User Guide for Hospice Quality Reporting Data Collection

Transcription

1 User Guide fr Hspice Quality Reprting Data Cllectin Fiscal Year 2015 Reprting Cycle: Data Cllectin: Calendar Year 2013 Data Submissin: by April 1, 2014 Payment Impact: Fiscal Year 2015 APU Versin 2.0 Last Updated: August 2013 PRA Disclsure Statement: Accrding t the Paperwrk Reductin Act f 1995, n persns are required t respnd t a cllectin f infrmatin unless it displays a valid OMB cntrl number. The valid OMB cntrl number fr this infrmatin cllectin is The time required t cmplete this infrmatin cllectin fr bth measures cmbined is estimated t average 181 hurs per hspice per year, including the time t review instructins, search existing data resurces, gather the data needed, and cmplete and review the infrmatin cllectin. If yu have cmments cncerning the accuracy f the time estimates r suggestins fr imprving this frm, please write t: CMS, 7500 Security Bulevard, Attn: PRA Reprts Clearance Officer, Mail Stp C , Baltimre, Maryland OMB Cntrl # Expiratin Date 9/30/2015

2 Table f Cntents Sectin I: Int rductin... 3 Purpse and Explanatin f Data Cllectin... 4 Fiscal Year 2015 Reprting Cycle Requirements: Wh, What, When & Hw... 5 Resurces... 7 Sectin II: The Structural Measure... 8 Backgrund... 9 Structural Measure Reprting Structural Measure Data Submissin: Sectin III: NQF #0209 Pain Measure Backgrund Implementing the NQF #0209 Pain Measure in Yur Hspice Organizatin Data Cllectin Initial Cmfrt Questin: Fllw-up Cmfrt Questin: NQF #0209 Data Submissin Sectin IV: Appendices Appendix A: NQF #0209 Pain Measure Wrksheet Appendix B: Glssary Page 2 f 29

3 Sectin I: Intrductin Page 3 f 29

4 Purpse and Explanatin f Data Cllectin The Hspice Quality Reprting Prgram (HQRP) was mandated by Sectin 3004 f the Affrdable Care Act (ACA). As part f the HQRP, all Medicare-certified hspices are required t submit quality data t CMS. Currently, hspice prviders submit quality data in the frm f facility-level quality measure data t CMS. Quality measures fr each HQRP cycle are selected by CMS. Thrugh rulemaking prcesses, hspice prviders are ntified f HQRP quality measures, data cllectin perids, data submissin deadlines, and ther requirements. Prviders that fail t meet HQRP requirements as specified in rulemaking will receive a 2 percentage pint reductin in their Annual Payment Update (APU) fr the upcming fiscal year (FY). The HQRP is currently a pay-fr-reprting prgram, meaning it is the act f submitting required data by specified deadlines that determines cmpliance. Perfrmance level n quality measures is nt a factr in determining cmpliance and APU. The HQRP currently perates n a cycle f data cllectin, data submissin, and payment impact that spans three years. HQRP reprting cycles are referenced by the FY they impact. Fr example, the current HQRP cycle -- the FY 2015 Cycle -- will cnsist f data cllectin in Calendar Year (CY) 2013, data submissin in CY 2014, impacting the APU fr FY See Figure 1, belw. T avid a reductin in the APU fr FY 2015, all hspice prviders that are Medicare-certified and have a valid CCN (CMS Certificatin Number; als knwn as the Medicare Prvider Number) as f March 3, 2014, are required t cllect and submit data t CMS fr tw measures: the structural measure and the NQF #0209 Pain Measure. Hspice prviders must submit data fr bth measures t CMS n later than April 1, 2014 t cmply with reprting requirements. Hspice prviders will submit their data t CMS using a web-based data entry system. Details f the data submissin prcess will be prvided n the CMS Hspice Quality Reprting Prgram (HQRP) website: Initiatives-Patient-Assessment-Instruments/Hspice-Quality-Reprting/index.html?redirect=/Hspice- Quality-Reprting/ Figure 1. FY 2015 Reprting Cycle Activities CY 2013 CY 2014 FY 2015 Data Cllectin fr 2 required measures: structural measure and NQF #0209 measure Data Submissin by April 1, 2014 fr 2 required measures: structural measure and NQF #0209 Payment Impact: data cllected in 2013 and submitted in 2014 affects APU in FY2015 (effective 10/1/2014) Page 4 f 29

5 Fiscal Year 2015 Reprting Cycle Requirements: Wh, What, When & Hw Wh: All hspice prviders that are Medicare-certified and have a valid CMS Certificatin Number (CCN, r Medicare Prvider Number) as f March 3, 2014, are required t cllect and submit data t meet the requirements fr the FY 2015 Reprting Cycle. Fr Hspices with Multiple Lcatins: Hspices will reprt data fr bth measures t CMS n a per-ccn basis. Hspice prviders with multiple lcatins, sharing ne CCN, shuld aggregate facility-level data frm all lcatins s the data entered n the CMS data entry site represent data fr the single CCN. FAQ: What s the CCN Number? The CCN number is the CMS Certificatin number, als knwn as the Medicare Prvider Number. It is a 6-digit number, usually in the frmat xx-xxxx. What: Quality Measure reprting is required fr all patients, which includes: All payers (Medicare, Medicaid, and private payers) and All hspice prvider settings (inpatient, hme care, nursing hme, assisted living facility, etc.) Fr FY 2015 Reprting Cycle, prviders will be required t submit data fr tw measures t CMS: 1. The structural measure prviders will answer ne yes/n questin regarding their Quality Assessment and Perfrmance Imprvement (QAPI) Prgram t fulfill reprting requirements fr this measure. Answering the single yes/n questin fulfills requirements fr this measure; n ther data r perfrmance scres will be submitted. Data Cllectin: hspices need t keep dcumentatin f the Quality Indicatrs (QIs) that they use in their QAPI prgrams. Hspices d nt need t cllect/submit any patient- r facility-level QI/QAPI data t meet the structural measure reprting requirements. Data Submissin: prviders must submit their answer t the structural measure questin by April 1, 2014 t cmply with requirements FAQ: Am I required t reprt fr this cycle? If yu did nt have a valid CCN n March 3, 2014, yu are nt required t reprt fr FY 2015 Reprting Cycle. Even if yur hspice was Medicarecertified as f March 3, 2014, if yur hspice did nt have an actual CCN n March 3, 2014, yu are nt required t reprt. 2. The NQF #0209 Pain Measure prviders will cllect patient-level data and submit facilitylevel data t CMS. Data Cllectin: prviders shuld cllect NQF #0209 pain measure data n all admissins January 1, 2013 December 26, 2013 t cmply with reprting requirements. Page 5 f 29

6 Data Submissin: Prviders will aggregate their calendar year 2013 data and submit their NQF #0209 data by April 1, 2014 t cmply with reprting requirements fr this measure. All NQF #0209 data cllected during 2013 will be reprted nce in 2014; there will be n quarterly reprting fr the FY 2015 Reprting Cycle. APU determinatin: The FY 2015 Reprting Cycle is pay fr reprting. This means that cmpliance with HQRP requirements and APU determinatin is based n the act f submitting data fr bth measures by the required deadline April 1, Perfrmance level is nt a cnsideratin in determining a hspice prvider s APU at this time. When: Fr the FY 2015 Reprting Cycle, there is a single reprting deadline fr bth the NQF #0209 and the structural measure. Data fr bth measures must be submitted t CMS via the data entry website n later than April 1, Data will be submitted in 2014 fr the entire Calendar Year 2013; there will be n quarterly r mnthly data reprting. Hw: Hspice prviders will enter their data nline and submit them t CMS using the designated data entry site. The data entry site will be active fr data entry and submissin January April 1, Prviders will be able t access the data entry site thrugh the Data Submissin prtin f the CMS Hspice Quality Reprting Prgram (HQRP) website: Quality-Reprting/Data-Submissin.html, at the bttm f the webpage under Related Links. Hspice prviders may utilize vendrs fr their individual hspice prvider data submissin, but CMS will nt supprt batch submissins invlving scripting r database imprts fr multiple hspice prviders frm vendrs. Page 6 f 29

7 Resurces CMS HQRP Webpage: The CMS HQRP webpage is the fficial website fr updates and annuncements pertinent t the HQRP, including infrmatin abut User Guides, trainings, and ther general resurces: Reprting/index.html. Prviders shuld bkmark the web address abve and visit the CMS HQRP site n a regular basis in rder t have the mst up-t-date infrmatin pertinent t the HQRP. User Guides Available fr Prviders: There are tw User Guides available fr prviders. Prviders shuld review bth User Guides carefully. 1. This Data Cllectin User Guide cntains instructin and guidance fr HQRP data cllectin prcesses nly. The Data Cllectin User Guide can be fund n the Data Cllectin prtin f the CMS HQRP website: Initiatives-Patient-Assessment-Instruments/Hspice-Quality-Reprting/Data-Cllectin.html, at the bttm f the webpage, under Dwnlads. 2. A Technical User Guide will als be available t instruct prviders n data entry and submissin prcesses. The Technical Guide fr Hspice Quality Reprting Data Entry and Submissin will be made available fr prvider dwnlad n the Data Submissin prtin f the CMS HQRP website: Assessment-Instruments/Hspice-Quality-Reprting/Data-Submissin.html at the bttm f the webpage, under Dwnlads. Resurces and Training Available fr Prviders: CMS will pst a slide presentatin that summarizes the clinical data cllectin prcesses. In additin, there will be a data submissin training t help prviders prepare fr the FY 2015 Reprting Cycle. Further details abut the availability f additinal resurces and training will be annunced n the CMS HQRP website: Instruments/Hspice-Quality-Reprting/index.html Help Desk Cntact Infrmatin: issues: There are tw Help Desks t assist hspice prviders with HQRP quality questins and technical 1. Quality Help Desk: Fr issues pertaining t either f the required measures reprting requirements(including wh is required t reprt), please the Quality Help Desk at the fllwing: HspiceQualityQuestins@cms.hhs.gv 2. Technical Help Desk: Fr technical website/data entry issues including finding the data entry site, username/passwrd issues, r general website difficulty/errr messages, please call r the Technical Help Desk at the fllwing: help@qts.cm Phne: Hurs: Mnday Friday 7:00 a.m. 7:00 p.m. Central Time Page 7 f 29

8 Sectin II: The Structural Measure Data Submissin: by April 1, 2014 Page 8 f 29

9 Backgrund The structural measure is intended t indicate whether a hspice rganizatin s calendar year 2013 (January 1 December 31, 2013) Quality Assessment and Perfrmance Imprvement (QAPI) prgram includes three r mre quality indicatrs related t patient care. Fr the FY 2015 Reprting Cycle, hspice prviders shall answer ne questin t satisfy measure reprting requirements: Q1: Des yur hspice have a Quality Assessment and Perfrmance Imprvement (QAPI) prgram that includes three r mre quality indicatrs related t patient care? Prviding a yes/n answer t Q1 satisfies the structural measure reprting requirement fr the FY 2015 Reprting Cycle. Hspice prviders will nt submit any infrmatin abut individual quality indicatrs, quality indicatr tpics, r QAPI perfrmance scres/raw data. Hspice prviders shall cmplete and submit their answer t Q1 t CMS n later than April 1, FAQ: Hw has the structural measure changed frm last year (FY 2014 FY 2015 Reprting Cycles)? Eliminatin f Q2 and Q3. Last year, prviders had t answer 3 questins as part f the FY 2014 structural measure: Q1 Q3. This year, Q2 (the QAPI/QI checklist) and Q3 (QAPI /QI Data Surce) have been eliminated. This means fr the FY 2015 Reprting Cycle, prviders are required nly t answer the ne structural measure questin t satisfy structural measure reprting requirements. Prviding a yes/n answer t this questin satisfies the entire FY 2015 Reprting Cycle requirement. Deadline is nw April 1. Last year, there were tw separate reprting deadlines fr the tw required measures. This year, there is a single deadline fr reprting bth measures. This means that fr the FY 2015 Reprting Cycle, prviders will have until April 1, 2014 t submit bth their structural and NQF #0209 measure data. Page 9 f 29

10 Structural Measure Reprting Structural measure reprting cnsists f answering ne yes/n questin. Answering the yes/n questin is the nly structural measure reprting requirement fr the FY 2015 Reprting Cycle. Hspices will nt be required t submit details abut individual quality indicatrs (QIs) r tpic areas; nr will they be required t submit any perfrmance scres r actual numeric data. Details n hw t answer the structural measure questin are utlined belw. Structural Measure Questin: Des yur hspice have a Quality Assessment and Perfrmance Imprvement (QAPI) prgram that includes three r mre quality indicatrs (QIs) related t patient care? Answer yes r n based n the structure and cntent f yur hspice rganizatin's QAPI prgram. Answer Yes if yur hspice s QAPI prgram included 3 r mre patient care-related quality indicatrs frm January 1, 2013, t December 31, In rder t answer Yes t the structural measure questin, hspice prviders must be able t identify at least 3 QIs in their QAPI prgram that meet all f the fllwing criteria: Are quality indicatrs: A quality indicatr is a metric used t assess hspice care prcesses r utcmes. It is aggregated frm patient-level data and reprted at the facility-level fr mnitring as part f yur QAPI prgram. Care gals such as all patients will be free f pain are nt quality indicatrs because they are nt clearly defined and measureable. Are related t patient care: Patient care-related indicatrs include QIs in patient care dmains such as management f physical r psychscial symptms, patient preferences, care crdinatin, patient safety, r medicatin errrs. Organizatinal r business-related quality indicatrs, such as staff turnver rates, patient cntact hurs, cst-savings metrics, emplyee training/certificatin/educatin, and patient length f stay/primary diagnsis, are nt patient care-related and shuld nt be included in structural measure reprting. Are in place (r were added) between January 1 and December 31, 2013: Quality Indicatrs that yu stpped using befre January 1, 2013, r any indicatrs added t yur QAPI prgram after December 31, 2013, shuld nt be cnsidered when determining yur answer t the structural measure questin. Answer N if yur hspice s QAPI prgram included fewer than 3 patient care-related quality indicatrs frm January 1, 2013, t December 31, Even if yu answer n, yu shuld still submit data t CMS. The FY 2015 Reprting Cycle is pay fr reprting. This means that cmpliance with the HQRP and the APU determinatin are based n the act f submitting data fr bth measures by the required deadline April 1, Perfrmance level is nt a cnsideratin in determining a hspice s APU in the FY 2015 Reprting Cycle. Page 10 f 29

11 Structural Measure Data Submissin: Data Submissin Deadline: April 1, 2014 Hspice prviders will reprt their structural measure t CMS via a web-based data entry and submissin website. The data entry website will be available fr data entry, attestatin, and data submissin January April 1, The link t the data entry site will be accessible t prviders via the Data Submissin prtin f the CMS HQRP website: Patient-Assessment-Instruments/Hspice-Quality-Reprting/Data-Submissin.html. Prviders must submit their structural measure via the data entry site n later than 11:59 PM Eastern Time n April 1, 2014 in rder t avid a 2 percentage pint reductin in their APU. After April 1, 2014, prviders will nly be able t view the data entry website via the Data Submissin prtin f the CMS HQRP webpage. N data entry r data submissin can ccur after 11:59 Eastern Time n April 1, Fr Hspice Prviders with Multiple Lcatins: Hspice prviders will reprt data t CMS n a per-ccn basis. Hspice prviders with multiple lcatins that share ne CCN shuld aggregate facility-level data frm all lcatins s the data entered n the CMS data entry site represent data fr the single CCN. Technical User Guide fr Data Submissin: This Data Cllectin User Guide cntains instructin and guidance fr HQRP data cllectin prcesses nly. A Technical User Guide will als be available t instruct prviders n data entry and submissin prcesses. The Technical Guide fr Hspice Quality Reprting Data Entry and Submissin will be made available fr prvider dwnlad n the Data Submissin prtin f the CMS HQRP website: Quality-Reprting/Data-Submissin.html at the bttm f the webpage, under Dwnlads. Prviders shuld review bth User Guides carefully. APU Determinatin: The FY 2015 Reprting Cycle is pay fr reprting. This means that cmpliance with HQRP requirements and APU determinatin is based n the act f submitting data fr bth measures by the required deadline April 1, Perfrmance level is nt a cnsideratin in determining a hspice s APU at this time. In practical terms, this means prviders shuld still submit their structural measure t CMS even if their answer t the structural measure questin is n. Page 11 f 29

12 Sectin III: NQF #0209 Pain Measure Data Cllectin: All admissins January 1, 2013 December 26, 2013 Data Submissin: by April 1, 2014 Page 12 f 29

13 Backgrund The NQF #0209 Pain Measure was re-endrsed by the Natinal Quality Frum (NQF) in February It measures the percentage f patients wh reprt being uncmfrtable because f pain at the initial assessment (after admissin t hspice) wh reprt that pain was brught t a cmfrtable level within 48 hurs. By implementing this measure, hspice prviders are able t determine what percentage f their patient ppulatin is admitted with pain and hw well that pain is managed in the early days f hspice care. This measure is particularly significant t hspice care as it addresses a basic aspect f hspice practice pain management and ensures integratin f patient chice fr desired level f treatment with the care prcess by incrprating the patient s wn pain gals and perceptin f his r her wn degree f cmfrt. Because the measure incrprates bth patient preference and measure utcmes, it is useful and meaningful fr cnsumers, prviders, and payers. Fr measure specificatins and details, please visit NQF: 0&SubmissinId=457#k=0209. Additinal details abut hw t use/implement this measure are available frm the measure steward, Natinal Hspice and Palliative Care Organizatin (NHPCO): Figure 3. FY 2015 Reprting Cycle: NQF #0209 Activities CY 2013 CY 2014 FY 2015 Data Cllectin: Cllect NQF #0209 data n all admissins 1/1/13 12/26/13 Data Submissin: submit NQF #0209 data by April 1, 2014 FAQ: Hw has the NQF #0209 Pain Measure changed frm last year (FY 2014 FY 2015 Reprting Cycles)? Data Cllectin Perid nw an entire Calendar Year: There were n changes in the NQF #0209 Pain Measure itself frm the FY 2014 t FY 2015 Reprting Cycles. As measure specificatins are the same, prviders shuld cllect and submit NQF #0209 data fr the FY 2015 Reprting Cycle in the same manner as they did last year. The nly NQF #0209 change frm the FY 2014 t FY 2015 Reprting Cycles is a change in the data cllectin perid. Last year, prviders cllected NQF #0209 data nly fr admissins during the 4 th quarter f This year, prviders shuld cllect NQF #0209 data n admissins n a calendar year schedule. This means that fr the FY 2015 Reprting Cycle, NQF #0209 data shuld be cllected n all admissins January 1, 2013 December 26, Payment Impact: data cllected in 2013 and submitted in 2014 affects APU in FY 2015 (effective 10/1/2014) Page 13 f 29

14 Implementing the NQF #0209 Pain Measure in Yur Hspice Organizatin NQF #0209 Pain Measure implementatin fr the Hspice Quality Reprting Prgram (HQRP) shuld ccur in tw brad phases: Data Cllectin and Data Submissin. Data Cllectin: generate and recrd NQF #0209 data n all admissins January 1 December 26, 2013 In rder t submit data fr the NQF #0209 Pain Measure fr the purpses f the CMS Hspice Quality Reprting Prgram (HQRP), hspice prviders will generate and recrd NQF #0209 Pain Measure data n all admissins frm January 1 t December 26, As previusly stated, the NQF #0209 Pain Measure calculates the percentage f patients wh reprt being uncmfrtable because f pain at the initial assessment (after admissin t hspice services) wh reprt that pain was brught t a cmfrtable level within 48 hurs. Data fr the measure are generated by asking patients tw cmfrt questins: The initial cmfrt questin Are yu uncmfrtable because f pain? is asked at the time f initial assessment. Fr patients that answer yes t the initial cmfrt questin, the fllw-up cmfrt questin Was yur pain brught t a cmfrtable level within 48 hurs f the start f hspice care? is asked between 48 t 72 hurs after initial pain assessment. T cmply with CMS requirements, the NQF #0209 cmfrt questins shuld be asked (and respnses dcumented) fr all admissins frm January 1 December 26, Data Submissin: retrieve and reprt cllected NQF #0209 data January April 1, 2014 After the data cllectin perid ends in December, the data submissin phase will begin. The NQF #0209 data submissin phase spans January 2014 t April 1, During this time, hspice prviders will retrieve all f their NQF #0209 data that were cllected during 2013, aggregate them, and reprt the seven data elements t CMS n later than April 1, Details n the seven data elements will be included later in this sectin. Page 14 f 29

15 Data Cllectin Generate and Recrd NQF #0209 data n all admissins January 1 December 26, NQF #0209 Pain Measure data cllectin cnsists f generating and recrding data fr the initial and/r the fllw-up cmfrt questins n all admissins January 1 December 26, T cllect the necessary data fr NQF #0209 measure reprting, hspice prviders shuld generate and recrd data fr the initial and/r fllw-up cmfrt questins using the fllwing prcess: I. Initial Cmfrt Questin: The initial cmfrt questin will be asked f all patients determined eligible fr the measure, based n step 1, belw. Step 1. Determine patient eligibility fr measure inclusin. In rder t be asked the initial cmfrt questin -- and t be eligible fr the NQF #0209 measure entirely a patient must meet three initial eligibility criteria. The patient must be: Criterin 1: At least 18 years f age Criterin 2: Able t self-reprt cmfrt The patient must be able t understand the initial questin and prvide a reliable yes/n respnse. The clinician cnducting the assessment must use his/her clinical judgment t evaluate the patient s ability t self-reprt. Criterin 3: Able understand the language f the clinician cnducting the assessment If a patient cannt understand the language f the clinician cnducting the assessment, the patient shuld nt be included in the NQF #0209 Pain Measure. Hspices are, hwever, FAQ: Which patients shuld be included in CMS HQRP NQF #0209 reprting? All admissins January 1 December 26, 2013 An admissin is defined as any and all patients wh are admitted t yur hspice fr the first time r readmitted t yur hspice after an interruptin in service prvisin. Patients wh are transferred frm anther hspice prvider t yur hspice rganizatin shuld als be included in the measure cllectin, even thugh the measure questins may have already been asked by the previus hspice. All payers (Medicare, Medicaid, and private payers) All hspice settings (inpatient, hme care, and nursing hme hspice patients) permitted t use interpreters if the patient cannt understand the language f the clinician cnducting the assessment. Use f a qualified interpreter will suffice t surmunt the language barrier and include the patient in the NQF #0209 measure. Hspices shuld apply the same standard regarding use f an interpreter fr the cmfrt questin(s) as they wuld fr any regular assessment r visit. If a patient des nt meet all three criteria listed abve, they shuld be excluded frm the NQF #0209 measure entirely. This means they shuld nt be asked the initial r the fllw-up cmfrt questin. Step 2. Ask the initial cmfrt questin. If a patient is eligible fr the measure based n Step 1, abve, ask the patient the initial cmfrt questin fr the NQF #0209 measure. Specifics fr asking the questin are as fllws: Page 15 f 29

16 Wh. The initial cmfrt questin shuld be asked by a nurse, and the nurse must ask the questin in-persn. Hw. The initial cmfrt questin shuld be asked exactly as fllws. The staff member cnducting the initial assessment shuld ask the patient the exact questin: Are yu uncmfrtable because f pain? D nt substitute a pain scale rating fr the patient s yes/n respnse. D nt substitute family/caregiver reprt f pain cmfrt fr patient self-reprt. D nt ask the initial cmfrt questin if the patient was excluded frm the measure because they were under 18, unable t self-reprt, r there was a language barrier. When. The initial cmfrt questin shuld be asked during the initial nursing assessment, prir t cmpleting a pain assessment. Step 3. Recrd initial cmfrt questin data in the patient s medical recrd. After asking the initial cmfrt questin, the clinician shuld recrd the initial cmfrt data in the patient s medical recrd. Initial cmfrt data shuld be recrded as: A patient s yes r n respnse t the initial cmfrt questin, alng with the time the questin was asked Or, if the patient was excluded frm the measure, the reasn fr exclusin: Remember: Under 18 years f age Unable t self-reprt at time f initial cmfrt questin Language barrier. In rder t avid missing data at the time f data submissin, it is imprtant fr hspice prviders t recrd cmplete initial cmfrt questin data (the patient s yes/n respnse and the time the questin was asked, r the reasn fr exclusin). Page 16 f 29

17 II. Fllw-up Cmfrt Questin: The fllw-up cmfrt questin will nly be asked f thse patients wh answered yes t the initial cmfrt questin. If the patient answered n r was determined t be ineligible fr the measure, the hspice prvider is nt required t cllect NQF #0209 fllw-up data fr that patient. Step 1. Ask the fllw-up cmfrt questin. If the patient answered yes t the initial cmfrt questin, the fllw-up cmfrt questin shuld be asked hurs after asking the initial cmfrt questin. Specifics fr asking the questin are as fllws: Wh. The fllw-up cmfrt questin can be asked by any member f the hspice staff; the questin des nt have t be asked by a nurse. Additinally, the hspice prvider can cntact the patient via telephne t ask the fllw-up cmfrt questin. Hw. The fllw-up cmfrt questin shuld be asked as fllws: Was yur pain brught t a cmfrtable level within 48 hurs? D nt substitute a pain scale rating fr the patient s yes/n respnse. D nt substitute family/caregiver reprt f pain cmfrt fr patient self-reprt. D nt ask the fllw-up cmfrt questin if the patient was determined ineligible fr the measure, r if the patient answered n t the initial cmfrt questin. When. Hspice prviders must cntact the patient between 48 t 72 hurs after asking the initial cmfrt questin t ask the fllw-up questin. The fllw-up questin shuld be asked 48 t72 hurs after the initial nursing assessment, nt the admissin t hspice, if these tw events ccurred at different times. The fllw-up questin shuld nt be asked earlier than 48 hurs after the initial assessment. Hspices shuld make every effrt t cntact the patient 48 t 72 hurs after the initial pain assessment t ask the measure fllw-up questin. At times it may nt be pssible t cntact the patient within 72 hurs (e.g., the patient is sleeping and the family caregiver asks that the hspice call back later). Therefre, the endpint fr asking the fllw-up questin can be defined as 3 days. Given this time frame, hspices shuld ask patients the fllw-up questin by 11:59 PM f the third day. FAQ: What s the earliest (and latest) I can ask the fllw-up questin fr the NQF #0209 Pain Measure? Earliest. If a patient is asked the initial questin n 11/6/13 at 2 pm, the fllw-up questin shuld nt be asked prir t 2 pm n 11/8/13 (r 48 hurs after the initial cmfrt questin was asked). Latest. While it is ideal t cntact the patient hurs after asking the initial questin, hspices are permitted up until midnight f the third day t ask the fllw-up questin. Fr a patient admitted 11/6/13 at 2pm, the hspice thus has until 11:59 pm n 11/9/13 (midnight f the third day) t ask the fllw-up questin. Page 17 f 29

18 Patients wh are unable t self-reprt (either due t decline in status, death, r live discharge) at the time f fllw-up. If at the time yu are t ask the fllw-up questin the patient is n lnger able t self-reprt r has been discharged (live r due t death), the patient cannt be asked the fllw-up cmfrt questin. Reasns fr nt asking the fllw-up questin can be summarized in 3 main categries, using the fllwing terminlgy: Discharge (live r due t death) Cnditin deterirated patient n lnger able t cmmunicate/self-reprt Other (with explanatin) Step 2. Recrd NQF #0209 fllw-up cmfrt questin data. After asking the fllw-up cmfrt questin, the clinician shuld recrd the patient s yes r n answer t the questin in the medical recrd, alng with the time the fllw-up questin was asked. If the patient was unable t self-reprt at the time f fllw-up, the clinician shuld recrd the reasn in the medical recrd in lieu f a yes/n respnse: Discharge (live r due t death) Cnditin deteriratin (patient n lnger able t cmmunicate/selfreprt) Other (with explanatin) Remember: Fllw-up data must nly be recrded fr patients wh answered yes t the initial cmfrt questin. If the patient answered n t the initial questin r was ineligible fr the measure, n NQF #0209 fllwup data are recrded in the chart. The fllw-up questin must be asked hurs after the initial cmfrt questin. It is imprtant fr hspice prviders t recrd cmplete fllw-up cmfrt questin data (the patient s respnse r the reasn why the patient was unable t answer the fllw-up questin) in rder t avid missing data at the time f data submissin. General Ntes abut the NQF #0209 Measure: FAQ: Is it acceptable t ask the fllw-up questin befre 48 hurs? Hspices shuld check in with the patient fr symptm management purpses befre 48 hurs. Hwever, yu cannt use these clinical check-ins fr NQF #0209 data cllectin purpses. Fr NQF #0209 measure purpses, the fllw-up cmfrt questin shuld nt be asked prir t 48 hurs. The nly data that can be used in NQF #0209 reprting is the data that was cllected by asking the exact NQF #0209 fllw-up questin between hurs. It is usual clinical practice t fllw-up with patients experiencing pain prir t the hur mark used fr the NQF #0209 measure. Clinicians ften assess pain daily r even mre frequently by asking patients t rate pain, describe whether their pain is imprving, wrsening, r staying the same in respnse t treatment, r perfrming ther apprpriate clinical assessment. These clinical assessments d nt preclude a patient frm NQF #0209 reprting. In additin t these usual clinical practices, hspices will ask the patient the specified NQF #0209 fllw-up questin between hurs: Was yur pain brught t a cmfrtable level within 48 hurs? NQF #0209 Pain Measure data cllectin is nt a substitute r replacement fr usual pain management practices. In practical terms, prviders may find that sme NQF #0209 measure specificatins appear t be at dds with their established clinical pain management practices. The tw NQF #0209 measure questins (initial cmfrt questin and fllw-up cmfrt questin) d nt replace usual clinical pain management practice and shuld nt be part f an nging pain assessment. Page 18 f 29

19 Data Submissin Retrieve and reprt NQF #0209 Pain Measure data January 2014 April 1, After the data cllectin phase ends in December 2013, hspice prviders will enter the data submissin phase, which spans January 2014 t April 1, During this time, hspice prviders will retrieve data cllected in calendar year (CY) 2013, aggregate them, and submit their data t CMS n later than April 1, During the data submissin perid, hspices will review their patients medical recrds t retrieve NQF #0209 Pain Measure data. Hspice prviders shuld review patient medical recrds fr all patients that were admitted between January 1 and December 26, 2013, extract, and aggregate applicable NQF #0209 data. After retrieving and aggregating their data, hspice prviders will submit seven data elements t CMS fr the NQF #0209 Pain Measure (described belw). Hspice prviders will submit NQF #0209 data fr the entire CY 2013; data will nt be reprted n a quarterly r mnthly basis. The seven data elements can be gruped int 3 categries: Ttal number f admissins (Data Element 1) Initial cmfrt questin data (Data Elements 2-4) Fllw-up cmfrt questin data (Data Elements 5-7) Details fr retrieving the 7 Data Elements are utlined n the next page. FAQ: Since data cllectin includes admissins 1/1/13 12/26/13, hw d I accunt fr admissins 12/27/13 12/31/13? Inclusin fr NQF #0209 measure reprting hinges n a patient s admissin date. Fr the NQF #0209 measure, yu will nly reprt data fr patients that were admitted 1/1/13-12/26/13. This means Data Element 1, "ttal admissins," will be defined as all admissins 1/1/13-12/26/13. Data Elements 2-7 will be based n thse patients that were included in Data Element #1. Fr example, a patient admitted n 12/26 may have their initial questin asked n 12/27 and their fllw up questin asked n 12/29. Inclusin in NQF #0209 reprting hinges n the admissin date; since the patient was admitted n 12/26, they, alng with the rest f their data, wuld be included. A patient admitted n 12/27 wh als had their initial questin asked n 12/27 and their fllw-up n 12/29 wuld nt be included in this Reprting Cycle at all since they were admitted after 12/26. Patients admitted 12/27/13 12/31/13 will nt be accunted fr in NQF #0209 reprting. T facilitate the NQF #0209 data entry/submissin prcess, prviders may wish t cmplete Appendix A: NQF #0209 Data Submissin Wrksheet fund in this User Guide. The Appendix A wrksheet is frmatted t match Data Elements 1 7 as they will appear n the Data Entry Website. Therefre, it is highly recmmended that prviders cmplete Appendix A prir t beginning their data entry n the data entry/submissin website. Prviders may als wish t have a cpy f Appendix A available fr cmpletin f data entry. Page 19 f 29

20 The fllwing pages detail the seven data elements that will be reprted t CMS fr the NQF #0209 measure. Included in the right-hand sidebar f the fllwing pages is an integrated example detailing hw NQF #0209 data cllectin maps t the seven data elements that will be reprted t CMS. The integrated example fllws 10 fictinal patients (Patients A J) frm Sunshine Hspice thrugh the NQF #0209 data cllectin prcess. Examples are gruped int the 3 data element categries: Ttal Admissins: Data Element 1 Initial Cmfrt Questin: Data Elements 2-4 Fllw-up Cmfrt Questin: Data Elements 5-7 Even thugh missing data are nt reprted t CMS, examples are als given fr hw t accunt fr missing data. Data Element 1: Ttal Number f Admissins Enter the number f admissins during the data cllectin perid (all admissins January 1, 2013 thrugh December 26, 2013) Hspice prviders shuld enter the ttal number f admissins frm January 1 t December 26, Example: Ttal Admissins: During Calendar Year 2013, Sunshine Hspice had 10 admissins (Patients A-J). Nine f the 10 patients were admitted during the data cllectin perid, which is defined as all admissins January 1, 2013 December 26, One f the 10 patients (Patient J) was admitted n December 28, Data Element 1: With respect t the Data Elements, this means that: Data Element 1 = 9 patients Explanatin: Patients A-I are included in Data Element 1 since they were admitted between January 1, 2013 and December 26, Patient J is nt included in Data Element 1, ttal number f admissins, since he/she was admitted n December 28, 2013, after the admissin cutff date. Since Patient J was admitted after the cutff date, he/she will nt be included in any f the 7 Data Elements. Prviders shuld answer Data Elements 2-7 based n the patients included in the ttal number f admissins fr Data Element 1. Page 20 f 29

21 Initial Cmfrt Questin - Data Elements 2-4: Data Element 2: Patients wh answered yes t the initial cmfrt questin Pain Measure Denminatr: Enter the number f patients wh answered yes t the questin Are yu uncmfrtable because f pain? at the initial assessment (after admissin t hspice services) during the data cllectin perid. Include nly the number f yes respnses yu generated and recrded in yur patient recrds, initial assessment frms, r n measure wrksheets Data Element 3: Patients wh answered n t the initial cmfrt questin Enter the number f patients wh answered n t the questin Are yu uncmfrtable because f pain? at the initial assessment (after admissin t hspice services) during the data cllectin perid. Include nly the number f n respnses yu generated and recrded in yur patient recrds, initial assessment frms, r n measure wrksheets Data Element 4: Patients excluded frm the measure Enter the number f patients excluded due t ineligibility. This data element is the number f patients wh were determined ineligible fr the measure at the initial nursing assessment because they were: less than 18 years f age unable t self-reprt r there was a language barrier. This data element shuld nly include patients wh were excluded fr ne f the three reasns listed abve; patients wh were eligible fr the measure but were simply nt asked the initial cmfrt questin are cnsidered missing and shuld nt be included in Data Element 4. Example: Initial Cmfrt Questin Data: The first step in cllecting initial cmfrt questin data is determining eligibility fr the measure. Remember, patient eligibility fr the measure is based n the patient being ver 18, able t self-reprt, and having n language barrier issues. Sunshine Hspice had 9 patients (A-I) admitted during the Data Cllectin perid. Of the 9 admissins fr the data cllectin perid: Patient A was unable t self-reprt at admissin Patients B-I met all eligibility criteria (were ver 18, able t self-reprt, n language barrier) The secnd step in initial cmfrt questin data is asking the initial cmfrt questin. Remember, the initial cmfrt questin shuld nly be asked f patients eligible fr the measure. Since ne patient (Patient A) was ineligible because he/she was unable t self-reprt, he will be excluded and will nt be asked the cmfrt questin. That leaves 8 patients (Patients B-I) eligible fr the measure and thus 8 patients t be asked the initial cmfrt questin: Patient B answers n he is nt uncmfrtable. Patients C-H answer yes they are uncmfrtable. Patient I was nt asked the initial cmfrt questin, despite meeting all eligibility criteria With respect t the Data Elements, this means that: Data Element 2 = 6 patients Explanatin: Patients C-H answered yes t the initial cmfrt questin Data Element 3 = 1 patient Explanatin: Patient B answered n t the initial cmfrt questin Data Element 4 = 1 patient Explanatin: Patient A was excluded frm the measure because they were unable t self reprt n admissin Nte: Patient I is nt included in Data Elements 2-4; even thugh Patient I was eligible fr the measure, Patient I was nt asked the initial cmfrt questin. This means Patient I is missing with respect t initial cmfrt questin data (Data Elements 2-4). Missing data fr the initial cmfrt questin is explained n the next page. Page 21 f 29

22 Missing Data fr the Initial Cmfrt Questin: Data Elements 2-4 A patient is cnsidered missing with respect t initial cmfrt questin data (Data Elements 2-4) if he/she: was eligible fr the measure, but was nt asked the initial cmfrt questin; was eligible fr the measure, was asked the initial cmfrt questin, but it was utside f the specified timeframe; was eligible fr the measure, was asked the initial cmfrt questin, but the patient s yes/n respnse was nt recrded in the medical recrd; r Missing data will nt be reprted t CMS. Thus, a patient wh is missing with respect t initial cmfrt questin data will nt be included in Data Elements 2, 3, r 4. A patient wh is missing with respect t initial cmfrt questin data will be accunted fr in the seven Data Elements as fllws: Data Element 1: Patients wh are missing with respect t the initial cmfrt questin will still be included in Data Element 1, ttal admissins Data Elements 2 4: Patients wh are missing with respect t the initial cmfrt questin will nt be reflected in Data Elements 2, 3, r 4. Data Elements 5-7: Patients wh are missing with respect t the initial cmfrt questin will nt be reflected in Data Elements 5, 6, r 7 Example: Initial Cmfrt Questin -- Missing Data: Patient I was eligible fr the measure and shuld have been asked the initial cmfrt questin, but was nt. This means initial cmfrt questin data is missing fr Patient I. Missing data is nt be reprted t CMS. Thus, Patient I will nt be included in Data Elements 2-4. Neither will Patient I be included in Data Elements 5-7. Patient I shuld still be included in Data Element 1. Althugh Patient I is nt reprted t CMS in Data Elements 2-7, hspice prviders may wish t track missing data patients fr internal quality imprvement purpses. Data Element Summary Table: Data Element 1: Ttal Admissins Data Element 2: Yes t Initial Questin Data Element 3: N t Initial Questin Data Element 4: Excluded frm Measure Initial Questin Missing Data (Nt reprted t CMS) 9 Patients (A- I) 6 Patients (C- H) 1 Patient (B) 1 Patient (A) 1 Patient (I) Althugh missing data are nt reprted t CMS, hspice rganizatins are encuraged t recrd missing data fr internal quality imprvement prcesses. Hspices shuld aim t have n missing data. Page 22 f 29

23 Fllw-up Cmfrt Questin - Data Elements 5-7: Data Elements 5-7 all relate t the fllw-up cmfrt questin. Remember, hspice prviders shuld nly cllect and reprt fllw-up data n thse patients wh answered yes t the initial cmfrt questin (Data Element 2). Patients wh answered n t the initial cmfrt questin (Data Elements 3) r were ineligible fr the measure (Data Element 4) shuld nt be included in fllw-up questin data (Data Elements 5-7). Data Element 5: Patients wh answered yes t the fllw-up cmfrt questin Enter the number f patients during the data cllectin perid wh answered yes t the fllw-up questin Was yur pain brught t a cmfrtable level within 48 hurs f the start f hspice care? at the time f fllw-up. Include nly the number f yes respnses generated and recrded in patient recrds, initial assessment frms, r n measure wrksheets Data Element 6 Patients wh answered n t the fllw-up cmfrt questin Enter the number f patients during the data cllectin perid wh answered n t the fllw-up questin Was yur pain brught t a cmfrtable level within 48 hurs f the start f hspice care? at the time f fllw-up. Include nly the number f n respnses generated and recrded in patient recrds, initial assessment frms, r n measure wrksheets Data Element 7: Patients unable t self-reprt (due t death, live discharge r cnditin deteriratin) at fllw-up Enter the number f patients unable t self reprt at fllw-up. This includes patients whse cnditin deterirated, leaving them unable t answer the fllw-up questin; patients wh died prir t fllw-up; and patients wh were discharged live prir t fllw-up. These reasns may appear in the medical recrd as: Discharge (live r due t death) Cnditin deterirated and patient is n lnger able t cmmunicate Other (with explanatin) Example: Fllw-up Cmfrt Questin Data: Fllw-up cmfrt data shuld nly be cllected n thse patients wh answered yes t the initial cmfrt questin. This means that fr Sunshine Hspice, fllw-up cmfrt questin data will be cllected n the 6 patients wh answered yes t the initial cmfrt questin, Patients C-H. With respect t fllw-up data: Patient C was unable t self-reprt at fllw-up Patient D answered yes t the fllwup questin, but the questin was asked after 11:59 PM f the third day Patient E died prir t the time f fllw-up Patient F-H said yes t the fllw-up cmfrt questin With respect t the Data Elements, this means that: Data Element 5 = 3 patients Explanatin: Patients F - H answered yes t the fllw-up questin. Patient D als answered yes t the fllw-up questin; hwever, Patient D was asked the fllw-up questin utside f the timeframe. This means data fr Patient D is missing and shuldn t be included in Data Element 5. Missing data is further explained n the next page. Data Element 6 = 0 patients Explanatin: Zer patients answered n t the fllw-up cmfrt questin. Data Element 7 = 2 patients Explanatin: Patient C and Patient E are included in Data Element 7 since they were bth unable t self-reprt at the time f fllw-up. Patient C was unable t self-reprt due t cnditin deteriratin; Patient E was unable t self-reprt due t death. This data element shuld nly include patients wh were unable t self-reprt at fllw-up fr ne f the three reasns listed abve; patients wh were nt asked the fllw-up cmfrt questin in accrdance with measure specificatins are cnsidered missing and shuld nt be included in Data Element 7. Page 23 f 29

24 Missing Data fr the Fllw-up Cmfrt Questin: Data Elements 5-7 A patient is cnsidered missing with respect t fllw-up cmfrt questin (Data Elements 5-7) if he/she: answered yes t the initial cmfrt questin, but was never asked the fllw-up questin; answered yes t the initial cmfrt questin, was asked the fllw-up cmfrt questin, but it was utside f the specified timeframe (either befre 48 hurs r after 11:59 PM f the 3 rd day); r answered yes t the initial cmfrt questin, was asked the fllw-up cmfrt questin, but the patient s yes/n respnse was nt recrded in the medical recrd. Missing data will nt be reprted t CMS. Thus, a patient wh is missing with respect t fllw-up cmfrt questin will nt be included in Data Elements 5, 6, r 7. A patient wh is missing with respect t fllw-up cmfrt questin data will be accunted fr in the seven Data Elements as fllws: Data Element 1: Patients wh are missing with respect t the fllw-up cmfrt questin will still be included in Data Element 1, ttal admissins. Data Elements 2-4: Patients wh are missing nly with respect t the fllwup questin are nt precluded frm being represented in initial cmfrt questin data (Data Elements 2-4). This means, even if a patient is nt included in Data Elements 5-7, he/she shuld still be accunted fr in initial cmfrt questin data elements (Data Element 2, 3, r 4). Data Elements 5-7: Patients wh are missing with respect t the fllw-up questin will nt be included in Data Elements 5-7. Example: Fllw-up Cmfrt Questin Missing Data: Fr Sunshine Hspice, Patient D was eligible fr the measure, answered yes t the initial cmfrt questin, and thus shuld have been tracked thrugh t fllw-up. Althugh the Patient D was asked the fllw-up cmfrt questin, it was utside the timeframe. This means fllw-up questin data is missing fr Patient D. Missing data is nt reprted t CMS. Thus, Patient D will nt be included in Data Elements 5-7. A patient wh is missing with respect t the fllwup cmfrt questin shuld still be included in initial cmfrt questin data; this means that Patient D will be included in Data Elements 2-4. Patient D shuld als still be included in Data Element 1, ttal number f admissins. Althugh Patient D is nt reprted t CMS in Data Elements 5-7, hspice prviders may wish t track missing data patients fr internal quality imprvement purpses. Data Element Summary Table: Data Element 5: Yes t Fllw-up Questin Data Element 6: N t Fllw-up Questin Data Element 7: Unable t Self- Reprt at Fllwup Fllw-up Questin Missing Data (nt reprted t CMS) 3 Patients: (F-H) 0 Patients 2 Patients (C, E) 1 Patient (D) Remember: patients wh are unable t self-reprt r are discharged prir t/at the time f fllw-up are nt cnsidered missing. These patients shuld be included in Data Element 7. Althugh missing data is nt reprted t CMS, hspice rganizatins are encuraged t recrd missing data fr internal quality imprvement prcesses. Hspices shuld aim t have n missing data. Page 24 f 29

25 NQF #0209 Measure Calculatin: Only the seven Data Elements shall be submitted t CMS fr the NQF #0209 Pain Measure. Hspice prviders will nt submit their actual NQF #0209 Pain Measure scre; hwever, yur scre will be autmatically calculated fr yu and displayed n the data entry site, based n the data yu enter. The NQF #0209 Pain Measure scre represents the percentage f patients wh were uncmfrtable because f pain at the initial assessment and had their pain brught t a cmfrtable level within 48 hurs f the initial assessment. Prviders may write dwn their facility-level scre fr use in internal quality imprvement initiatives. The NQF #0209 facility scre that will be displayed n the data entry site is calculated using the fllwing frmula: Example: Calculatin f the NQF #0209 measure scre is based nly n Data Elements 5 and 2; there are n exclusins fr this measure. This means that patients wh are unable t self-reprt at fllw-up remain in the measure denminatr. Numeratr: Number f patients wh replied yes when asked if their pain was brught t a cmfrtable level within 48 hurs f initial assessment (fllw-up questin) Data Element 5 Data Element 2 Denminatr: Patients wh replied yes when asked if they were uncmfrtable because f pain at the initial assessment (after admissin t hspice services) FAQ: Why are patients wh are unable t self-reprt at fllw-up nt excluded frm the measure? As per measure steward specificatins, all patients wh reprt being uncmfrtable because f pain n admissin remain in the denminatr fr the NQF #0209 measure, including thse wh are unable t self-reprt at fllw-up. This specificatin is designed t minimize patients "lst t fllw-up" by incentivizing hspices t make every effrt t fllwup with the patient. The number f patients wh are unable t self-reprt at fllw-up shuld be tracked carefully by hspices. This number is a reprtable data element and des prvide imprtant cntext in interpreting NQF #0209 measure scres fr perfrmance imprvement. NQF #0209 Measure Calculatin: Sunshine Hspice had 9 admissins fr the Data Cllectin perid (January 1 December 26, 2013). Their NQF #0209 scre is calculated as fllws: Data Element 5/ Data Element 2 r 3/6 = 50% Explanatin: The NQF #0209 Measure is calculated using nly tw f Data Elements Data Element 2 (number f patients wh answered yes t fllw-up cmfrt questin) and Data Element 5 (number f patients wh answered yes t initial cmfrt questin). Nne f the ther Data Elements are used in calculating the scre, but they d prvide imprtant cntextual infrmatin that is useful fr interpreting the scre. Even thugh there were tw patients unable t self-reprt at fllw-up, these patients are nt excluded frm measure calculatin and remain in the denminatr f the measure. Page 25 f 29