concerning this information, please contact the QTSO Help Desk at help@qtso.com or 1-877-201-4721.

August 30, 2017

Hospice Provider Preview Reports Now Available

Hospice Provider Preview Reports are now available. Hospice providers are encouraged to preview their quality measure results based on Quarter 1- 2016 to Quarter 4- 2016 data, prior to the November 2017 Hospice Compare refresh.

Providers have 30 days to preview their quality measure results (August 29, 2017 through September 28, 2017).

Directions on how to retrieve these reports can be found in the Downloads section of this webpage below. 

June 1, 2017

Hospice Provider Preview Reports for the Hospice Item Set (HIS) are now available. Hospice providers are encouraged to preview their quality measure results based on Quarter 4- 2015 to Quarter 3-2016 data, prior to the inaugural release of Hospice Compare in summer 2017.

Providers have 30 days to preview their quality measure results (June 1, 2017 through June 30, 2017).  

Directions on how to retrieve these reports can be found in the Download section of this webpage.

May 10, 2017

Hospice Quality Reporting Program: Public Reporting Webinar

When: Thursday, April 27, 2017

Time: 1:30 PM - 3:00 PM Eastern Time

During this webinar, CMS discusses the new Preview Reports for Hospices that will be available to providers in the near future. Participants will gain an understanding of how to access these reports, how to interpret the contents of these reports, and what to do if they believe their report contains an error.

View the transcript and audio.

Hospice Public Reporting Archives

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