NQF

Agenda Synopsis

Full Agenda

Measure Index

• The Percent of Home Health Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Public comments received:1; MUC ID: MUC16-061)
  
  
• The Percent of Home Health Residents Experiencing One or More Falls with Major Injury (Public comments received:2; MUC ID: MUC16-063)
  
  
• The Percent of Residents or Home Health Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:1; MUC ID: MUC16-145)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:1; MUC ID: MUC16-347)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:2; MUC ID: MUC16-357)
  
  

• CAHPS Hospice Survey: Getting Emotional and Spiritual Support (Public comments received:1; MUC ID: MUC16-037)
  
  
• CAHPS Hospice Survey: Getting Help for Symptoms (Public comments received:2; MUC ID: MUC16-039)
  
  
• CAHPS Hospice Survey: Getting Hospice Care Training (Public comments received:1; MUC ID: MUC16-035)
  
  
• CAHPS Hospice Survey: Getting Timely Care (Public comments received:2; MUC ID: MUC16-036)
  
  
• CAHPS Hospice Survey: Hospice Team Communications (Public comments received:4; MUC ID: MUC16-032)
  
  
• CAHPS Hospice Survey: Rating of Hospice (Public comments received:3; MUC ID: MUC16-031)
  
  
• CAHPS Hospice Survey: Treating Family Member with Respect (Public comments received:2; MUC ID: MUC16-040)
  
  
• CAHPS Hospice Survey: Willingness to Recommend (Public comments received:1; MUC ID: MUC16-033)
  
  

• Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:3; MUC ID: MUC16-143)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:1; MUC ID: MUC16-319)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:2; MUC ID: MUC16-325)
  
  

• Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:1; MUC ID: MUC16-144)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:3; MUC ID: MUC16-321)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:3; MUC ID: MUC16-327)
  
  

• Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:1; MUC ID: MUC16-142)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:1; MUC ID: MUC16-314)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:1; MUC ID: MUC16-323)
  
  

Full Measure Information

Measure Specifications

• NQF Number (if applicable): 2631
  
  
• Description: This quality measure reports the percent of patients/residents with an admission and a discharge functional assessment and a treatment goal that addresses function. The treatment goal provides evidence that a care plan with a goal has been established for the patient/resident. (The endorsed specifications of the measure are: This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.)
  
  
• Numerator: The numerator for this quality measure is the number of patient/resident stays with functional assessment data for each self-care and mobility activity and at least one self-care or mobility goal. (The endorsed specifications of the measure are: The numerator for this quality measure is the number of Long-Term Care Hospital (LTCH) patients with complete functional assessment data and at least one self-care or mobility goal.For patients with a complete stay, all three of the following are required for the patient to be counted in the numerator: (1) a valid numeric score indicating the patient’s status or response, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the admission assessment; (2) a valid numeric score, which is a discharge goal indicating the patient’s expected level of independence, for at least one self-care or mobility item on the admission assessment; and (3) a valid numeric score indicating the patient’s status or response, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the discharge assessment.For patients who have an incomplete stay, discharge data are not required. The following are required for the patients who have an incomplete stay to be counted in the numerator: (1) a valid numeric score indicating the patient’s status or response, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the admission assessment; and (2) a valid numeric score, which is a discharge goal indicating the patient’s expected level of independence, for at least one self-care or mobility item on the admission assessment.Patients who have incomplete stays are defined as those patients (1) with incomplete stays due to a medical emergency, (2) who leave the LTCH against medical advice, or (3) who die while in the LTCH. Discharge functional status data are not required for these patients because these data may be difficult to collect at the time of the medical emergency, if the patient dies or if the patient leaves against medical advice.)
  
  
• Denominator: Home Health patients included in this measure are at least 18 years of age, and have complete episodes. (The endorsed specifications of the measure are: The denominator is the number of LTCH patients discharged during the targeted 12 month (i.e., 4 quarters) time period.)
  
  
• Exclusions: There are no denominator exclusion criteria for this measure.
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional Support for Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:In addition to satisfying a requirement of the IMPACT Act, this MUC promotes the importance of using standardized functional assessment items across PAC populations. Whether a patient is discharged to home or to another care setting for continuing healthcare, the patient’s functional status is an important aspect of a person’s health status to document at the time of the transition.
  • Impact on quality of care for patients:This quality measure offers the opportunity to inform providers about opportunities to improve care related to functional status and level of support needed and strengthen incentives for quality improvement. In addition, it should assist with improving care transitions and care coordination across settings of care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. Under the IMPACT ACT, home health providers are required to submit standardized patient assessment data and other necessary data specified by the Secretary to five quality domains, one of which is functional status, cognitive function, and changes in function and cognitive function.Although a few measures in the set currently assess outcomes related to functional status (e.g. improvement in management of oral medication, bathing), they are not comprehensive. This measure also adds the component of a care plan which has been identified as an important contribution to quality of care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. In a 2015 Consensus Development Process review, the Person and Family-Centered Care Standing Committee found sufficient evidence was presented to link this process measure to important function-related care outcomes, including improved strength, functional status, mobility, walking distance, and self-reported function. Other evidence linked the process to other care outcomes, including reduced delirium, readmissions, and length of stay. The measure reviewed by the PFCC Standing Committee was specific to the LTCH setting, however, the evidence submitted was broad enough to be applicable to multiple settings with a focus on critically ill patients.
  
  
• Does the measure address a quality challenge? Yes. This MUC is based on a similar measure endorsed for the long-term care hospital setting. In that measure submission, the rationale for the measure submission indicated: many patients have functional limitations and are at high risk for functional decline during the hospital stay; therefore, this measure addresses the assessment of functional status on admission and discharge and the inclusion of function in the patient’s care plan, as evidenced by a goal for at least one of the self-care or mobility function assessment items. At the time, the measure (NQF #2631) was new and performance gap data was unavailable. The importance of using standardized functional assessment items is supported by the high prevalence of therapy services provided in this setting, and the need for good care coordination. Whether an patient is discharged home or to another care setting for continuing healthcare, the patient’s functional status is an important aspect of a person’s health status to document at the time of the transition. This quality measure will inform applicable providers about opportunities to improve care in the area of function and strengthen incentives for quality improvement related to patient function.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This measure is an adaptation of a measure used in other PAC settings, and is intended to promote alignment and harmonization across PAC/LTC settings as required by the IMPACT Act.
  
  
• Can the measure can be feasibly reported? Yes. The measure can be entirely calculated using data from the Outcome and Assessment Information Set (OASIS), required for all home health agencies seeking Medicare certification. The feasibility of collecting information for component functional status items was established via the PAC PRD. Feasibility will be enhanced through more granular guidance informed by the second round of field testing. CMS intends to add the required items to the next version of the OASIS item set, which HHAs must complete for patients and episodes of care meeting statutorily-defined criteria..
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes . For the LTCH version of the masure, in a 2015 Consensus Development Process review, the Person and Family-Centered Care Standing Committee expressed concern over the absence of reliability and validity data for the component of the measure assessing the presence of a care plan that addressed function; however, they ultimately voted to pass the scientific acceptability criteria. Empirical testing was conducting in all post-acute care settings, including home health (HH), during the PAC PRD.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? No. The measure has only been in use in the Long-Term Care Hospital Reporting Program as of April 2016, and is not yet in use in the home health setting.The measure is not in current use, although similar items are currently used on the OASIS to document functional status. However, current OASIS items to assess functional status do not include the breadth of items incorporated in this measure, nor are these items standardized as mandated under the IMPACT Act. The function process measure under consideration complements existing HH outcome measures by combining several self-care and mobility skills into a single measure that will contribute to the overall goal of standardizing measures across the continuum of care.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Function
  
  
• IMPACT Act Domain addressed by the measure: Functional status, cognitive function, and changes in function and cognitive function
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
See literature for NQF# 2631 about the importance of the admission and discharge functional assessment and a care plan that addresses function among home health patients and developing interventions.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2015
  
  
• Project for Most Recent Endorsement Review: Person and Family Centered Care Project 2015
  
  
• Review for Importance: 1a. Evidence, 1b. Performance Gap, 1c. High Impact) 1a. Evidence: H-1; M-5; L-9; I-9; IE-3; 1b. Performance Gap: H-1; M-2; L-3; I-12; 1c. High Priority: H-0; M- 0; L-0; I-0 UPDATED VOTES FOR 1a. Evidence: H-4; M-10; L-1; I-0; IE-2; (pass) 1b. Performance Gap: H-2; M-8; L-3; I-4; (consensus not reached) 1c. High Priority: H-10; M-6; L-1; I-0 (pass) UPDATED VOTES FOR 1b. Performance Gap: H-4; M-11; L-2; I-1 Rationale: • This measure was not recommended initially in the January 21-22 Committee in-person meeting because it did not pass the importance criteria. However, the Committee conducted a subsequent review of this measure on the January 28 post-meeting call per the developer’s request. This time the measure passed the importance criteria in the gray zone based on the additional information that was presented by the developers. • The developer noted that this measure has two components, including: 1) the collection of standardized functional assessment data in the areas of self-care, mobility, cognition, and bladder management, and 2) the reporting, on admission, of a discharge goal (i.e., score) for one or more self-care or mobility items. • The Committee questioned whether the two components of documenting a functional status assessment on admission and a goal for function are linked together. The developer responded that the goal has to be tied to one of the self-care or mobility items. So if the person has a functional limitation in eating, rolling left or right, getting on and off the toilet, the clinicians have to report a goal for at least one of those items using the functional scale. • The Committee expressed concern that the only data presented to support the performance gap was qualitative data collected from site visits to 28 facilities and there were no quantitative data and data for a care plan gap. The developer stated that based on their understanding, qualitative data is sometimes adequate for a measure when it is first being proposed especially process measures that are directly tied to expert opinion in terms of validity and clinical practice guidelines. • The Committee also had concerns that this might be a hard measure to get a good grade on because there are three components to the numerator which the long-term care facilities have to comply with. The developer explained that all the items will be nested within the LTCH care data set and collected through a standardized assessment tool, which long-term hospitals are required to use. • Additional questions were raised regarding the assessment in setting a goal for the purpose of data collection versus holding the facility accountable for that goal. The developer explained that CMS is attempting to collect data to examine a change in independence on self-care and mobility and see if these items line up to a goal of care and then standardize data assessment across settings to follow persons as they traverse across care settings.
  
  
• Review for Scientific Acceptability: 2a. Reliability: H-0; M-0; L-0; I-0 2b. Validity: H-0; M-0; L-0; I-0 UPDATED VOTES FOR 2a. Reliability: H-0; M-7; L-5; I-5 (consensus not reached) 2b. Validity: H-0; M-7; L-4; I-6 (consensus not reached) UPDATED VOTES FOR 2a. Reliability: H-4; M-12; L-2; I-0 2b. Validity: H-2; M-14; L-2; I-0 Rationale: 101 • The Committee noted that there is a good evidence for reliability and validity of the care component and the functional status component, but there is no data regarding the care plan piece of the measure. The measure also lacks the inter-rater reliability data on the degree to which an appropriate goal is set. The developer responded that the “appropriate” in this argument may not essentially fit within this measure. This measure is just looking at the items for self-care and mobility and whether one of those items was documented on the goal of care at discharge. • One Committee member raised concerns about the face validity of the measure if documentation of functional status and a related goal is called a care plan. Another Committee member agreed that a goal is not equal to a care plan; however, she supported the idea of a measure that links current functional status and the goal for improvement and suggested the developer tweak the semantics for this measure. CMS will consider revising the measure title to address the Committee’s concerns. • One Committee member pointed out that there is no evidence of intraclass correlation coefficients that would suggest the signal to noise ratio which helps distinguish within facility variability from between facility variation and asked the developers whether they have the data to analyze that. The developer explained that they don’t have data to analyze facilities over time. As part of the post-acute payment reform demonstration, they had 28 LTCHs volunteered to use the standardized dataset to collect and enter data into an electronic system whereby provided the reliability and validity data.
  
  
• Review for Feasibility: 4. Feasibility: H-0; M-0; L-0; I-0UPDATED VOTES FOR Feasibility: H-4; M-12; L-1; I-0(4a. Clinical data generated during care delivery; 4b. Electronic sources; 4c.Susceptibility to inaccuracies/unintended consequences identified 4d. Data collection strategy can be implemented)Rationale:• All data elements are in defined fields in electronic clinical data and the functional assessmentitems included in this quality measure will be included in a future version of the LTCH CARE DataSet (Version 3.00). The LTCH CARE Data Set has been the assessment data set used in LTCHssince 2012, when the LTCH Quality Reporting Program was implemented, as required by thePatient Protection and Affordable Care Act.
  
  
• Review for Usability: 3. Use and Usability: H-0; M-0; L-0; I-0UPDATED VOTES FOR Use and Usability: H-2; M-12; L-3; I-0(Meaningful, understandable, and useful to the intended audiences for 3a. PublicReporting/Accountability and 3b. Quality Improvement)Rationale:• Data collection for this quality measure begins on April 1, 2016 as part of the Long-Term CareHospital Quality Reporting Program. Proposed plans for the public reporting of this qualitymeasure will be included in future rulemaking published in the Federal Register.• A Committee member raised a question regarding the possibility of non-response rate offacilities in terms of reporting this data. CMS explained that LTCHs that do not collect andsubmit data for this measure by the submission deadline may be subject to a two percentagepoint reduction in the annual payment update for fiscal year 2018 and subsequent years.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• No related or competing measures noted.
  
  
• Endorsement Public Comments: 6. Public and Member Comment: March 2, 2015- March 31, 2015 Comments received: • Two comments were received on this measure of which one supported the endorsement of this measure. The second commenter noted that this measure is an important topic within the PAC industry and has been subject to contentious discussions across NQF committees and raised concern about the NQF processes for re-consideration and re-voting. The commenter further noted that the MAP Committees have “Conditionally Supported” this measure for use within all PAC venues and recommended that the Committee take all PAC settings into consideration when reviewing this measure to identify whether it meets all of the criteria previously reviewed not just for LTCHs, but also for SNFs, IRFs, and Home Health agencies. NQF response: • We appreciate your input, but would note that this measure was re-discussed during the follow up call after the in-person meeting. During the meeting, the Committee requested additional information regarding the measure. The developers had already submitted this information; however, due to timing of receipt being just prior to the in-person meeting; the Committee did not have time to review it. Due to the fact the information was already available, NQF agreed to have the Committee re-discuss the measure during the post-meeting call rather than waiting until after the public comment period. Committee response: • This comment was addressed on the post-comment call. Consensus has not been reached on some of the required criteria, and additional information was requested. While the comments on expanding the settings for the measure’s use are appreciated, the Committee is charged with evaluating measures based on the information submitted and for the level of analysis and care setting as submitted by the developer. This measure was recommended by the Committee after reviewing the additional information and the comments. Developer response: • Thank you for your comment. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act directs the Secretary to specify quality measures on which PAC providers are required to submit standardized patient assessment data and other necessary data specified by the Secretary with respect to five quality domains, one of which is functional status, cognitive function, and changes in function and cognitive function. Following the enactment of the IMPACT Act, a technical expert panel (TEP) was convened by the Centers for Medicare and Medicare Services’ measure development contractor and provided input on implementing an application of this measure across four post-acute care settings, including IRFs, LTCHs, SNFs and HHAs. The TEP supported the implementation of this measure as specified across PAC providers and also supported our efforts to standardize this measure for cross-setting use. The Measures Application Partnership (MAP) met on February 9, 2015 and conditionally supported the specification of an application of Percent of LTCH Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631; under 103 review) for use as a cross-setting measure. MAP conditionally supported this measure pending NQF-endorsement and resolution of the use of two different functional status scales for quality reporting and payment purposes. MAP reiterated its support for adding measures addressing function, noting the group's special interest in this PAC/LTC core concept. More information about the MAPs recommendations for this measure is available at: http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.
  
  
• Endorsement Committee Recommendation: Standing Committee Recommendation for Endorsement: Y-9; N-8 (consensus not reached) UPDATED Y-15; N-3
  
  

Measure Specifications

• NQF Number (if applicable): 674
  
  
• Description: This quality measure reports the percentage of patients/residents who experience one or more falls with major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) during the Home Health episode. (The endorsed measure specifications are: This measure reports the percentage of residents who have experienced one or more falls with major injury during their episode of nursing home care ending in the target quarter (3-month period). Major injury is defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma. The measure is based on MDS 3.0 item J1900C, which indicates whether any falls that occurred were associated with major injury. Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.)
  
  
• Numerator: The numerator for this quality measure is the number of patients/residents who experienced one or more falls that resulted in major injury during the episode. (The endorsed measure specifications are: The numerator is the number of long-stay nursing home residents who experienced one or more falls that resulted in major injury (J1900C = 1 or 2) on one or more look-back scan assessments during their episode ending in the target quarter (assessments may be OBRA, PPS or discharge). In the MDS 3.0, major injury is defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma.)
  
  
• Denominator: Home Health patients included in this measure are at least 18 years of age, and have complete episodes. (The endorsed measure specifications are: The denominator is the total number of long-stay residents in the nursing facility who were assessed during the selected target quarter and who did not meet the exclusion criteria.)
  
  
• Exclusions: A patient/resident stay is excluded from the denominator if missing data precludes calculation of the measure. (The endorsed measure specifications are: Long-stay residents for whom data from J1800 (Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)) or J1900C (Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)) is missing on all qualifying assessments included in the look-back are excluded from this measure. Residents must be present for more 101 days or more in the facility to be included in long-stay measures. If the facility sample includes fewer than 30 residents, then the facility is excluded from public reporting because of small sample size.)
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional Support for Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Treating fall injuries is very costly. In 2015, costs for falls to Medicare alone totaled over $31 billion. Because the U.S. population is aging, both the number of falls and the costs to treat fall injuries are likely to rise. In addition to satisfying a requirement of the IMPACT Act, incorporating this measure into the Home Health Quality Reporting Program will measure a critical driver of patient safety and cost burden. Moreover, the measure aligns with other reporting programs that evaluate post-acute and long-term care settings. Falls are prevalent among community-dwelling older adults and a major source of morbidity and mortality. (source: http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html, accessed 11/21/2016)
  • Impact on quality of care for patients:The current population of older adults (i.e., greater than 65) in the United States is increasing rapidly due to medical advancements and longer life expectancies. Along with this increase in population, the incidence of fall-related injuries and hospitalizations is also rising. In adults over the age of 65, approximately 30% of individuals experience a fall annually (Avin et al., 2015). Using data from the Web-based Injury Statistics Query and Reporting System, a study conducted by Orces and Alamgir (2014) found that fall-related hospitalization rates among the same population were increasing as well by 4% per year. If this increase remains constant, the number of fall-related injuries may increase from 2.4 million in 2012 to 5.7 million by the year 2030 (Orces & Alamgir, 2014). A likely contributor to this rapid escalation is that the annual rate of falls increases by 50 percent among individuals who are over 80 years old—the fastest growing age segment of adults (Grundstrom, 2012; Orces, 2013). Falls during home health episodes that result in major injuries have not been widely studied in the Medicare population. Home health care services, however, are a growing medical trend due to the convenience and associated cost savings of receiving health care at home. The adoption of effective fall prevention interventions by home health agencies may therefore provide patients with more focused care and avoid preventable falls, resulting in lower overall costs to the Medicare program (Bamgbade & Dearmon, 2016).1.Avin, G. K., Hanke, A. T., Kirk-Sanche, N., McDonough, M. C., Shubert, E. T., Hardage, J., & Hartley, G. (2015). Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Physical Therapy, 95(6), 815–8342.Bamgbade, S., & Dearmon, V. (2016). Fall prevention for older adults receiving home healthcare. Home Healthcare Now, 34(2), 68-75. 3.Grundstrom, A. C., Guse, C. E., & Layde, P. M. (2012). Risk factors for falls and fall-related injuries in adults 85 years of age and older. Archives of Gerontology and Geriatrics, 54: 421-428.4.Orces, C. H. (2013). Emergency department visits for fall-related fractures among older adults in the USA: a retrospective cross-sectional analysis of the National Electronic Injury Surveillance System All Injury Program, 2001-2008. BMJ Open, 3:e001722. doi:10.1136/bmjopen-2012-0017225.Orces, C. H. & Alamgir, H. (2014). Trends in fall-related injuries among older adults treated in emergency departments in the USA. Injury Prevention, 20: 421-423.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. Under the IMPACT ACT, home health providers are required under the applicable reporting provisions to submit standardized patient assessment data and other necessary data specified by the Secretary to five quality domains, one of which is incidence of major falls.This is an outcome measure and beyond promoting alignment across PAC settings, offers the potential to assess if improvements in falls can be attributed to any particular setting of care. The Home Health Quality Reporting Program (HH QRP) includes a measure of whether ambulatory patients were assessed for fall risk; as an outcome measure, MUC16-63 is preferable.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The measure assesses the incidence of falls, an outcome that affects patient safety and presents a significant cost burden. In a 2015 Consensus Development Process review of this measure, albeit focused on the nursing home setting, the Patient Safety Standing Committee unanimously agreed the evidence presented was sufficient to pass the criteria. Evidence provided included: The Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons citation is: American Geriatrics Society, British Geriatrics Society. AGS/BGS clinical practice guideline: prevention of falls in older persons. New York (NY): American Geriatrics Society; 2010
  
  
• Does the measure address a quality challenge? Yes. A CMS analysis of 2015 OASIS data confirms the prevalence of injurious falls and falls risk among HH patients. In nearly 32% of the 5.3 million episodes with relevant data, the patient had a history of falls, defined as two or more falls, or any fall with an injury, in the previous 12 months. For the more than 6.1 million episodes where the patient received a multi-factor falls risk assessment using a standardized, validated assessment tool, the patient was found to have falls risk 93% of the time. There were nearly 100,000 instances documented where a patient required emergency care for an injury due to a fall. According to the CDC; each year, millions of older people—those 65 and older—fall. In fact, more than one out of four older people falls each year, but less than half tell their doctor.1 Falling once doubles your chances of falling again. In addition, direct medical costs include fees for hospital and nursing home care, doctors and other professional services, rehabilitation, community-based services, use of medical equipment, prescription drugs, and insurance processing. Direct costs do not account for the long-term effects of these injuries such as disability, dependence on others, lost time from work and household duties, and reduced quality of life. (source: http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html, accessed 11/21/2016)
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This measure is an adaptation of a measure used in other PAC settings, and is intended to promote alignment and harmonization across PAC/LTC settings as required by the IMPACT Act.
  
  
• Can the measure can be feasibly reported? Yes. The measure will be entirely calculated using data from the Outcome and Assessment Information Set (OASIS), required for all home health agencies seeking Medicare certification. It is based on an existing measure specification with no reported implementation challenges. Although the exact measure has not been implemented, similar data on injurious falls has been successfully collected by home health clinicians as part of the OASIS data collection. Implementation guidance for this specific measure is under development by CMS, on the basis of an ongoing field test. CMS intends to add the required items (standardized to meet the mandates of the IMPACT Act) to the next version of the OASIS item set, which HHAs must complete for patients and episodes of care meeting statutorily-defined criteria.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Although this measure is based on an endorsed measure, the specification for application to Home Health is new and testing is not complete, however, a comparable OASIS item on emergent care for injuries caused by a fall (currently M2310) was tested in 2008. There was near perfect agreement among participating clinicians, with a resulting unweighted kappa of 1.0 and a standard error of 0.134. In addition, the PAC PRD did test an item assessing the history of falls among PAC patients; the kappa for HHA clinicians was 0.874.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. Given the high morbidity burden of falls among older adults, this measure will complement current data on falls risk and emergent or inpatient care for injurious falls. As HH clinicians already assess and report on this important dimension of HH quality, CMS anticipates minimal implementation issues, which will be balanced by a standardized metric across the continuum of care. Additionally, current field testing efforts could inform future removal of OASIS items, to reduce burden..
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Safety/Falls
  
  
• IMPACT Act Domain addressed by the measure: Incidence of major falls
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Falls are prevalent among community-dwelling older adults and a major source of morbidity and mortality; see the literature for NQF #0674.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Patient Safety 2015
  
  
• Review for Importance: 1a. Evidence: 23-Y; 0-N; 1b. Performance Gap: 16-H; 7-M; 1-L; 0-I; Rationale: • The developers provided a summary of a systematic review and listed several processes of care associated with major falls with injury, including a multi-factor risk assessment, management programs, exercise interventions etc. • Approximately 75% of nursing facility residents fall at least once a year, a rate twice that of their community living counterparts, and this represents a significant cost burden both for the immediate treatment of the fall-related injury, as well as for the long-term increase in costs. • To demonstrate a gap in performance, the measure was tested using nationwide data from the Second Quarter of 2014. The average facility score was 3.2% (standard deviation 2.6%), with a median of 2.7%. The rate had decreased in comparison to previous years, but has been stable since the third quarter of 2013. • The Committee agreed that there was sufficient evidence to demonstrate that falls assessment, plans of care, and interventions are effective in reducing falls in nursing homes.
  
  
• Review for Scientific Acceptability: 2a. Reliability: 8-H; 15-M; 0-L; 0-I 2b. Validity: 12-H; 11-M; 0-L; 0-I 47 Rationale: • The measure captures variation across facilities. At least 10% of facilities had 6.6% of residents who had fallen with a major injury, a rate more than twice the facility average. • The measure is not risk adjusted, because by admitting the resident, the facility is assuming responsibility for them. • There were sufficient results for both reliability and validity; therefore the Committee thought that the scientific validity of this measure was adequate.
  
  
• Review for Feasibility: 3. Feasibility: 18-H; 6-M; 0-L; 0-I (3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c.Susceptibility to inaccuracies/ unintended consequences identified 3d. Data collection strategy can be implemented) Rationale: • It is a single question in the MDS and reporting via MDS is something nursing homes are required to do on a regular basis, therefore there were no concerns about feasibility.
  
  
• Review for Usability: 4. Use and Usability: 17-H; 7-M; 0-L; 0-I (Meaningful, understandable, and useful to the intended audiences for 4a. Public Reporting/Accountability and 4b. Quality Improvement) Rationale: • The measure is currently used in Nursing Home Compare and is publicly reported, so the Committee was not concerned about use and usability of this measure.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures • This measure is related to, but not competing with: o 141: Patient Fall Rate (ANA) o 202: Falls with Injury (ANA)
  
  
• Endorsement Public Comments: Comments were in support of endorsement.
  
  
• Endorsement Committee Recommendation: 23-Y; 1-N
  
  

Measure Specifications

• NQF Number (if applicable): 678
  
  
• Description: This quality measure reports the percent of Home Health patient episodes with Stage 2-4 or unstageable pressure ulcers that are new or worsened since Start of Care (SOC) or Resumption of Care (ROC). (The endorsed measure specifications are: This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments ofSkilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings. For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Part C) patients. In LTCHs, this measure includes all patients.)
  
  
• Numerator: The numerator is the number of episodes for which the OASIS assessment indicates one or more Stage 2-4 or unstageable pressure ulcer(s) that are new or worsened compared to the start or resumption of care. (The endorsed measure specifications are: SNF/NH Numerator: The numerator is the number of short-stay residents with an MDS assessment during the selected time window who have one or more Stage 2-4 pressure ulcer(s), that are new or worsened, based on examination of all assessments in a resident’s episode for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on prior assessment. LTCH Numerator: The numerator is the number of stays for which the discharge assessment indicates one or more new or worsened Stage 2-4 pressure ulcer(s) compared to the admission assessment.IRF Numerator: The numerator is the number of stays for which the IRF-PAI indicates one or more Stage 2-4 pressure ulcer(s) that are new or worsened at discharge compared to admission.)
  
  
• Denominator: The denominator is the number of patient episodes with both a start or resumption of care and end of care OASIS assessment, except those that meet the exclusion criteria. (The endorsed measure specifications are: SNF/NH Denominator: The denominator is the number of short-stay residents with one or more MDS assessments that are eligible for a look-back scan (except those with exclusions). Assessment types include: an admission, quarterly, annual, significant change/correction OBRA assessment; or a PPS 5-, 14-, 30-, 60-, or 90-day, or discharge with or without return anticipated; or SNF PPS Part A Discharge Assessment.LTCH Denominator: The denominator is the number of patient stays with both an admission and discharge LTCH CARE Data Set assessment, except those who meet the exclusion criteria.IRF Denominator: The denominator is the number of Medicare patient stays* (Part A and Part C) with an IRF-PAI assessment, except those who meet the exclusion criteria.*IRF-PAI data are submitted for Medicare patients (Part A and Part C) only.)
  
  
• Exclusions: 1. Patient episode is excluded if data on new or worsened Stage 2, 3, 4, and unstageable pressure ulcers are missing on the End of Care. 2. Patient episode is excluded if the patient died during the home health episode. 3. Patient episode is excluded if there is no SOC/ROC available to derive data for risk adjustment (covariates). (The endorsed measure specifications are: SNF/NH Denominator Exclusions:1. Short-stay residents are excluded if none of the assessments that are included in the look-back scan has a usable response for items indicating the presence of new or worsened Stage 2, 3, or 4 pressure ulcer(s) since the prior assessment. 2. Short-stay residents are excluded if there is no initial assessment available to derive data for risk adjustment (covariates).3. Death in facility tracking records are excluded from measure calculations. LTCH Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing on the planned or unplanned discharge assessment. 2. Patient stay is excluded if the patient died during the LTCH stay.3. Patient stay is excluded if there is no admission assessment available to derive data for risk adjustment (covariates).IRF Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing at discharge. 2. Patient stay is excluded if the patient died during the IRF stay.)
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support for Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). The measure offers the opportunity for monitoring of pressure ulcer incidence and prevelance and thus can identify where quality improvement efforts might be implemented or strengthened.
  • Impact on quality of care for patients:The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education. If pressure ulcers are identified and mitigated, there should be a resulting decrease in morbidity and mortality.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. Under the IMPACT ACT, PAC providers are required under the applicable reporting provisions to submit standardized patient assessment data and other necessary data specified by the Secretary to 5 quality domains, one of which is skin integrity and changes in skin integrity.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is an outcome measure supported by the following guideline: The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education.
  
  
• Does the measure address a quality challenge? Yes. As described in the FY 2012 IRF PPSfinal rule (76 FR 47876 through 47878),pressure ulcers are high-cost adverseevents and are an important measure ofquality. Pressure ulcer incidence rates vary considerably by clinical setting, ranging from 0.4% to 38% in acute care, 2.2% to 23.9% in (SNFs and NHs, and 0% to 17% in home care (AHRQ, 2009; IHI, 2007). A study evaluating 2009 Medicare FFS claims data from post-acute care facilities found 2,342 secondary diagnosis claims of Stage 3 or 4 pressure ulcers in IRFs.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This measure is an adaptation of a measure used in other PAC settings, and is intended to promote alignment and harmonization across PAC/LTC settings as required by the IMPACT Act.
  
  
• Can the measure can be feasibly reported? Yes. The data required for reporting the measure is collected through the IRF-PAI.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Although this measure is an adaptation of an endorsed measure (#0678), material changes to the measure have been made since the last endorsement evaluation. CMS indicates: The numerator of this measure has been updated to include new unstageable pressure ulcers, in addition to new or worsened Stage 2-4 pressure ulcers. While since waiting for the appropriate NQF endorsement project to become available, the measure developer has worked to revise and improve the measure to include new unstageable pressure ulcers in the measure numerator, based on TEP feedback and public comment. These revisions are viewed as improvements to the measure, as unstageable pressure ulcers are usually preventable and pose a serious patient safety issue. Also, adding new unstageable pressure ulcers increases variability of the measure scores, thereby improving the ability to discriminate among poor- and high-performing facilities. CMS has submitted additional testing information confirming the measure is reliable in the home health setting (kappa=.889).
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The measure is in current use, and CMS noted: A possible unintended consequence is that there could be reduced access to care for patients who are expected to be at higher risk for pressure ulcers. We apply several exclusion criteria and risk adjust this measure in order to address this concern.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Safety/Pressure Ulcers
  
  
• IMPACT Act Domain addressed by the measure: Skin integrity and changes in skin integrity
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2011
  
  
• Project for Most Recent Endorsement Review: Nursing Home Measures 2010
  
  
• Review for Importance: N/A
  
  
• Review for Scientific Acceptability: N/A
  
  
• Review for Feasibility: N/A
  
  
• Review for Usability: N/A
  
  
• Review for Related and Competing Measures: N/A
  
  
• Endorsement Public Comments: N/A
  
  
• Endorsement Committee Recommendation: The Committee agreed this is a well-specified and important measure that addresses an area of care where there is room for improvement. Despite the overall strength of the measure, the Committee discussed a few weaknesses: • lack of harmonization with pressure ulcer measures for other care settings; • seasonal variation is not considered in the measure specifications; and • lack of attention to other factors that may influence the development of pressure ulcers, including the patient’s level of skin moisture or nutrition, as well as the use of lifting devices and levels of nurse staffing. The developer will consider these issues during measure testing. One Committee member raised the concern that the MDS coding requirement, as used by CMS, conflicts with recommendations of relevant expert groups. The CMS definition of a deep tissue injury (DTI) wound differs from the definition used by the National Pressure Ulcer Advisory Panel. The Committee voted to recommend this measure for time-limited endorsement. 20 National Quality Forum There were multiple comments about this measure, primarily focused on two issues: that the measure does not allow a realistic amount of time for pressure ulcers to heal, and that combining new pressure ulcers and pressure ulcers that fail to improve is confusing and does not reflect the true quality of care in a facility. After extensive discussion, the Committee agreed to a title change that reflects MDS 3.0 item M0800, “Worsening in pressure ulcer status since prior assessment (OBRA, PPS, or Discharge),” and that also reflects the lack of evidence about the degree to which pressure ulcers can improve during a short time. The new title is 678: Percent of residents with pressure ulcers that are new or worsened (short stay). This measure meets the National Priority of Safety
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the previous provider/setting at admission or the start/resumption of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the subsequent provider/setting.
  
  
• Numerator: The numerator for the admission measure is the number of patient/resident stays/episodes with an admission assessment indicating that health information and/or care preferences were received at admission, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for the admission measure is the number of Medicare (Part A and Part C) and Medicaid home health quality episodes.
  
  
• Exclusions: Patient was not under the care of another provider immediately prior to this Admission/SOC/ROC.
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC admission is part of a paired set of measures that assess transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the PAC provider to the subsequent provider/provider at discharge or end of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the next.
  
  
• Numerator: The numerator for the discharge measure is the number of patient/resident stays with a discharge assessment indicating that health information and/or care preferences were provided to the next provider or agency at discharge, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for this measure is the number of Medicare (Part A and Part C) and Medicaid home health quality episodes. The receiving/admitting provider will be another PAC, a hospital or a critical access hospital, or, for home and community-setting patients, a physician(s) (e.g., primary care provider, family physician, specialist).
  
  
• Exclusions: Expired patients. The agency was not made aware of this transfer timely and therefore was unable to transfer health information to the receiving facility
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC discharge is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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?” (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A.)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• 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 P3). (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | 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).) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | -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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on how patients and family caregivers perceive their emotional and spiritual needs to have been met allows hospices to evaluate their progress on this dimension of care unique to the setting. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. This item from the CAHPS Hospice Survey assesses how well hospices are meeting the emotional and spiritual needs of patients and family caregivers. Assessing patient and family caregiver experience is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).The multiple survey items that correspond to the individual measure under consideration, ‘getting emotional and spiritual support’, assess effectiveness of hospices at meeting a critical component of palliative and end-of-life care. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 91.8, with an interquartile range of 88.8-96.4. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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?” (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• 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 P4). (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | 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).) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | -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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on how patients and family caregivers rate the outcome of addressing symptoms such as pain allows hospice to evaluate the effectiveness of their care. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregiver experience. Assessing patient and family caregivers is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).The multi-item measure that corresponds to the individual measure under consideration, ‘getting help with symptoms’, is a critical component of effective care delivery. Survey questions include whether care recipients, when needed, received help with breathing, pain, constipation, or anxiety and sadness. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 75.7, with an interquartile range of 69.3-83.2. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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? (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• 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 P5). (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | 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).) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | -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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on how family caregivers are trained to administer care allows hospices to evaluate their effectiveness beyond their direct care work. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregivers. Assessing patient and family caregiver experience is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).This multi-item measure assesses whether family members are ‘getting hospice care training’ by asking whether the caregiver received training on managing side effects, pain medicine, trouble breathing, and restlessness or agitation. Hospice care training is critical for family caregivers who need support to be effective in their role. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 72.7, with an interquartile range of 65.5-81.0. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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?” (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• 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 or P2). (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | 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).) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item.)
  
  
• 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | 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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on timeliness of care administration allows hospices to evaluate their effectiveness at meeting patient and family caregiver needs and expectations. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregivers. Assessing patient and family caregiver experience is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).This multi-item measures whether hospice patients were ‘getting timely care’ by asking how often care recipients received help when requested, and help when requested on weekends and holidays. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 77.4, with an interquartile range of 70.7-85.3. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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?" (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• 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). (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | 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).) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | 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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on how hospice staff communicate with patients and family caregivers allows hospices to evaluate their approach to patient care. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregivers. Assessing patient and family caregiver experience is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).This is a multi-item measure that assesses ‘hospice team communications’ through asking how staff kept caregivers informed, explained things, listened, and whether they gave confusing information. Communication skills are a critical component of understanding the effectiveness of hospice staff. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 82.0, with an interquartile range of 77.0-87.7. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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 (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A.)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• Denominator: The top box denominator is the total number of respondents in the hospice who answered the item. (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | The top box denominator is the total number of respondents in the hospice who answered the item.) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | -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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on how patients and family caregivers rate their experience with care allows hospices to gain a holistic sense of their performance. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregivers. Assessing patient and family caregiver experience is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).The survey item that corresponds to the individual measure under consideration, ‘rating of hospice’, is a critical component of understanding patient and family care preferences. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care. This approach can assist with identifying specific opportunities for improvement.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 84.0, with an interquartile range of 78.0-91.4. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• 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? (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A.)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• 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 or P2). (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | 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).) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | -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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on whether family caregivers felt they were treated with respect allows hospices to evaluate whether they are effectively engaging family caregivers as partners in care. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregiver experience. Assessing patient and family caregivers is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).The multi-item measure that corresponds to the individual measure under consideration, ‘treating family member with respect’, is a critical component of understanding whether family caregivers are engaged as partners in care. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 91.4, with an interquartile range of 88.0-96.3. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 2651
  
  
• Description: Individual survey item asking respondents: “Would you recommend this hospice to your friends and family?” (The endorsed specifications of the measure are: The measures submitted here are derived from the CAHPS® Hospice Survey, which is a 47-item standardized questionnaire and data collection methodology. The survey is intended to measure the experiences of hospice patients and their primary caregivers.The measures proposed here include the following six multi-item measures.•Hospice Team Communication•Getting Timely Care•Treating Family Member with Respect•Getting Emotional and Religious Support•Getting Help for Symptoms•Getting Hospice TrainingIn addition, there are two other measures, also called “global ratings.”•Rating of the hospice care•Willingness to recommend the hospiceBelow we list each multi-item measure and its constituent items, along with the two ratings questions. Then we briefly provide some general background information about CAHPS surveys.List of CAHPS Hospice Survey MeasuresMulti-Item MeasuresHospice Team Communication (Composed of 6 items)+While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member?+While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?+How often did the hospice team listen carefully to you when you talked with them about problems with your family member’s hospice care?+While your family member was in hospice care, how often did the hospice team keep you informed about your family member’s condition?+While your family member was in hospice care, how often did the hospice team listen carefully to you?+While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member’s condition or care?Getting Timely Care (Composed of 2 items)+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?+How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating Family Member with Respect (Composed of 2 items)+While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect?+While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member?Providing Emotional Support (Composed of 3 items)+While your family member was in hospice care, how much emotional support did you get from the hospice team? +In the weeks after your family member died, how much emotional support did you get from the hospice team? +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?Getting Help for Symptoms (Composed of 4 items)+Did your family member get as much help with pain as he or she needed?+How often did your family member get the help he or she needed for trouble breathing? +How often did your family member get the help he or she needed for trouble with constipation?+How often did your family member receive the help he or she needed from the hospice team for feelings of anxiety or sadness?Getting Hospice Care Training (Composed of 5 items)+Did the hospice team give you enough training about what side effects to watch for from pain medicine? +Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member?+Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing?+Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? +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?Rating Measures:In addition to the multi-item measures, there are two “global” ratings measures. These single-item measures indicate on the one hand the need for quality improvement and on the other hand provide families and patients looking for care with evaluations of the care provided by the hospice. The items are rating of hospice care and willingness to recommend the hospice.+Rating of Hospice Care: 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?+Willingness to Recommend Hospice: Would you recommend this hospice to your friends and family?The CAHPS Hospice Survey is a standardized survey instrument designed to collect reports and ratings of experiences with hospice care. The survey is completed by the primary caregiver of the patient who died while receiving hospice care (hereafter, “decedent”). The primary caregiver is intended to be the family member or friend most knowledgeable about the decedent’s hospice care, and is identified through hospice administrative records. Data collection for sampled decedents/caregivers is initiated two months following the month of the decedent’s death.The CAHPS Hospice Survey is part of the CAHPS family of experience of care surveys and is available in the public domain at https://cahps.ahrq.gov/surveys-guidance/hospice/index.html. CMS initiated national implementation of the CAHPS Hospice Survey in 2015. Hospices meeting CMS eligibility criteria were required to administer the survey for a “dry run” for at least one month of sample from the first quarter of 2015. Beginning with the second quarter of 2015, hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS. Information regarding survey content and national implementation requirements, including the latest versions of the survey instrument and standardized protocols for data collection and submission, are available at: http://www.hospicecahpssurvey.org/.A list of the CAHPS Hospice Survey measures, including the components of the multi-item measures can be found in Appendix A.)
  
  
• Numerator: 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. (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below. | 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.) (The endorsed specifications of the measure are: CMS calculates CAHPS Hospice Survey measures using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. Details regarding the definition of most positive response are noted in Section S.6 below.)
  
  
• Denominator: The top box denominator is the total number of respondents in the hospice that answered the item. (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each item. | The top box denominator is the total number of respondents in the hospice that answered the item.) (The endorsed specifications of the measure are: The measure’s denominator is the number of survey respondents who answered the item. The target population for the survey is primary caregivers of hospice decedents. The survey uses screener questions to identify respondents eligible to respond to subsequent items. Therefore, denominators will vary by survey item (and corresponding multi-item measures, if applicable) according to the eligibility of respondents for each 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 (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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 | -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 ) (The endorsed specifications of the measure are: The exclusions noted in here are those who are ineligible to participate in the survey. The one exception is caregivers who report on the survey that they “never” oversaw or took part in the decedent’s care; these respondents are instructed to complete the “About You” and “About Your Family Member” sections of the survey only. Cases are excluded from the survey target population if:•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)
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Survey
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Although the CAHPS Hospice Survey is currently incorporated in the Hospice Quality Reporting Program, this measure allows greater precision in performance evaluation by breaking out an individual survey item into a performance measure. Eight new performance measures are proposed to add to the aggregate Hospice CAHPS measure. In addition, inclusion of the CAHPS Hospice metrics supports the National Quality Strategy and goals of the Affordable Care Act for greater focus on person and family centered care.
  • Impact on quality of care for patients:Measuring performance on whether patients and family caregivers would recommend the hospice allows facilities to gain a holistic sense of their performance. While the existing measure set includes assessments of symptom management and respect for treatment preferences, many other aspects of hospice care exist that are not captured by individual measures. The CAHPS Hospice measures support the National Quality Aim for Better Care, and the Priority of ensuring that each person and family is engaged as partners in their care.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The CAHPS Hospice Survey assesses how well hospices are meeting the self-reported preferences of patients and family caregivers. Assessing patient and family caregiver experience is consistent with the NQF Framework and Preferred Practices for Palliative and Hospice Care Quality (2009).The survey item that corresponds to the individual measure under consideration, ‘willingness to recommend’, is a critical component of understanding patient and family care experience of care. Although a performance measure based on the Hospice CAHPS survey is already included in the program, splitting the aggregate measure into eight performance measures that track with individual survey questions permits discrete evaluation of aspects of patient-reported satisfaction with hospice care.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is a patient-reported outcome performance measure (PRO-PM), with the “primary informal caregiver of the decendant” completing the survey. The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models.
  
  
• Does the measure address a quality challenge? Yes. Mean reported score on the performance measure is 84.9, with an interquartile range of 79.3-92.7. These performance scores indicate most hospices have an opportunity to improve care.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. No other patient-reported outcomes or patient satisfaction measures are included in the Hospice Quality Reporting Program, other than the aggregate Hospice CAHPS survey measure. This measure will offer additional information on a discrete aspect of care important to patients and caregivers.
  
  
• Can the measure can be feasibly reported? Yes. Data was collected for the measure at 2,512 hospices in the second quarter of 2015, with no unintended consequences cited.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Both the Palliative and End-of-Life Care Standing Committee and the Consensus Standards Approval Committee have voted to endorse the measure, affirming the reliability and validity of the measure for the hospice setting.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The Palliative and End-of-Life Care Standing Committee noted that receiving the survey may be upsetting to the decedent’s caregiver; however, the Committee affirmed that the value of the survey outweighs this potential consequence, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.
  
  
• PAC/LTC core competency addressed by the measure: Experience of Care
  
  
• IMPACT Act Domain addressed by the measure: N/A
  
  
• Hospice High Priority Area addressed by the measure: Experience of Care
  
  

Rationale for measure provided by HHS
The CAHPS Hospice Survey assesses key processes of care identified as critical to high quality hospice care by existing guidelines and conceptual models, including National Hospice and Palliative Care Organization standards of practice for hospice programs and the National Quality Forum Preferred Practices of Palliative and Hospice Care (Teno et al. 2001; Stewart et al. 1999; NQF 2006; NHPCO). Informal caregivers of hospice decedents are the best and only source of information for these measures. Survey measure content was developed based on responses to a call for topic areas in the Federal Register, a technical expert panel, an environmental scan of existing surveys for assessing experiences of end-of-life care, interviews with caregivers, as well as cognitive testing and a field test of draft survey instruments. A description of the development of the CAHPS Hospice Survey is available at: http://www.hospicecahpssurvey.org/globalassets/hospice-cahps3/home-page/hospice_field_test_report_2014.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2016
  
  
• Project for Most Recent Endorsement Review: Palliative and End-of-Life Care Project 2015-2016
  
  
• Review for Importance: 1a. Evidence: Pass-23; No Pass-0; 1b. Performance Gap: H-6; M-17; L-0; I-0; Rationale:• As evidence for this measure, the developer provided a table linking multiple processes or structures of care to the outcomes captured in the 8 measures that are derived from the Hospice CAHPS survey. The developer also summarized results from focus groups and individual interviews with family members of hospice decedents who reviewed the Survey and supported its contents.• The Committee agreed the evidence presented met NQF’s requirements for patient-reported outcome measures and passed all eight measures on the evidence criterion.• The developer provided performance data from 2,512 hospice agencies serving at least 50 patients in second quarter of FY 2015. Mean measures scores ranged from 72.1 (Standard Deviation (SD) =12.8) for “Getting hospice care training” to 91.8 (SD=6.5) for “Getting emotional and religious support”. • The developers presented data from the first half of 2015 showing variations in the PRO-PM results by race, suggesting potential disparities in care, and noted cited several studies that have also found disparities in hospice care. • The Committee agreed that variation in agency scores for each measure indicates a performance gap exists. Members also noted that the disparities data were particularly compelling, given the direction of the identified disparities varies across the measures.
  
  
• Review for Scientific Acceptability: 2a. Reliability: Two measures pulled out for separate voting:• Hospice team communication; getting timely care; Getting emotional and religious support; Getting hospice training; Rating of the hospice care; Willingness to recommend the hospice-H-1; M-20; L-2; I-0 • Treating family member with respect)-H-0; M-10; L-10; I-2 (Consensus not reached)• Getting help for symptoms-H-0; M-14; L-7; I-2 2b. Validity: H-6; M-14; L-3; I-0Rationale: • One member voiced concern about use of the “top-box” scoring approach, suggesting that it is too stringent, as some people never respond with the most positive answer on a survey. This member suggested that with this scoring approach, the results may not accurately reflect the quality of care provided. The developers’ rationale for using top-box scoring was that (1) their testing showed that this scoring approach was the most easily understood and meaningful to consumers and (2) compared to a linear mean scoring approach, the ability to distinguish between providers is better when the top-box approach is used.• Some Committee members expressed concern about combining emotional and religious items for the “Getting emotional and religious support” measure, seeing them as distinct concepts. The developer noted that in their testing of the survey instrument, including all three items into this domain improved the Cronbach’s alpha reliability result. • The Committee asked why of hospice agencies that have fewer than 50 decedents per year are exempted from fielding the Hospice CAHPS survey. The developers stated that the cost of the survey may be prohibitive for very small agencies. They also noted that because the response rate is relatively low, very small agencies may not have enough respondents to achieve reliable results on the measures. The developers also clarified that there are no payment penalties for small hospice agencies that do not field the survey. • Another Committee member asked about the exclusion due to language barriers. The developers noted that the Hospice CAHPS survey is available in English, Spanish, two versions of Chinese, Vietnamese, Portuguese, and Russian, and that additional languages would be added over time. • Reliability testing of the Hospice CAHPS survey (i.e., data element testing) included examination of the internal consistency of the multi-item measures using Cronbach’s alpha and the item-total correlation using Pearson’s correlation for the multi-item and single-item measures. Cronbach’s alpha results ranged from 0.60 to 0.86. • Measure score reliability was calculated using 1) intra-class correlations (ICCs) computed from the case mix-adjusted 0-100 top-box scores and 2) estimating reliability via the Spearman-Brown prophecy formula assuming 200 surveys were completed in each agency. ICC values ranged from 0.008 to 0.017, and the estimated reliability from the Spearman-Brown prophecy formula ranged from 0.61 to 0.78.• Because the estimated reliability estimates were relatively lower for the “Treating family member with respect” and “Getting help for symptoms” measures, the Committee asked to vote on those separately. The Committee did not reach consensus on the reliability subcriterion for the “Treating family member with respect” measure; however, the remaining seven measures passed the reliability subcriterion. • Validity testing of the measure score included examination of the relationship of agency-level results from the 6 multi-item measures to the agency-level results of the global rating and willingness to recommend measures via linear regression analysis and examination of the Pearson correlations between the agency-level multi-item measures to assess the magnitude of association. Results indicated all relationships were statistically significant and in the expected direction.• All 8 of the PRO-PMs are case-mix adjusted for 9 factors: (1) response percentile; (2) decedent age group; (3) payer; (4) primary diagnosis; (5) length of final hospice episode; (6) respondent age group; (7) respondent education;(8) decedent’s relationship to respondent; and(9) a variable indicating survey language and respondent’s home language. One member noted that low literacy and low socio-economic status might also affect response rate.• The Committee questioned the developer about potential threats to validity related non-response bias, the developers stated that response bias is difficult to assess directly, but surveys of varying lengths were used during field testing, but this had no effect on response rates. The developers also noted that the measure results are adjusted for mode of administration, because mode affects response rates. Specifically, the mail-only mode is the least expensive but has lower response rates. Higher response rates are possible with the mixed mode of administration (mail with telephone follow-up, but this is the most expensive option.• One Committee member also asked if the developers can be sure that the performance results from caregivers of decedents who resided in a nursing home reflect the quality of care provided by the hospice rather than the quality of care provided by the nursing home. The developers stated that they ask specific questions on the survey to try to ascertain whether information provided by the hospice team differed from that given by nursing home staff and whether the hospice team and nursing home staff worked well together.
  
  
• Review for Feasibility: 3. Feasibility: H-0; M-17; L-6; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Data collection strategy can be implemented)Rationale: • The Committee questioned the developer as to whether feasibility of the measures varied by the mode administration (mail only, phone only, or mixed mode) or respondents’ level of health literacy. The developer again noted that the responses are adjusted for mode of administration. With respect to health literacy, they developers stated that they were not certain as to the current reading level of survey, but believe it to be around at 10th grade reading level.• The Committed voiced concern regarding the impact of cost on smaller hospice agencies’ ability to participate in the survey. Committee members noted that agencies are required to contract with specific survey vendors and devote additional resources (e.g., staff time) to participate. The Committee asked the developer whether the Centers for Medicare and Medicaid considered provided monetary support to smaller agencies to enable their participation. The developers acknowledged the additional hospice agency resources required to conduct the survey, but stated they were not aware of any plans for offering monetary support to smaller hospice agencies.
  
  
• Review for Usability: 4. Usability and Use: H-8; M-13; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement; and 4c. Benefits outweigh evidence of unintended consequences) Rationale:• The measures are currently included in the Hospice Quality Reporting Program (HQRP). The Committee discussed the exclusion of small hospice agencies (i.e., those with less than 50 decedents per year) from reporting to the HQRP and that this is a potential limitation to the measures’ usability and use. • The Committee discussed a potential unintended consequence of the measures in that receiving the survey may be upsetting to the decedent’s caregiver. The Committee agreed this may happen, but the benefits of the measures outweigh this undesirable effect, particularly if a hospice agency provides bereavement support to individuals who report upset at the survey.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• These measures compete with two other patient-reported outcome measures: o 0208: Family Evaluation of Hospice Care.? The result of the Family Evaluation of Hospice Care (FEHC) measure (#0208) is a single score that indicates a hospice agency’s overall performance on symptom management, communication, provision of information, emotional support, and care coordination. Note that only hospice agencies exempt from the Hospice CAHPS survey (i.e., <50 decedents per year) utilize the FEHC.o 1623: Bereaved Family Survey? The result of the Bereaved Family Survey measure (#1623) is a single score that indicates the family’s perceptions of the quality of care that veterans received from the VA during the last month of life; aspects of care included in the measure are communication, emotional and spiritual support, pain management, and personal care needs. • Although these measures are competing, they are targeted to different groups of hospice patients and their families (i.e., those served by small agencies and those in the VA). Also, as these two measures were recently evaluated by another Standing Committee, NQF staff did not ask the Committee to choose a superior measure or discuss potential areas of harmonization.
  
  
• Endorsement Public Comments: Comments received:• NQF received 3 post-evaluation comments the 8 PRO-PMs under NQF #2651, all of which were supportive of the measures.• NQF also sought feedback on the measure from the Person- and Family-Centered Care Standing Committee, as this Committee has extensive experience in evaluating PRO-PMs from CAHPS surveys and other PRO-PM/instrument-based measures. One of the PFCC Committee members expressed concern with the low ICC values for all of the measures. Developer response regarding the Treating Family Member with Respect measure: • To address the Committee’s lack of consensus on reliability, the developer updated the reliability estimates for all 8 PRO-PMs based on data from April-September, 2015. The addition of an extra three months of data resulted in increased reliability estimates for 7 or the 8 PRO-PMs. For the “Treating family member with respect” measure, the estimate increased from 0.61 to 0.68).• To address the concern regarding the low ICC values, the developer cited Lyratzopoulos et al. (2011), who suggested benchmarks such that ICCs less than 0.01 are labeled “Low” and ICCs greater than 0.10 are labeled “High.” Lyratzopoulos, et al. also states that the ICC can be interpreted as the reliability of the quality measure with a sample size = 1 respondent per hospice. The developers therefore applied the Spearman-Brown prophecy formula to estimate the reliability assuming 200 respondents per hospice (with estimates for the 8 measures ranging from 0.66 to 0.81, based on the April-September, 2015 data).Committee response:• After discussion, the Committee re-voted on the Reliability subcritierion. Upon revote, the Committee agreed that the developer had demonstrated adequate reliability for the Treating Family Member with Respect measure, based on April-September, 2015 data .Vote Following Consideration of Public and Member Comments: Reliability: H-0; M-17; L-1; I-0Standing Committee Overall Recommendation for Endorsement: Y-18; N-0
  
  
• Endorsement Committee Recommendation: Y-22; N-1
  
  

Measure Specifications

• NQF Number (if applicable): 678
  
  
• Description: This quality measure reports the percent of IRF patient stays with Stage 2-4 or unstageable pressure ulcers that are new or worsened since admission (The endorsed measure specifications are: This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments ofSkilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings. For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Part C) patients. In LTCHs, this measure includes all patients.)
  
  
• Numerator: IRF Numerator: The numerator is the number of stays for which the IRF-PAI discharge assessment indicates one or more Stage 2-4 or unstageable pressure ulcer(s) that are new or worsened compared to the admission assessment. (The endorsed measure specifications are: SNF/NH Numerator: The numerator is the number of short-stay residents with an MDS assessment during the selected time window who have one or more Stage 2-4 pressure ulcer(s), that are new or worsened, based on examination of all assessments in a resident’s episode for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on prior assessment. LTCH Numerator: The numerator is the number of stays for which the discharge assessment indicates one or more new or worsened Stage 2-4 pressure ulcer(s) compared to the admission assessment.IRF Numerator: The numerator is the number of stays for which the IRF-PAI indicates one or more Stage 2-4 pressure ulcer(s) that are new or worsened at discharge compared to admission.)
  
  
• Denominator: IRF Denominator: The denominator is the number of Medicare patient stays* (Part A and Part C) with an IRF-PAI assessment, except those that meet the exclusion criteria. *IRF-PAI data are submitted for Medicare patients (Part A and Part C) only. (The endorsed measure specifications are: SNF/NH Denominator: The denominator is the number of short-stay residents with one or more MDS assessments that are eligible for a look-back scan (except those with exclusions). Assessment types include: an admission, quarterly, annual, significant change/correction OBRA assessment; or a PPS 5-, 14-, 30-, 60-, or 90-day, or discharge with or without return anticipated; or SNF PPS Part A Discharge Assessment.LTCH Denominator: The denominator is the number of patient stays with both an admission and discharge LTCH CARE Data Set assessment, except those who meet the exclusion criteria.IRF Denominator: The denominator is the number of Medicare patient stays* (Part A and Part C) with an IRF-PAI assessment, except those who meet the exclusion criteria.*IRF-PAI data are submitted for Medicare patients (Part A and Part C) only.)
  
  
• Exclusions: IRF Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, 4, and unstageable pressure ulcers are missing at discharge. 2. Patient stay is excluded if the patient died during the IRF stay. (The endorsed measure specifications are: SNF/NH Denominator Exclusions:1. Short-stay residents are excluded if none of the assessments that are included in the look-back scan has a usable response for items indicating the presence of new or worsened Stage 2, 3, or 4 pressure ulcer(s) since the prior assessment. 2. Short-stay residents are excluded if there is no initial assessment available to derive data for risk adjustment (covariates).3. Death in facility tracking records are excluded from measure calculations. LTCH Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing on the planned or unplanned discharge assessment. 2. Patient stay is excluded if the patient died during the LTCH stay.3. Patient stay is excluded if there is no admission assessment available to derive data for risk adjustment (covariates).IRF Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing at discharge. 2. Patient stay is excluded if the patient died during the IRF stay.)
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: IRF-PAI
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support for Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). The measure offers the opportunity for monitoring of pressure ulcer incidence and prevelance and thus can identify where quality improvement efforts might be implemented or strengthened.
  • Impact on quality of care for patients:The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education. If pressure ulcers are identified and mitigated, there should be a resulting decrease in morbidity and mortality.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. Under the IMPACT ACT, PAC providers are required under the applicable reporting provisions to submit standardized patient assessment data and other necessary data specified by the Secretary to 5 quality domains, one of which is skin integrity and changes in skin integrity.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is an outcome measure supported by the following guideline: The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education.
  
  
• Does the measure address a quality challenge? Yes. As described in the FY 2012 IRF PPSfinal rule (76 FR 47876 through 47878),pressure ulcers are high-cost adverseevents and are an important measure ofquality. Pressure ulcer incidence rates vary considerably by clinical setting, ranging from 0.4% to 38% in acute care, 2.2% to 23.9% in (SNFs and NHs, and 0% to 17% in home care (AHRQ, 2009; IHI, 2007). A study evaluating 2009 Medicare FFS claims data from post-acute care facilities found 2,342 secondary diagnosis claims of Stage 3 or 4 pressure ulcers in IRFs.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This measure is an adaptation of a measure used in other PAC settings, and is intended to promote alignment and harmonization across PAC/LTC settings as required by the IMPACT Act.
  
  
• Can the measure can be feasibly reported? Yes. The data required for reporting the measure is collected through the IRF-PAI.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Although this measure is an adaptation of an endorsed measure (#0678), material changes to the measure have been made since the last endorsement evaluation. CMS indicates: The numerator of this measure has been updated to include new unstageable pressure ulcers, in addition to new or worsened Stage 2-4 pressure ulcers. While since waiting for the appropriate NQF endorsement project to become available, the measure developer has worked to revise and improve the measure to include new unstageable pressure ulcers in the measure numerator, based on TEP feedback and public comment. These revisions are viewed as improvements to the measure, as unstageable pressure ulcers are usually preventable and pose a serious patient safety issue. Also, adding new unstageable pressure ulcers increases variability of the measure scores, thereby improving the ability to discriminate among poor- and high-performing facilities. CMS has submitted additional testing information confirming the measure is reliable in the home health setting (kappa=.889).
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The measure is in current use, and CMS noted: A possible unintended consequence is that there could be reduced access to care for patients who are expected to be at higher risk for pressure ulcers. We apply several exclusion criteria and risk adjust this measure in order to address this concern.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Safety/Pressure Ulcers
  
  
• IMPACT Act Domain addressed by the measure: Skin integrity and changes in skin integrity
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2011
  
  
• Project for Most Recent Endorsement Review: Nursing Home Measures 2010
  
  
• Review for Importance: N/A
  
  
• Review for Scientific Acceptability: N/A
  
  
• Review for Feasibility: N/A
  
  
• Review for Usability: N/A
  
  
• Review for Related and Competing Measures: N/A
  
  
• Endorsement Public Comments: N/A
  
  
• Endorsement Committee Recommendation: The Committee agreed this is a well-specified and important measure that addresses an area of care where there is room for improvement. Despite the overall strength of the measure, the Committee discussed a few weaknesses: • lack of harmonization with pressure ulcer measures for other care settings; • seasonal variation is not considered in the measure specifications; and • lack of attention to other factors that may influence the development of pressure ulcers, including the patient’s level of skin moisture or nutrition, as well as the use of lifting devices and levels of nurse staffing. The developer will consider these issues during measure testing. One Committee member raised the concern that the MDS coding requirement, as used by CMS, conflicts with recommendations of relevant expert groups. The CMS definition of a deep tissue injury (DTI) wound differs from the definition used by the National Pressure Ulcer Advisory Panel. The Committee voted to recommend this measure for time-limited endorsement. 20 National Quality Forum There were multiple comments about this measure, primarily focused on two issues: that the measure does not allow a realistic amount of time for pressure ulcers to heal, and that combining new pressure ulcers and pressure ulcers that fail to improve is confusing and does not reflect the true quality of care in a facility. After extensive discussion, the Committee agreed to a title change that reflects MDS 3.0 item M0800, “Worsening in pressure ulcer status since prior assessment (OBRA, PPS, or Discharge),” and that also reflects the lack of evidence about the degree to which pressure ulcers can improve during a short time. The new title is 678: Percent of residents with pressure ulcers that are new or worsened (short stay). This measure meets the National Priority of Safety
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the previous provider/home at admission or the start/resumption of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the subsequent provider/home.
  
  
• Numerator: The numerator for the admission measure is the number of patient/resident stays/episodes with an admission assessment indicating that health information and/or care preferences were received at admission, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for the admission measure is the total number of IRF patient stays (Part A and Part C).
  
  
• Exclusions: Patient was not under the care of another provider immediately prior to this Admission/SOC/ROC.
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: IRF-PAI
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC admission is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the PAC provider to the subsequent provider/home at discharge or end of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the next.
  
  
• Numerator: The numerator for the discharge measure is the number of patient/resident stays with a discharge assessment indicating that health information and/or care preferences were provided to the next provider or agency at discharge, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for this measure is the total number of IRF patient stays (Part A and Part C). The receiving/admitting provider will be another PAC, a hospital or a critical access hospital, or, for home and community-setting patients, a physician(s) (e.g., primary care provider, family physician, specialist).
  
  
• Exclusions: Expired patients/residents
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: IRF-PAI
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC admission is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications

• NQF Number (if applicable): 678
  
  
• Description: This quality measure reports the percent of LTCH patient stays with Stage 2-4 or unstageable pressure ulcers that are new or worsened since admission (The endorsed measure specifications are: This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments ofSkilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings. For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Part C) patients. In LTCHs, this measure includes all patients.)
  
  
• Numerator: LTCH Numerator: The numerator is the number of stays for which the LTCH CARE Data Set discharge assessment indicates one or more new or worsened Stage 2-4 or unstageable pressure ulcers compared to the admission assessment. (The endorsed measure specifications are: SNF/NH Numerator: The numerator is the number of short-stay residents with an MDS assessment during the selected time window who have one or more Stage 2-4 pressure ulcer(s), that are new or worsened, based on examination of all assessments in a resident’s episode for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on prior assessment. LTCH Numerator: The numerator is the number of stays for which the discharge assessment indicates one or more new or worsened Stage 2-4 pressure ulcer(s) compared to the admission assessment.IRF Numerator: The numerator is the number of stays for which the IRF-PAI indicates one or more Stage 2-4 pressure ulcer(s) that are new or worsened at discharge compared to admission.)
  
  
• Denominator: LTCH Denominator: The denominator is the number of patient stays with both an admission and discharge LTCH CARE Data Set assessment, except those that meet the exclusion criteria. (The endorsed measure specifications are: SNF/NH Denominator: The denominator is the number of short-stay residents with one or more MDS assessments that are eligible for a look-back scan (except those with exclusions). Assessment types include: an admission, quarterly, annual, significant change/correction OBRA assessment; or a PPS 5-, 14-, 30-, 60-, or 90-day, or discharge with or without return anticipated; or SNF PPS Part A Discharge Assessment.LTCH Denominator: The denominator is the number of patient stays with both an admission and discharge LTCH CARE Data Set assessment, except those who meet the exclusion criteria.IRF Denominator: The denominator is the number of Medicare patient stays* (Part A and Part C) with an IRF-PAI assessment, except those who meet the exclusion criteria.*IRF-PAI data are submitted for Medicare patients (Part A and Part C) only.)
  
  
• Exclusions: LTCH Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, 4, and unstageable pressure ulcers are missing on the planned or unplanned discharge assessment. 2. Patient stay is excluded if the patient died during the LTCH stay. 3. Patient stay is excluded if there is no admission assessment available to derive data for risk adjustment (covariates). (The endorsed measure specifications are: SNF/NH Denominator Exclusions:1. Short-stay residents are excluded if none of the assessments that are included in the look-back scan has a usable response for items indicating the presence of new or worsened Stage 2, 3, or 4 pressure ulcer(s) since the prior assessment. 2. Short-stay residents are excluded if there is no initial assessment available to derive data for risk adjustment (covariates).3. Death in facility tracking records are excluded from measure calculations. LTCH Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing on the planned or unplanned discharge assessment. 2. Patient stay is excluded if the patient died during the LTCH stay.3. Patient stay is excluded if there is no admission assessment available to derive data for risk adjustment (covariates).IRF Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing at discharge. 2. Patient stay is excluded if the patient died during the IRF stay.)
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: LTCH CARE data set
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support for Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). The measure offers the opportunity for monitoring of pressure ulcer incidence and prevelance and thus can identify where quality improvement efforts might be implemented or strengthened.
  • Impact on quality of care for patients:The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education. If pressure ulcers are identified and mitigated, there should be a resulting decrease in morbidity and mortality.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. Under the IMPACT ACT, PAC providers are required under the applicable reporting provisions to submit standardized patient assessment data and other necessary data specified by the Secretary to 5 quality domains, one of which is skin integrity and changes in skin integrity.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is an outcome measure supported by the following guideline: The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education.
  
  
• Does the measure address a quality challenge? Yes. As described in the FY 2012 IRF PPSfinal rule (76 FR 47876 through 47878),pressure ulcers are high-cost adverseevents and are an important measure ofquality. Pressure ulcer incidence rates vary considerably by clinical setting, ranging from 0.4% to 38% in acute care, 2.2% to 23.9% in (SNFs and NHs, and 0% to 17% in home care (AHRQ, 2009; IHI, 2007). A study evaluating 2009 Medicare FFS claims data from post-acute care facilities found 2,342 secondary diagnosis claims of Stage 3 or 4 pressure ulcers in IRFs.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This measure is an adaptation of a measure used in other PAC settings, and is intended to promote alignment and harmonization across PAC/LTC settings as required by the IMPACT Act.
  
  
• Can the measure can be feasibly reported? Yes. The data required for reporting the measure is collected through the IRF-PAI.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Although this measure is an adaptation of an endorsed measure (#0678), material changes to the measure have been made since the last endorsement evaluation. CMS indicates: The numerator of this measure has been updated to include new unstageable pressure ulcers, in addition to new or worsened Stage 2-4 pressure ulcers. While since waiting for the appropriate NQF endorsement project to become available, the measure developer has worked to revise and improve the measure to include new unstageable pressure ulcers in the measure numerator, based on TEP feedback and public comment. These revisions are viewed as improvements to the measure, as unstageable pressure ulcers are usually preventable and pose a serious patient safety issue. Also, adding new unstageable pressure ulcers increases variability of the measure scores, thereby improving the ability to discriminate among poor- and high-performing facilities. CMS has submitted additional testing information confirming the measure is reliable in the home health setting (kappa=.889).
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The measure is in current use, and CMS noted: A possible unintended consequence is that there could be reduced access to care for patients who are expected to be at higher risk for pressure ulcers. We apply several exclusion criteria and risk adjust this measure in order to address this concern.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Safety/Pressure Ulcers
  
  
• IMPACT Act Domain addressed by the measure: Skin integrity and changes in skin integrity
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2011
  
  
• Project for Most Recent Endorsement Review: Nursing Home Measures 2010
  
  
• Review for Importance: N/A
  
  
• Review for Scientific Acceptability: N/A
  
  
• Review for Feasibility: N/A
  
  
• Review for Usability: N/A
  
  
• Review for Related and Competing Measures: N/A
  
  
• Endorsement Public Comments: N/A
  
  
• Endorsement Committee Recommendation: The Committee agreed this is a well-specified and important measure that addresses an area of care where there is room for improvement. Despite the overall strength of the measure, the Committee discussed a few weaknesses: • lack of harmonization with pressure ulcer measures for other care settings; • seasonal variation is not considered in the measure specifications; and • lack of attention to other factors that may influence the development of pressure ulcers, including the patient’s level of skin moisture or nutrition, as well as the use of lifting devices and levels of nurse staffing. The developer will consider these issues during measure testing. One Committee member raised the concern that the MDS coding requirement, as used by CMS, conflicts with recommendations of relevant expert groups. The CMS definition of a deep tissue injury (DTI) wound differs from the definition used by the National Pressure Ulcer Advisory Panel. The Committee voted to recommend this measure for time-limited endorsement. 20 National Quality Forum There were multiple comments about this measure, primarily focused on two issues: that the measure does not allow a realistic amount of time for pressure ulcers to heal, and that combining new pressure ulcers and pressure ulcers that fail to improve is confusing and does not reflect the true quality of care in a facility. After extensive discussion, the Committee agreed to a title change that reflects MDS 3.0 item M0800, “Worsening in pressure ulcer status since prior assessment (OBRA, PPS, or Discharge),” and that also reflects the lack of evidence about the degree to which pressure ulcers can improve during a short time. The new title is 678: Percent of residents with pressure ulcers that are new or worsened (short stay). This measure meets the National Priority of Safety
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the previous provider/home at admission or the start/resumption of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the subsequent provider/home.
  
  
• Numerator: The numerator for the admission measure is the number of patient/resident stays/episodes with an admission assessment indicating that health information and/or care preferences were received at admission, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for the admission measure is the total number of LTCH patient stays.
  
  
• Exclusions: Patient was not under the care of another provider immediately prior to this Admission/SOC/ROC.
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: LTCH CARE data set
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC admission is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the PAC provider to the subsequent provider/home at discharge or end of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the next.
  
  
• Numerator: The numerator for the discharge measure is the number of patient/resident stays with a discharge assessment indicating that health information and/or care preferences were provided to the next provider or agency at discharge, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for this measure is the total number of LTCH patient stays. The receiving/admitting provider will be another PAC, a hospital or a critical access hospital, or, for home and community-setting patients, a physician(s) (e.g., primary care provider, family physician, specialist).
  
  
• Exclusions: Expired patients/residents
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: LTCH CARE data set
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:The transfer of information between settings at PAC discharge is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC discharge is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Measure Specifications

• NQF Number (if applicable): 678
  
  
• Description: This quality measure reports the percent of SNF resident Part A stays with Stage 2-4 or unstageable pressure ulcers that are new or worsened since admission (The endorsed measure specifications are: This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments ofSkilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings. For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Part C) patients. In LTCHs, this measure includes all patients.)
  
  
• Numerator: SNF Numerator: The numerator is the number of SNF resident Medicare Part A stays that ended during the selected time window indicating one or more Stage 2-4 or unstageable pressure ulcers that were new or worsened since the start of the Medicare Part A Stay. (The endorsed measure specifications are: SNF/NH Numerator: The numerator is the number of short-stay residents with an MDS assessment during the selected time window who have one or more Stage 2-4 pressure ulcer(s), that are new or worsened, based on examination of all assessments in a resident’s episode for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on prior assessment. LTCH Numerator: The numerator is the number of stays for which the discharge assessment indicates one or more new or worsened Stage 2-4 pressure ulcer(s) compared to the admission assessment.IRF Numerator: The numerator is the number of stays for which the IRF-PAI indicates one or more Stage 2-4 pressure ulcer(s) that are new or worsened at discharge compared to admission.)
  
  
• Denominator: SNF Denominator: The denominator is the number of SNF resident Medicare Part A Stays with one or more MDS assessments included in their stay that are eligible for a look-back scan (except those with exclusions). (The endorsed measure specifications are: SNF/NH Denominator: The denominator is the number of short-stay residents with one or more MDS assessments that are eligible for a look-back scan (except those with exclusions). Assessment types include: an admission, quarterly, annual, significant change/correction OBRA assessment; or a PPS 5-, 14-, 30-, 60-, or 90-day, or discharge with or without return anticipated; or SNF PPS Part A Discharge Assessment.LTCH Denominator: The denominator is the number of patient stays with both an admission and discharge LTCH CARE Data Set assessment, except those who meet the exclusion criteria.IRF Denominator: The denominator is the number of Medicare patient stays* (Part A and Part C) with an IRF-PAI assessment, except those who meet the exclusion criteria.*IRF-PAI data are submitted for Medicare patients (Part A and Part C) only.)
  
  
• Exclusions: SNF Denominator Exclusions: 1. Resident Part A stays are excluded if none of the assessments that are included in the look-back scan has a usable response for items indicating the presence of new or worsened Stage 2, 3, 4, or unstageable pressure ulcers since the prior assessment. 2. Resident Part A stays are excluded if there is no initial assessment available to derive data for risk adjustment (covariates). 3. Death in facility tracking records are excluded from measure calculations. 4. Short-stay residents are excluded if the resident died during the stay. (The endorsed measure specifications are: SNF/NH Denominator Exclusions:1. Short-stay residents are excluded if none of the assessments that are included in the look-back scan has a usable response for items indicating the presence of new or worsened Stage 2, 3, or 4 pressure ulcer(s) since the prior assessment. 2. Short-stay residents are excluded if there is no initial assessment available to derive data for risk adjustment (covariates).3. Death in facility tracking records are excluded from measure calculations. LTCH Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing on the planned or unplanned discharge assessment. 2. Patient stay is excluded if the patient died during the LTCH stay.3. Patient stay is excluded if there is no admission assessment available to derive data for risk adjustment (covariates).IRF Denominator Exclusions: 1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing at discharge. 2. Patient stay is excluded if the patient died during the IRF stay.)
  
  
• HHS NQS Priority: Making Care Safer
  
  
• HHS Data Source: MDS 3.0
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has not been modified from its endorsed version.
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support for Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). The measure offers the opportunity for monitoring of pressure ulcer incidence and prevelance and thus can identify where quality improvement efforts might be implemented or strengthened.
  • Impact on quality of care for patients:The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education. If pressure ulcers are identified and mitigated, there should be a resulting decrease in morbidity and mortality.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. Under the IMPACT ACT, PAC providers are required under the applicable reporting provisions to submit standardized patient assessment data and other necessary data specified by the Secretary to 5 quality domains, one of which is skin integrity and changes in skin integrity.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. This is an outcome measure supported by the following guideline: The National Pressure Ulcer Advisory Panel (NPUAP) considers the vast majority of pressure ulcers to be preventable or minimized with appropriate identification and mitigation of risk factors. NPUAP recommends prevention through risk assessment, skin care, nutrition, repositioning and mobilization, and education.
  
  
• Does the measure address a quality challenge? Yes. As described in the FY 2012 IRF PPSfinal rule (76 FR 47876 through 47878),pressure ulcers are high-cost adverseevents and are an important measure ofquality. Pressure ulcer incidence rates vary considerably by clinical setting, ranging from 0.4% to 38% in acute care, 2.2% to 23.9% in (SNFs and NHs, and 0% to 17% in home care (AHRQ, 2009; IHI, 2007). A study evaluating 2009 Medicare FFS claims data from post-acute care facilities found 2,342 secondary diagnosis claims of Stage 3 or 4 pressure ulcers in IRFs.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This measure is an adaptation of a measure used in other PAC settings, and is intended to promote alignment and harmonization across PAC/LTC settings as required by the IMPACT Act.
  
  
• Can the measure can be feasibly reported? Yes. The data required for reporting the measure is collected through the IRF-PAI.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. Although this measure is an adaptation of an endorsed measure (#0678), material changes to the measure have been made since the last endorsement evaluation. CMS indicates: The numerator of this measure has been updated to include new unstageable pressure ulcers, in addition to new or worsened Stage 2-4 pressure ulcers. While since waiting for the appropriate NQF endorsement project to become available, the measure developer has worked to revise and improve the measure to include new unstageable pressure ulcers in the measure numerator, based on TEP feedback and public comment. These revisions are viewed as improvements to the measure, as unstageable pressure ulcers are usually preventable and pose a serious patient safety issue. Also, adding new unstageable pressure ulcers increases variability of the measure scores, thereby improving the ability to discriminate among poor- and high-performing facilities. CMS has submitted additional testing information confirming the measure is reliable in the home health setting (kappa=.889).
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? Yes. The measure is in current use, and CMS noted: A possible unintended consequence is that there could be reduced access to care for patients who are expected to be at higher risk for pressure ulcers. We apply several exclusion criteria and risk adjust this measure in order to address this concern.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Safety/Pressure Ulcers
  
  
• IMPACT Act Domain addressed by the measure: Skin integrity and changes in skin integrity
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Pressure ulcers are recognized as a serious medical condition. Considerable evidence exists regarding the seriousness of pressure ulcers, and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations (Casey, 2013; Gorzoni and Pires, 2011; Thomas et al., 2013; Wuite-Chu, et al., 2011). Pressure ulcers interfere with activities of daily living and functional gains made during rehabilitation, predispose patients to osteomyelitis and septicemia, and are strongly associated with longer hospital stays, longer IRF stays, and mortality (Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Wang, et al., 2014). Additionally, patients with acute care hospitalizations related to pressure ulcers are more likely to be discharged to long-term care facilities (e.g., a nursing facility, an intermediate care facility, or a nursing home) than hospitalizations for all other conditions (Hurd, et al., 2010; IHI, 2007). Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle, or bone (Bates-Jensen, 2001; IHI, 2007; Russo, et al., 2006). Elderly individuals in SNFs/NHs, LTCHs, and IRFs have a wide range of impairments or medical conditions that increase their risk of developing pressure ulcers, including but not limited to, impaired mobility or sensation, malnutrition or under-nutrition, obesity, stroke, diabetes, dementia, cognitive impairments, circulatory diseases, and dehydration. The use of wheelchairs and medical devices (e.g., hearing aid, feeding tubes, tracheostomies, percutaneous endoscopic gastrostomy tubes), a history of pressure ulcers, or presence of a pressure ulcer at admission are additional factors that increase pressure ulcer risk in elderly patients (Casey, 2013; Bates-Jensen, 2001; Park-Lee and Caffrey, 2009; Hurde, et al., 2010; AHRQ, 2009; Cai, et al., 2013; DeJong, et al., 2014; MacLean, 2003; Michel, et al., 2012; NPUAP, 2001; Reddy, 2011; Teno, et al., 2012). Many pressure ulcers are avoidable and can be prevented with appropriate intervention (Levine and Zulkowski, 2015; Crawford et al., 2014; Defloor et al., 2005) Casey, G. (2013). "Pressure ulcers reflect quality of nursing care." Nurs N Z 19(10): 20-24. Gorzoni, M. L. and S. L. Pires (2011). "Deaths in nursing homes." Rev Assoc Med Bras 57(3): 327-331. Thomas, J. M., et al. (2013). "Systematic review: health-related characteristics of elderly hospitalized adults and nursing home residents associated with short-term mortality." J Am Geriatr Soc 61(6): 902-911. White-Chu, E. F., et al. (2011). "Pressure ulcers in long-term care." Clin Geriatr Med 27(2): 241-258. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Int Med. 2001;135 (8 Part 2), 744-51. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004 (NCHS Data Brief No. 14). Hyattsville, MD: National Center for Health Statistics, 2009. Available from http://www.cdc.gov/nchs/data/databriefs/db14.htm. Wang, H., et al. (2014). "Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities." Am J Phys Med Rehabil 93(3): 207-216. Hurd D, Moore T, Radley D, Williams C. Pressure ulcer prevalence and incidence across post-acute care settings. Home Health Quality Measures & Data Analysis Project, Report of Findings, prepared for CMS/OCSQ, Baltimore, MD, under Contract No. 500-2005-000181 TO 0002. 2010. Institute for Healthcare Improvement (IHI). Relieve the pressure and reduce harm. May 21, 2007. Available from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.htm. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006 (Healthcare Cost and Utilization Project Statistical Brief No. 64). December 2008. Available from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. Levine JM, Zulkowski KM. Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm. Adv Skin Wound Care. 2015 Sep;28(9):420-8; quiz 429-30. doi: 10.1097/01.ASW.0000470070.23694.f3. PubMed PMID: 26280701. Crawford B, Corbett N, Zuniga A. Reducing hospital-acquired pressure ulcers: a quality improvement project across 21 hospitals. J Nurs Care Qual. 2014 Oct-Dec;29(4):303-10. doi: 10.1097/NCQ.0000000000000060. PubMed PMID: 24647120. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud. 2005 Jan;42(1):37-46. PubMed PMID: 15582638.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2011
  
  
• Project for Most Recent Endorsement Review: Nursing Home Measures 2010
  
  
• Review for Importance: N/A
  
  
• Review for Scientific Acceptability: N/A
  
  
• Review for Feasibility: N/A
  
  
• Review for Usability: N/A
  
  
• Review for Related and Competing Measures: N/A
  
  
• Endorsement Public Comments: N/A
  
  
• Endorsement Committee Recommendation: The Committee agreed this is a well-specified and important measure that addresses an area of care where there is room for improvement. Despite the overall strength of the measure, the Committee discussed a few weaknesses: • lack of harmonization with pressure ulcer measures for other care settings; • seasonal variation is not considered in the measure specifications; and • lack of attention to other factors that may influence the development of pressure ulcers, including the patient’s level of skin moisture or nutrition, as well as the use of lifting devices and levels of nurse staffing. The developer will consider these issues during measure testing. One Committee member raised the concern that the MDS coding requirement, as used by CMS, conflicts with recommendations of relevant expert groups. The CMS definition of a deep tissue injury (DTI) wound differs from the definition used by the National Pressure Ulcer Advisory Panel. The Committee voted to recommend this measure for time-limited endorsement. 20 National Quality Forum There were multiple comments about this measure, primarily focused on two issues: that the measure does not allow a realistic amount of time for pressure ulcers to heal, and that combining new pressure ulcers and pressure ulcers that fail to improve is confusing and does not reflect the true quality of care in a facility. After extensive discussion, the Committee agreed to a title change that reflects MDS 3.0 item M0800, “Worsening in pressure ulcer status since prior assessment (OBRA, PPS, or Discharge),” and that also reflects the lack of evidence about the degree to which pressure ulcers can improve during a short time. The new title is 678: Percent of residents with pressure ulcers that are new or worsened (short stay). This measure meets the National Priority of Safety
  
  

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the previous provider/home at admission or the start/resumption of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the subsequent provider/home.
  
  
• Numerator: The numerator for the admission measure is the number of patient/resident stays/episodes with an admission assessment indicating that health information and/or care preferences were received at admission, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for the admission measure is the total number of SNF Medicare Part A covered resident stays.
  
  
• Exclusions: Patient was not under the care of another provider immediately prior to this Admission/SOC/ROC.
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: MDS 3.0
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC admission is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting, from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007; Pinelli, 2015). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and QM uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Pinelli, V., et al (2015). “Interprofessional communication patterns during patient discharges: A social network analysis.” Journal of General Internal Medicine. 30(9): 1299-1306. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf Verhaegh, K. J., et al (2015) “Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.” Health Affairs. 33 (9): 1531-1539.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The IMPACT Act requires a quality measure on the transfer of health information and care preferences when an individual transitions between post-acute care (PAC) and hospitals, other PAC providers, or home. This process-based quality measure estimates the percent of patient or resident stays or episodes where information was sent from the PAC provider to the subsequent provider/home at discharge or end of care. In addition, this quality measure assesses the modes of information transfer from one care provider to the next.
  
  
• Numerator: The numerator for the discharge measure is the number of patient/resident stays with a discharge assessment indicating that health information and/or care preferences were provided to the next provider or agency at discharge, and the information transferred was from at least one of eight categories of information.
  
  
• Denominator: The denominator for this measure is the total number of SNF Medicare Part A covered resident stays. The receiving/admitting provider will be another PAC, a hospital or a critical access hospital, or, for home and community-setting patients, a physician(s) (e.g., primary care provider, family physician, specialist).
  
  
• Exclusions: Expired patients/residents
  
  
• HHS NQS Priority: Making Care Safer, Communication and Care Coordination
  
  
• HHS Data Source: MDS 3.0
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Never Submitted
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Refine and Resubmit Prior to Rulemaking
  
  
• Preliminary analysis summary
  • Contribution to program measure set:When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent readmissions and medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014; Verhaegh et al, 2015). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010; Verhaegh et al, 2015). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010).
  • Impact on quality of care for patients:Transfer forms, continuity of care forms, and other types of forms are among the tools used by hospitals and PAC providers to communicate and transfer information at transitions. Medicare sets standards for discharge planning for hospitals and PAC settings. Some states set minimum data standards including required information to be sent at care transitions/transfers. Despite these standards, there is limited information about the types of information transferred by and to PAC providers at transitions and the methods (e.g., paper-based, verbal, and electronic) used to transfer this information. Increasingly information exchange with and by PAC is recognized as necessary to improve quality and coordination care and reduce unnecessary costs. This quality measure will help CMS to better understand and monitor how patient or resident health information is transferred between PAC, acute care, home, and community settings during transitions.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. The transfer of information between settings at PAC discharge is part of a paired set of measures that assesses transitions of care at admission and discharge as patients move between care settings. The measure addresses care coordination, a key leverage area identified for the PAC/LTC settings.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? Yes. The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. The IMPACT Act requires standardized patient assessment data that will enable assessment and quality measurement uniformity; quality care and improved outcomes; comparison of quality across PAC settings; improved discharge planning; interoperability; and facilitate care coordination. Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003.
  
  
• Does the measure address a quality challenge? Yes. Communication has been cited as the most frequent root cause in sentinel events (The Joint Commission, 2016) with failed patient handoffs playing a role in an estimated 80% of serious preventable adverse events. (The Joint Commission, 2010).
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. This MUC is proposed for SNF, IRF, Home Health and LTHC settings and is being tested to ensure alignment.
  
  
• Can the measure can be feasibly reported? Unknown. Measure is still in testing/early development phase.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Unknown. Measure testing has not been finalized; no data on the scientific soundness of the MUC is available at this time. CMS is testing the measures across PAC settings to ensure reliability and validity.
  
  
• Measure development status: Early Development
  
  
• If the measure is in current use, do the benefits of the measure outweigh any unreasonable implementation issues that have been identified? N/A.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted
  
  
• Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.
  
  
• PAC/LTC core competency addressed by the measure: Care Coordination/Effective Transitions of Care
  
  
• IMPACT Act Domain addressed by the measure: Transfer of health information and care preferences when an individual transitions
  
  
• Hospice High Priority Area addressed by the measure: N/A
  
  

Rationale for measure provided by HHS
Nationwide, approximately 22 percent of older adults experience a transition annually. Half of those transitions involve going to and from a hospital setting from either a skilled nursing facility or home, but the other half often involve complicated trajectories across different settings (Callahan, 2012). Almost 8 million inpatient stays were discharged to post-acute care (PAC) settings, accounting for 22.3 percent of all hospital discharges in 2013. The rates of inpatient discharge to PAC were 41.7 percent for Medicare, 11.7 percent for private insurance, 8.1 percent for Medicaid, and only 4.8 percent for uninsured stays. Home health agencies accounted for 50 percent of discharges to PAC. More than 40 percent of discharges to PACs were to SNFs (AHRQ, 2016). Among beneficiaries enrolled in fee-for-service (FFS) Medicare and discharged from an acute care hospital in 2013, 42 percent went on to post-acute care: 20 percent were discharged to a SNF, 17 percent were discharged to an HHA, 4 percent were discharged to an IRF, and 1 percent were discharged to an LTCH (MEDPAC, 2015). Inpatient stays discharged to PAC are much longer and more costly than those with routine discharges (7.0 days vs. 3.6 days; $16,900 vs. $8,300 on average) (AHRQ, 2016). Of the Medicare beneficiaries discharged from PAC to use other services, a little over 40 percent go to SNFs, and 37 percent are sent home with home health services. The rest of post-acute patients are discharged to outpatient therapy services, or they receive continued services at a specialized hospital, like an IRF or LTCH (Gage, Morely, Spain, & Ingber, 2009). Whether these patients use home health services as opposed to other services depends not only on their conditions but also on the organizational relationships of the hospital. (Gage, Morely, Spain, & Ingber, 2009). The communication of health information and patient care preferences is critical to ensuring safe and effective patient transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions, have drawn national attention to the importance of the timely transfer of important health information and care preferences at transitions. Communication has been cited as the third most frequent root cause in sentinel events. Failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events (The Joint Commission, 2016). Further, shared understanding of patients’ care goals, particularly with serious illness, is an important element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care have been found to be associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs (Bernacki & Block, 2014). According to the Institute of Medicine (2007) and other studies, the lack of coordination and communication across health care settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits (Kitson et al, 2013; Forster et al, 2003). Care coordination within and across care settings has been shown to provide better quality of care at lower cost. A critical component of care coordination is communication and the exchange of information (McDonald et al, 2007). When care transitions are enhanced through care coordination activities such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans (Mor, 2010) and prevent medical errors (Institute of Medicine Committee on Identifying and Preventing Medication Errors, 2010; Starmer et al, 2014). Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between transferring and receiving providers. (AHRQ, 2016, Murray & Laditka, 2010; LaMantia et al, 2010). In a systematic review of interventions to improve transitional care between nursing homes and hospitals, a standardized patient transfer form was found to facilitate communication of advance directives and medication reconciliation (LaMantia et al, 2010). Bernacki, R. E. and Block S. D. (2014). “Communication about serious illness care goals: a review and synthesis of best practices.” JAMA Intern Med. 2014; 174(12):1994-2003. Callahan, C. M., et al (2012). “Transitions in care for older adults with and without dementia.” Journal of the American Geriatrics Society. 2012; 60(5): 813-820. Forster, A. J., et al (2003). “The incidence and severity of adverse events affecting patients after discharge from the hospital.” Ann Intern Med. 2003; 138(3):161-167. Gage, B., Morely, M., Spain, P., & Ingber, M. (2009). Examining Post Acute Care Relationships in an Integrated Hospital System: Final Report. RTI International. Washington, D.C.: ASPE. Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007. Kitson, N. A., et al (2013). “Developing a medication communication framework across continuums of care using the circle of care modeling approach.” BMC Health Services Research. 2013; 13:418. Available from: http://www.biomedcentral.com/1472-6963/13/418 LaMantia, M. A., et al (2010). “Interventions to improve transitional care between nursing homes and hospitals: A systematic review.” Journal of the American Geriatrics Society. 2010; 58 (4): 777-782. McDonald, K.M., et al (2007). “Closing the quality gap: a critical analysis of quality improvement strategies.” Stanford, CA: Stanford University. Available at http://www.ncbi.nlm.nih.gov/books/NBK44015/pdf/TOC.pdf Mor, V., et al (2010). “The revolving door of rehospitalization from skilled nursing facilities.” Health Affairs, 29(1), 57-64. Murray, L. M. and Laditka, S. B. (2010). “Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research.” Journal of the American Medical Directors Association 2010: 11(4): 231-238. National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. AHRQ Pub. No. 16-0015-6-EF. Starmer, A. J., et al (2014). “Changes in medical errors after implementation of a handoff program.” N Engl J Med 2014; 371:1803-12. Statistical Brief #205. Healthcare Cost and Utilization Project (HCUP). June 2016. Agency for Healthcare Research and Quality, Rockville, MD. The Joint Commission. (2016). Sentinel Event Data Root Causes by Event Type 2004 –2015. Retrieved from https://www.jointcommission.org/assets/1/23/jconline_Mar_2_2016.pdf

Program Index

• Inpatient Rehabilitation Facility Quality Reporting Program 
  
  
• Skilled Nursing Facility Quality Reporting Program 
  
  
• Home Health Quality Reporting Program 
  
  
• Long-Term Care Hospital Quality Reporting Program 
  
  
• Hospice Quality Reporting Program 
  
  

Full Program Summaries

Program History and Structure: The Quality Reporting Program (QRP) for Inpatient Rehabilitation Facilities (IRFs) was established in accordance with section 1886(j) of the Social Security Act as amended by section 3004(b) of the Affordable Care Act. The IRF QRP applies to all IRF facilities that receive the IRF PPS (e.g., IRF hospitals, IRF units that are co-located with affiliated acute care facilities, and IRF units affiliated with critical access hospitals [CAHs]). Data sources for IRF QRP measures include Medicare FFS claims, the Center for Disease Control’s National Health Safety Network (CDC NHSN) data submissions, and Inpatient Rehabilitation Facility - Patient Assessment instrument (IRF-PAI) records. The IRF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, IRFs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable IRF Prospective Payment System (PPS) payment update. Plans for future public reporting of IRF QRP measures are under development. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following four domains as high-priority for future measure consideration:

1. Making Care Affordable: An important consideration for the IRF QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiencybased measures such as a Medicare Spending per Beneficiary measure concept.

2. Communication/Care Coordination: Assessing resident care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.

3. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the IRF QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Medication reconciliation conceptually highlights care transitions and resident follow-up. Therefore, a medication reconciliation quality measure for IRF patients is being considered for future quality measure development. 

4. Communication/Care Coordination: Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many patients for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, a discharge to community measure for IRFs is being considered for the future use in the IRF QRP.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Improving Medicare Post-Acute Care Transitions Act of 2014 (The IMPACT Act) added Section 1899B to the Social Security Act establishing the Skilled Nursing Facility Quality Reporting Program (SNF QRP). Facilities that submit data under the SNF PPS are required to participate in the SNF QRP, excluding units that are affiliated with critical access hospitals (CAHs). Data sources for SNF QRP measures include Medicare FFS claims as well as Minimum Data Set (MDS) assessment data. The SNF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2018, providers that fail to submit required quality data to CMS will have their annual updates reduced by 2.0 percentage points. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Home Health Quality Reporting Program (HH QRP) was established in accordance with section 1895 (b)(3)(B)(v)(II) of the Social Security Act. Home Health Agencies (HHAs) are required by the Act to submit quality data for use in evaluating quality for Home Health agencies. Section 1895(b) (3)(B)(v)(I) of the Act also requires that HHAs that do not submit quality data to the Secretary be subject to a 2 percent reduction in the annual payment update, effective in calendar year 2007 and every subsequent year. Data sources for the HH QRP include the Outcome and Assessment Information Set (OASIS) and Medicare FFS claims. Data is publically reported on the Home Health Compare website. The HH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for future measure consideration:

1. Patient and Family Engagement: Functional status and functional decline are important to assess for residents in HH settings. Patients who receive care while in a HH may have functional limitations and may be at risk for further decline in function due to limited mobility and ambulation. Therefore, measures to assess functional status are in development.
2. Making Care Safer: Safety for individuals in a home-based setting is an important priority for the HH QRP as persons in home health settings are at risk for major injury due to falls, new or worsened pressure ulcers, pain, and functional decline. Therefore, these concepts will be considered for future measure development.
3. Making Care Affordable: An important consideration for the HH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiencybased measures such as a Medicare Spending per Beneficiary measure concept.
4. Communication/Care Coordination: Assessing an individual’s care transitions and rehospitalizations is important. Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many individuals for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
5. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the HH QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Therefore, a medication reconciliation quality measure for individuals in a home health setting is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) was established in accordance with section 1886(m) of the Social Security Act, as amended by Section 3004(a) of the Affordable Care Act. The LTCH QRP applies to all LTCHs facilities designated as an LTCH under the Medicare program. Data sources for LTCH QRP measures include Medicare FFS claims, the Center for Disease Control and Prevention’s National Health Safety Network (CDC’s NHSN) data submissions, and the LTCH Continuity Assessment Record and Evaluation Data Sets (LCDS). The LTCH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, LTCHs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable Prospective Payment System (PPS) increase factor. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for LTCH QRP future measure consideration:

1. Effective Prevention and Treatment: Having measures related to ventilator use, ventilator- associated event and ventilator weaning rate are a high priority for CMS as prolonged mechanical ventilator use is quite common in LTCHs and respiratory diagnosis with ventilator support for 96 or more hours is the most frequently occurring diagnosis.
2. Effective Prevention and Treatment (Aim: Healthy People/Healthy Communities): In discussions with LTCH providers, it was noted that mental health status is an important measure of care for LTCH patients. CMS is considering a Depression Assessment & Management quality measure.
3. Patient and Family Engagement: While rehabilitation and restoring functional status are not the primary goals of patient care in the LTCH setting, functional outcomes remain an important indicator of LTCH quality as well as key to LTCH care trajectories. Providers must be able to provide functional support to patients with impairments. Thus, metrics showing change in self- care and mobility function are under development.
4. atient and Family Engagement: CMS would like to explore measures that will evaluate the patient’s experiences of care as this is a high priority of providers. Therefore, the HCAHPS and Care Transition quality measure (CTM)-3 is being considered.
5. Making Care Affordable: An important consideration for the LTCH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
6. Communication/Care Coordination: Assessing patient care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
7. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the LTCH QRP. Therefore, a medication reconciliation quality measure for LTCH patients is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Hospice Quality Reporting Program (HQRP) was established in accordance with section 1814(i) of the Social Security Act, as amended by section 3004(c) of the Affordable Care Act. The HQRP applies to all hospices, regardless of setting. Proposed data sources for future HQRP measures include the Hospice Item Set and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. HQRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, Hospices that fail to submit quality data will be subject to a 2.0 percentage point reduction to their annual payment update.

High Priority Domains for Future Measure Consideration:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Index of Measures (by Program)

General Comments

• General comments
  
  

• The Percent of Home Health Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Public comments received:1; MUC ID: MUC16-061)
  
  
• The Percent of Home Health Residents Experiencing One or More Falls with Major Injury (Public comments received:2; MUC ID: MUC16-063)
  
  
• The Percent of Residents or Home Health Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:1; MUC ID: MUC16-145)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:1; MUC ID: MUC16-347)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:2; MUC ID: MUC16-357)
  
  

• CAHPS Hospice Survey: Getting Emotional and Spiritual Support (Public comments received:1; MUC ID: MUC16-037)
  
  
• CAHPS Hospice Survey: Getting Help for Symptoms (Public comments received:2; MUC ID: MUC16-039)
  
  
• CAHPS Hospice Survey: Getting Hospice Care Training (Public comments received:1; MUC ID: MUC16-035)
  
  
• CAHPS Hospice Survey: Getting Timely Care (Public comments received:2; MUC ID: MUC16-036)
  
  
• CAHPS Hospice Survey: Hospice Team Communications (Public comments received:4; MUC ID: MUC16-032)
  
  
• CAHPS Hospice Survey: Rating of Hospice (Public comments received:3; MUC ID: MUC16-031)
  
  
• CAHPS Hospice Survey: Treating Family Member with Respect (Public comments received:2; MUC ID: MUC16-040)
  
  
• CAHPS Hospice Survey: Willingness to Recommend (Public comments received:1; MUC ID: MUC16-033)
  
  

• Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:3; MUC ID: MUC16-143)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:1; MUC ID: MUC16-319)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:2; MUC ID: MUC16-325)
  
  

• Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:1; MUC ID: MUC16-144)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:3; MUC ID: MUC16-321)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:3; MUC ID: MUC16-327)
  
  

• Application of Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (Public comments received:1; MUC ID: MUC16-142)
  
  
• Transfer of Information at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings (Public comments received:1; MUC ID: MUC16-314)
  
  
• Transfer of Information at Post-Acute Care Discharge or End of Care to Other Providers/Settings (Public comments received:1; MUC ID: MUC16-323)
  
  

Full Comments (Listed by Measure)

• General comment-We were concerned that no measures were approved for either hospital acquired conditions or hospital readmissions per Appendix C. Although hospital readmissions are down this year, data indicates that 30% of pediatric readmissions are preventable (source: https://pediatrics.aappublications.org/content/early/2016/07/20/peds.2015-4182). Hospital acquired conditions data has improved as CMS notes “across the FY 2015 and FY 2016 programs, the average performance across eligible hospitals improved on two of the three measures included in both program years” (source: https://www.acep.org/Clinical---Practice-Management/Health-Care-Acquired---Provider-Preventable-Conditions-FAQ/.) Nevertheless, there is increasing awareness of “superbugs” and most hospital acquired infections by their very nature are preventable. Addressing this will decrease costs and improve health care outcomes. (Submitted by: Statewide Parent Advocacy Network/Family Voices NJ)
  
  
• · No quality measure should be publicly reported without having been collected and reported in the same fashion and subject to the same processes as a HEDIS first year measure. · Any publicly reported quality measure must at least meet the NQF criteria for measure endorsement. The NQF criteria require the measure be: o Important to measure and report, where the evidence is highest that measurement can have a positive impact on healthcare quality. o Scientifically acceptable, so that the measure when implemented will produce consistent (reliable) and credible (valid) results about the quality of care. o Useable and relevant to ensure that intended users — consumers, purchasers, providers, and policy makers — can understand the results of the measure and are likely to find them useful for quality improvement and decision making. o Feasible to collect with data that can be readily available for measurement and retrievable without undue burden." · Performance reports aimed at consumers must be displayed in a way that is easily understood by a consumer. Performance reports developed for clinicians would require a different, more detailed format. (Submitted by: Kaiser Permanente)
  
  
• Asking whether or not a patient received pain medication during their visit automatically ensures negative responses in many cases. These questions should focus on pain assessment and treatment in general, not on the prescribing of medication. (Submitted by: Community Health Network)
  
  
• Centers for Medicare & Medicaid Services Department of Health and Human Services Mail Stop C4-26-05 Baltimore, MD 21244-8050 Re: MAP Pre-Rulemaking 2016-2017: Comment on Measures Under Consideration CVS Health is pleased to provide comments in response to the Centers for Medicare & Medicaid Services (CMS) request for comments on the list of Measures Under Consideration (MUC) for NQF’s Measure Applications Partnership (MAP), which provides input to HHS and private sector initiatives on measures for use in public reporting, performance-based payment, and other programs. CVS Health is a pharmacy innovation company helping people on their path to better health. Through its more than 7,900 retail drugstores, more than 1,000 walk-in medical clinics, a leading pharmacy benefits manager with more than 70 million plan members, a dedicated senior pharmacy care business serving more than one million patients per year, and expanding specialty pharmacy services, the Company enables people, businesses and communities to manage health in more affordable, effective ways. This unique integrated model increases access to quality care, delivers better health outcomes and lowers overall health care costs. The Pharmacy Services Segment provides a full range of pharmacy benefit management (PBM) services to our clients consisting primarily of employers, insurance companies, unions, government employee groups, managed care organizations (MCOs) and other sponsors of health benefit plans and individuals throughout the United States. Background The Centers for Medicare & Medicaid Services (CMS) issued the List of Measures under Consideration (MUC) to comply with Section 1890A(a)(2) of the Social Security Act (the Act), which requires the Department of Health and Human Services (DHHS) to make publicly available a list of certain categories of quality and efficiency measures it is considering for adoption through rulemaking for the Medicare program. Among the measures, the list includes measures CMS is considering that were suggested to by the public. When organizations, such as physician specialty societies, request that CMS consider measures, CMS attempts to include those measures and make them available to the public so that the Measure Applications Partnership (MAP), the multistakeholder groups convened as required under 1890A of the Act, can provide their input on all potential measures and ensure alignment where appropriate. The list is larger than what will ultimately be adopted by CMS for optional or mandatory reporting programs in Medicare. CMS will continue its goal of aligning measures across programs. Measure alignment includes establishing core measure sets for use across similar programs, and looking first to existing program measures for use in new programs. Further, CMS programs must balance competing goals of establishing parsimonious sets of measures, while including sufficient measures to facilitate multispecialty provider participation. CVS Health Comments CVS Health appreciates the opportunity to provide comments, especially as it pertains to measures for inclusion in the the Merit-based Incentive Payment System (MIPS). PBMs, pharmacies, and pharmacists play an integral role in health quality outcomes. With the Medicare Access & CHIP Reauthorization Act (MACRA) moving health plans and health care providers into alternative payment models, pharmacists are in an important position within the value-based care transition to assist in quality metrics that have an emphasis on medication management and optimization of medication use. Providing comprehensive pharmacy care management services, such as immunization, diabetes, hypertension, high cholesterol management and medication reconciliation post inpatient discharge helps to drive population health and chronic disease management. Pharmacists have an important role in partnering with the health care team. Through the MIPS program CMS proposes that most MIPS-eligible clinicians would be required to report on at least six quality measures, including at least one cross-cutting measure and an outcome measure if available. Evidence supports that optimal prescription utilization has a positive impact on reducing the total cost of care, increasing patient safety and improving clinical outcomes. A successful MIPS strategy will be dependent on a clear definition of goals and measures to monitor the effectiveness of the value based approach. Prescription drugs have been shown to lower overall medical costs through reduced hospitalization, emergency room utilization and outpatient visits, while medication therapy management programs and pharmacy counseling play an important role in optimizing prescription adherence to improve quality outcomes for individuals with chronic conditions. Through the implementation of the Medicare Part D program, prescription coverage has been shown to reduce Medicare Parts A and B medical expenses for beneficiaries compared to those with no or limited prior drug coverage. Research conducted by CVS Health also indicates that investment in resources to improve drug adherence among Medicare Part D beneficiaries has been shown to lower overall medical costs through reduced hospitalization, emergency room utilization and outpatient visits. CVS Health encourages balance and parsimony in the selection of quality measures to monitor the quality performance. In pursuit of consistency, parsimony, and reducing the burden of measurement and reporting, the alignment of measures across federal programs should be an important health system priority. Alignment, or use of the same or related high value measures when appropriate, is a critical strategy for accelerating improvement in priority areas, reducing duplicative data collection and enhancing comparability and transparency of quality performance. CVS Health was encouraged by the alignment of MIPS measures with measures used in other government programs (e.g., Medicare STARS, Medicaid Core Sets, Health Insurance Marketplaces, etc.) when possible. Therefore we were pleased to see several pharmacy influenced measures proposed for MIPS, such as: • Antidepressant medication management • Medication management for people with Asthma • Medication reconciliation post-discharge and Management in Women who had a Fracture • Controlling high blood pressure, etc. CVS Health would like recommend the following measures that align with measures used in other Federal programs for inclusion: Measure Recommendations Rationale Proportion of Days Covered – 3 rates While measures such as “Documentation of Current Medications in the Medical Record” and “Medication Reconciliation Post-Discharge” are key indicators of high quality medication management, additional measures that assess medication adherence are necessary to ensure that patients are actually receiving the therapy they need. A strong case can be made for the importance of physician insight into their patients’ medication adherence enabling them to make informed decisions regarding therapeutic choices, and which could improve patient empowerment to take their medications. We would recommend the “Proportion of Days Covered (PDC) – three rates” measure be included in the MIPs due to its proven ability to help improve medication adherence and health outcomes in the Medicare Stars program. Proportion of Days Covered (PDC) is the Pharmacy Quality Alliance (PQA)-recommended metric for estimation of medication adherence for patients using chronic medications. This metric is also endorsed by the National Quality Forum (NQF). The metric identifies the percentage of patients taking medications in a particular drug class that have high adherence (PDC > 80% for the individual). The measure tracks medication adherence for conditions that are highly prevalent in Medicare-Medicaid populations. It includes three rates - one for blood pressure medications (renin angiotensin system antagonists [RASA]), one for cholesterol medications (statins), and one for diabetes medications (roll-up across 4 classes of oral diabetes drugs). A form of this measure is currently being used in Medicare STARS and the Health Insurance marketplaces. Inclusion in MIPS would allow further alignment across programs to promote consistent performance measurement where it can have the most impact and give a more complete view of the quality of care delivered across healthcare settings. Proportion of days covered: Antiretroviral adherence for HIV-specialists. Again, while the Prescription of HIV Antiretroviral Therapy measure is a key indicator of high quality medication management, evaluation of medication adherence is necessary to ensure that patients are actually receiving the therapy they need. Human immunodeficiency virus (HIV) can cause life-long infection that results in a chronic debilitating disease usually ending in death. Adherence to multiple anti-HIV medications has been shown to dramatically slow the progression of disease and prolong survival. This measure is used to assess the percentage of patients 18 years and older who filled a prescription for at least two individual antiretroviral drugs (as single agents or as a combination) on two unique dates of service who met the Proportion of Days Covered (PDC) threshold of 90% during the measurement period. Antiretroviral adherence is currently a Part D Patient Safety measure, reported monthly though the Acumen Patient Safety Analysis website. Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy This measure is used to monitor the percentage of patients aged 18 years and older who were diagnosed with rheumatoid arthritis (RA) and were prescribed, dispensed, or administered at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD). This measure calculates the percent of plan members with Rheumatoid Arthritis who got one or more prescription(s) for a DMARD, pivotal to long term treatment. Further, inclusion of the RA measure would align with the measure used in the Medicare STARS program. Antipsychotic Use in Persons with Dementia (APD) CMS has been particularly concerned with the unnecessary use of antipsychotic drugs particularly in nursing homes and, as a result, has pursued strategies to increase awareness of antipsychotic use in long term care settings. In 2013, CMS began to calculate a general atypical antipsychotic utilization rate, called Rate of Chronic Use of Atypical Antipsychotics by Elderly Beneficiaries in Nursing Homes, for inclusion in the Part D display measures. The average rates decreased from approximately 24.0% in 2011 to 21.4% in 2013. There continues to be increased attention on this important issue. The United States Government Accountability Office (GAO) released a report in January 2015 describing the inappropriate use of antipsychotics in Part D beneficiaries with dementia, in both community (i.e., outside of nursing homes) and long-stay nursing home residents during 2012, with Antipsychotic Drug Use. The GAO conducted this study due to concerns raised regarding the use of antipsychotic drugs to address the behavioral symptoms associated with dementia, the FDA’s boxed warning that these drugs may cause an increased risk of death when used by older adults with dementia, and because the drugs are not approved for this use. HHS has Initiatives to reduce use among older adults in nursing homes, but should consider expanding efforts to other settings. Further, inclusion would align with the Medicare display measure and Part D Patient Safety measure. Statin Use in Persons with Diabetes The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend moderate- to high-intensity statin therapy for primary prevention for persons aged 40 to 75 years with diabetes. This measure is used to assess the percentage of patients ages 40 to 75 years who were dispensed a medication for diabetes that receive a statin medication. This measure is very much prescriber influenced and inclusion will align with the health care system goals. Further, inclusion of “Statin Use in Persons with Diabetes” would align with the Medicare display measure and Part D Patient Safety measure. Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer CVS Health recommends the inclusion of all three measures. • Measure 1: Use of Opioids at High Dosage • Measure 2: Use of Opioids from Multiple Providers • Measure 3: Use of Opioids at High Dosage and from Multiple Providers Measure one can be directly influenced by providers while measure 3 would also align with the Medicaid adult core set measure adopted in 2016. These measures are currently Part D Patient Safety measures, reported monthly though the Acumen Patient Safety Analysis website. CVS Health appreciates the opportunity to provide comments to CMS. If you have any questions, please feel free to contact Emily Kloeblen at Emily.Kloeblen@cvshealth.com. Sincerely, Emily Kloeblen Director, Government Performance Measures CVS Health (Submitted by: CVS Health)
  
  
• I am not commenting by individual MUC but some general thoughts/concerns. I would still like to see us focus on strategy that drives us selecting the critical few measures that will build a healthy American and place them in the appropriate program where the responsibility lies verses in some of the inpatient measures where the patient is for such a short time and there really is no way the intervention will be sustained.I was concerned about the tobacco measures since I thought those were topped out and did not know why they were back in. Are the opiods in the correct program to be fully managed and see ongoing improvement of the user of the opiod? The EHR use for med rec in the behavioral health measure may not be feasible due to the lack of sophistication of the EHR in the behavioral world but the concept of the med rec is good. I also think that the cancer measures are a lot and have artificial boundaries for outpatient and inpatient. in this disease like many of the chronic illnesses it is about the patients treatment plan not the location of the care. I (Submitted by: American Hospital Association representative on the MAP Coordinating Committee)
  
  
• General Comments: The Federation of American Hospitals (FAH) appreciates the opportunity to provide comments on the Measures Under Consideration (MUC) list prior to the individual workgroup discussions and voting. The FAH believes that the Measures Application Partnership (MAP) should support only those measures that truly represent the quality of care provided within a hospital, physician or other provider. Any new measures added to these programs should focus on a targeted set of issues and topics, effectively leverage electronic health record systems and other health information technologies, and drive improvement in the overall delivery of patient care. In addition, we ask that the MAP be judicious in selecting measures where there is limited evidence that improvements (or lack thereof) on the process or outcome of interest are within the control of the measure entity (e.g., follow-up after hospitalization for mental illness) or where performance has proven to be generally high (e.g., the tobacco use measures). (Submitted by: Federation of American Hospitals )
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  
• Date: December 2, 2016 To: National Quality Forum Measure Applications Partnership (MAP) From: David Cloud, CEO, National Sleep Foundation Re: Comments on the following MAP MUC: MUC16-32 - CAHPS Hospice Survey: Hospice Team Communications, MUC16-35 - CAHPS Hospice Survey: Getting Hospice Care Training, and MUC16-264 - Communication about Treating Pain Post Discharge. The National Sleep Foundation (NSF) thanks the National Quality Forum (NQF) for providing the opportunity to comment on the Measures under Consideration (MUC). NSF applauds the efforts of the Measure Applications Partnership (MAP) and asks that it consider adding the simple sleep assessment of, “How did you sleep?” to MUC16-32, MUC16-35, and MUC16-264. Sleep is vital to health. A measure of sleep, whereby a healthcare provider asks a patient, “How did you sleep?” is an effective means of promoting health and wellness, increasing patient engagement, preventing potential illnesses and decreasing healthcare costs. This short assessment places only minimal burden on providers and patients. In addition, the assessment is applicable to all populations and has utility in nearly every medical specialty. As a matter of standard procedure, healthcare providers should inquire about sleep in every patient encounter and record the results of the inquiry in electronic health records. Data gleaned from an assessment of sleep can be particularly helpful to primary care providers for determining when patient education is needed. The sleep measure can also assist when referring out for further clinical diagnoses and interventions is more appropriate. We commend MUC16-35, which assesses whether hospice teams ask patients about their sleepiness as a side effect of pain medication. However, MUC16–32 and MUC16-264, which also measures assessment of pain, should similarly include a prompt for healthcare providers to follow up with a question about sleep. People sleep more poorly when their pain is inadequately controlled, resulting in stress, more pain, and worse outcomes in general. Sleep can also be affected by pain medications, potentially leading to co-morbidities if not properly assessed. This is especially a concern in older adults, given their increased vulnerability to the side effects of pain medications. NSF urges the MAP to consider adding “How did you sleep?” to MUC16-32 and MUC16-264. We are ready to support them in these efforts. As sleep is truly a vital sign of health, this simple measure will significantly improve clinical decisions, patient outcomes and population health. Please do not hesitate to contact me (dcloud@sleepfoundation.org) if you have any questions. Best regards, David Cloud (Submitted by: National Sleep Foundation)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  
• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  
• It is well established that behavioral health disorders are the largest cost driver in the US with a price tag of over $200 billion annually (Roehring, C Hlth Aff 2016 35 (6)). Annual anxiety prevalence is 18% which is greater than that of depression at 6.6% annually (NIMH 2016 https://www.nimh.nih.gov/health/statistics/index.shtml). In the Department of Health and Human Services’ (HHS) Top 20 High-Impact Medicare Conditions Crosswalk (2015 National Impact Assessment of CMS Quality Measures Report) major depression is ranked number one. This HHS report lists cardiovascular, diabetes, cerebrovascular, and cancer as the next highest high-impact disorders. Thirty-five percent of patients with chronic medical conditions have a mental illness (2014 Milliman Report for the American Psychiatric Association). The underdiagnosed and undertreated mental health disorders in these high-impact categories should be expanded, addressing these unmet patient needs in order to improve outcomes, decrease costs and improve the experience of patients. There should be a national imperative to diagnose and treat these conditions in primary and specialty care considering the prevalence and comorbidity with chronic medical conditions. Use of multidimensional mental health screens that provide measures can drive the healthcare system to higher performance and can be accomplished through minimal disruption in clinical workflow. M3 recommends the adoption of measures that incentivize comprehensive assessment of a patient’s risk for a behavioral health condition and fit seamlessly into the physician workflow. M3 is appreciative of the MUCs listed that incorporate behavioral health issues such as: • tobacco use screening & treatment (MUC16-50 to 52) • alcohol screening & treatment (MUC16-178 to 180) • opioid safety, screening & use (MUC16-167 & 428) • anxiety related to hospice care (MUC16-39) • harm to self for patients with dementia & their caregivers (MUC16-317) The current list of MUC touches on several mental health issues in tangential ways as seen from the list above. The MAP can drive the healthcare system to higher performance through the use mental measurement system that can be used across healthcare settings, reports functional status, addresses patient safety, provides longitudinal comparisons, reports results electronically, and fills gaps for multiple behavioral health conditions, rather than just depression. With this in mind M3 recommends NQF endorse multidimensional measures with a similar to NQF-2620. NQF-2620 measures the percentage of people in primary care settings who have had an annual multi-dimensional mental health screening assessment, which is operationally defined as "a validated screening tool that screens for the presence or risk of having the more common psychiatric conditions, which for this measure include major depression, bipolar disorder, PTSD, one or more anxiety disorders (specifically, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and/or social phobia), and substance abuse." (Kessler RC, NEJM 2005; 352(24): 2515) among the most common behavioral health conditions, and there exist multi-dimensional behavioral health assessment tools that can be used across primary and specialty care settings (Kennedy Forum 2016, A Core Set of Outcome Measures for Behavioral Health Across Service Settings). MUC16-039 (anxiety in pt &/or caregiver related to hospice care) – M3 applauds addressing anxiety that occurs in patients and their caregivers when the patient is in hospice care. M3 recommends the use of multidimensional screening and measurement rather than only focusing on anxiety when other mental health conditions may be present. This type of assessment simultaneously screens and measures for risk of multiple mental health and substance use disorders and decreases the clinical workflow burden. The challenge is the lack of multidimensional measures. (Submitted by: M3 Information, 155 Gibbs St #522 Rockville, MD 20850)
  
  

• CAPC recommends the use of this measure for the HQRP. (Submitted by: Center to Advance Palliative Care)
  
  

• Identify all measures based on requirements from IMPACT Act to include this information in the measure description. (Submitted by: University of Colorado, Anschutz Medical Campus)
  
  
• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would like to note that while this measure has been implemented for other settings (IRF, SNF and LTCH), a Public Comment period is currently open with a deadline of December 9th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. The proposed measure does not provide testing of this measure or the measurement items within the Home Health setting. While the items for this measure were a part of the PAC-PRD project, only 44 of the over 12,400 home health agencies participated in the project, representing less than 1% of all home health providers. Additionally, the PAC-PRD project collected admission and discharge assessments on roughly 4,500 home health patients, out of the nearly 3.4-3.5 million Medicare beneficiaries who utilize home health care services, again representing less than 1% of all home health episodes. Without proper testing of this measure within the Home Health setting, we question the reliability and validity of the data collection, and the resulting measurement values to be utilized for a quality reporting program. Additionally, the proposed measure and measurement items would also be placed on top of existing OASIS items which are found to be duplicative or similar in nature. Without testing the proposed items in conjunction with existing OASIS items, we cannot determine the reliability and validity of the information being collected and utilized as part of this measure. The proposed measure is also a process measure, requiring only that the provider assess, data enter, and transmit the data to CMS. A provider that may perform well on this measure does not necessarily mean that the provider is producing quality outcomes, but instead that they are able to assess and transmit data on patients. We question whether this process measure and the resulting measurement values are representative of the quality of care being delivered, and would ask CMS and the measure developers to provide evidence that this specific measure improves the quality of patient care. Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 13 items and another 2 pages to the existing 21 page SOC OASIS form, 22 page ROC OASIS form, and 15 page Discharge from Agency OASIS form. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• ARN affirms that patient outcome quality measures must be measured and monitored to evaluate, advance, and compare patient safety programs in health care. The impact and burden of falls and fall-related injuries among vulnerable home-bound patients enrolled in home health settings contribute to increased hospitalization, morbidity, and mortality. Therefore, ARN asserts that the CMS impact measure “Major Falls” is insufficient to evaluate, compare, and contrast the burden of falls experienced by this patient population. ARN believes the following: 1). Falls of all severity levels of injury should be reported, as is required in hospitals and long-term care settings. Among frail, geriatric, and /or disabled populations, minor injuries can result in grave consequences such as loss of function and loss of life. 2). We recommend the falls with major injury proposal be a bundled composite measure that includes structure and process components. The structure measure specific to a fall-related injury should include assessment of fall injury risk and fall injury history upon enrollment in home health care services, and evidence of an injury prevention plan of care developed by the HHA. 3). CMS should include the level of health care and cost burden of the fall by requiring the reporting of emergency medical response to the home, emergency room admission and/or hospital admission. Such process of care measures would increase validity and reliability of the fall and fall injury impact measure. ARN believes it is important to monitor and track falls which occur during the home health episode in an effort to improve patient outcomes. Nurses play a critical role in ensuring the safety of our patients as well as the quality of care that is delivered. However, ARN has concerns with the accuracy of the proposed quality measure, Falls with Major Injury in the home health setting, given that it is based on patient-level data reported to home health staff at the time of discharge. For the quality measure to properly serve its purpose, the accuracy of patient data is critical, and while patients’ recollection may be reasonably accurate, it is likely subject to distortion. Moreover, we have concerns that documentation of falls with major injury may be prone to inaccuracies, which has previously been observed in the nursing home setting. As noted in the February 13, 2015 CMS Survey and Certification Memorandum (S&C 15-25-NH), CMS conducted a voluntary pilot that was focused on coding practices and their relationship to resident care in nursing homes. During the pilot study, CMS found that nursing home staff, in an effort to capture falls and the level of injury sustained, often failed to accurately denote the level of injury following a fall. The presence and severity of a fall-related injury is not always immediately diagnosed at the time of the fall, but may be discoverable days or months after the fall, such as with hip fractures and delayed onset subdural hematoma. The inclusion of structure, process, and outcome measures aligns with the National Quality Forum’s Patient Safety Measures for hospital, long-term care, and primary care settings. 4). Risk-adjust falls and falls with injury by age, comorbidity, and disability. It is well known that falls frequently occur in the home health setting. ARN has stated in previous comments the many confounding factors that contribute to a fall, repeat falls, and resulting injuries. A quality measure that merely tracks falls with major injury fails to provide an adequate comparison under a pay-for-performance model. One HHA may admit more patients who are prone to falling due to various risk factors, such as difficulty walking, use of certain medicines, or home hazards or dangers, than another HHA. Because the falls with major injury measure is not risk-adjusted by population, we have concerns that the measure will be better at identifying the HHAs that have the highest and lowest rates of falls resulting in major injury, which may inaccurately portray the quality of care being furnished. To properly measure and compare patient safety in the home health setting, ARN strongly believes that any measurement of falls and injury should be expanded, as previously discussed. We encourage CMS and Abt Associates to consider the development of a falls measure in the home health setting that is “with or without injury” and “assisted or non-assisted.” This should be tracked by preventable falls (patient-related or environment- and other-related) and non-preventable (patient condition like fainting). (Submitted by: Association of Rehabilitation Nurses)
  
  
• Advocate Health Care (Advocate) has concerns with the measure as currently proposed. We appreciate your consideration of our recommendations and comments below. Risk-Adjustment Home health agencies provide intermittent care to patients with varying levels of care needs and caregiver support and diverse living environments. Agencies have limited control over a patient/caregiver’s ability or willingness to comply with fall prevention strategies. For example, patients may choose not to install grab bars for bathroom safety, make necessary home repairs, or use prescribed ambulatory aids. Advocate has concerns that because the measure is not risk-adjusted, the measure fails to give home health agencies meaningful feedback in the category of major injury from the falls expected rate versus the actual fall rate. With major injury, it is critical for home health providers to understand performance improvement opportunities in order to assess how to address and decrease the rate of falls. We recommend including risk-adjustment in the proposed measure. Recommendations 1). The Falls with Major Injury measure should be risk-adjusted at minimum for the following variables: • Diagnosis; • Functional ability; • Cognition; • Vision and hearing; • Caregiver support; • Living environment; and • Number of therapy visits. 2). Prior to implementation, testing and validation of the measure in the home health setting should be conducted. 3). As the Centers for Medicare and Medicaid Services (CMS) continues to implement the IMPACT Act, we encourage CMS to control for duplication of home health quality measures and account for the administrative burden on home health agencies associated with increasing the number of Outcome and Assessment Information Set (OASIS) data set items. Fall Reporting Categories Advocate has concerns regarding the accuracy of reporting the number of falls in three categories: no injury, minor injury, and major injury. Currently, home health documentation systems do not differentiate falls into these categories. Clinical documentation systems will need to be modified in order to collect fall information for no injury, minor, and major injury. This could lead to inaccurate data collection if the entire record must be reviewed to obtain this data on discharge or transfer. As major injury is the easiest to detect, we suggest initiating the measure with only this category. Fall Risks and Prevention Standard We also have concerns that the IMPACT Act requires the falls with major injury measure to be applied across all post-acute care settings, including community care settings; not all of which are facility-based with 24/7 staff supervision. Due to intermittent patient contact, home care workers have limited ability to affect fall prevention. Most falls that occur at home are not witnessed by home care staff; as such, staff members are unable to directly prevent falls in unsafe or high-risk situations. Advocate encourages CMS not to adopt the measure into the Home Health Quality Reporting Program until the Agency has considered how to address our concerns and recommendations as outlined above. Advocate greatly appreciates the opportunity to share our comments on the home health falls with major injury measure. We look forward to continuing to work with CMS and the National Quality Forum’s Measure Applications Partnership on these important issues. (Submitted by: Advocate Health Care)
  
  
• The Alliance is concerned about whether it is possible for this measure to be comparable across postacute care settings, as in home health care there usually is nobody present to witness and document the fall and the consequent injury at the time of the incident. The Alliance is therefore concerned about the reliability of the data collection for this measure as it applies to home health care. If a goal is for this measure to be meaningful across settings, standardization is key. At the very least, appropriate adjustment should take into consideration the very different nature of home health in comparison to the facility-based settings. The Alliance recommends that any falls measure that is publicly reported be risk adjusted. (Submitted by: Alliance for Home Health Quality and Innovation)
  
  
• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". The proposed measure does not provide testing of the measure values or the measurement items within the Home Health setting, and the MUC List notes indicate that the measure is currently in the process of “Field Testing”. The referenced endorsed measure, NQF #0674, was tested on long-stay residents in a Skilled Nursing setting, where the resident had to be present for 101 days or more to be included in the measure. We would suggest that the skilled nursing setting differs greatly from home health services, and as such testing within the home health population should be required to determine the reliability and validity of the measurement items and resulting measurement values. We also question whether this measure adequately captures the quality of care provided by a home health agency, especially when a patient may experience a fall with major injury at a time when home health personnel are not present. Because this measure is not risk-adjusted and does not provide exclusion for circumstances that may occur when home health personnel are not present, a home health agency’s performance may be outside their control and instead be the result of negative patient actions. We would recommend CMS and their measure developer consider whether or not risk-adjustment factors and/or exclusion criteria could be added to account for circumstances that fall outside of the home health agency’s control. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the inclusion of this measure across PAC settings with the updated specifications provided by CMS and the contractor RTI which is found at the link below. The updated language standadrizes terminology utliizing the recommendations from the National Pressure Ulcer Advisory Panel (NPUAP) from 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Refinement-of-Percent-of-Residents.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the IRF QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. A review of the UDSMR IRF database indicates that a change to the new items would increase the number of cases identified as having a new or worsened pressure ulcer by 60%, bringing into question the reliability and validity of the item set utilized for this purpose. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 1% for IRFs, as detailed in the most recently published CMS IRF Provider Preview Reporting. While the measure may be able to differentiate value amongst some of the IRFs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of IRF performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the PAC/LTC workgroup consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• Unstageable pressure ulcers have a place in the measure calculation but we do not agree with the addition of Deep Tissue Injuries at this time. There is far too little research on Deep Tissue Injuries and there is not a solid consensus on how long it may take for the body to actually reveal a Deep Tissue Injury. This matters because determining community acquired vs. facility acquired is almost impossible on a consistent and reliable basis within a single setting much less consistently across all of PAC. Additionally, significant education is needed in differentiating between a Stage 2 blister and deep tissue injury. We also have these comments on the proposal to change the pressure injury terminology for coding blisters vs deep tissue injuries: The term pressure ulcer injury is very controversial. This needs to be explored further before adoption in the RAI. Words matter, particularly in the nursing facility setting where legally, the nursing facility is the patient’s home. The term injury carries much more than just a description of an open area. The use of the word injury has a negative context, connotes trauma and all but says there is fault to be determined. We absolutely disagree with the adoption of NPUAP definitions that differentiate Stage 2 blister from deep tissue injury. The RAI takes assessment to a necessary level for differentiation. We have found that our clinicians are far more accurate in staging by using the steps to evaluate the surrounding skin vs. solely relying on the contents of a blister. To adopt NPUAP definitions/assessment instructions would be a step backwards. Additionally, we are concerned about the timing of the date of "admission" to Home Health and the clinician opening the HH case could impact the reported "outcome" of the PAC care provided in the preceding PAC setting. For example, if the patient with a wound is not "admitted" to HH for several days after the discharge from a SNF, how will the condition of the patient reflect on and/or impact the patient outcome reported by the SNF? This can be further complicated when addressing a wound care patient when an SLP or a PT without wound care credentials opens the HH case (and completes the OASIS) and the patient has not followed discharge guidance for daily wound care. Wound assessment is a special skill and requires training. It could be another day or more before a nurse assesses the condition of the wound. In this example, there is no way a wound will be in the same condition upon HH "admission assessment" as it was upon "discharge assessment" from the SNF. There are other medical conditions that could create a similar scenario. We also note that HH is the only PAC setting among the IMPACT Act PAC settings that is not an inpatient setting, so does not have a team of staff all working in the same place at the same time. The start of care is not necessarily driven by a transfer admission, as there could be varying lapses in the time between the patient arriving home and when the first HH professional opens the case. Therefore, unlike an admission date in SNF, IRF and LTCH, which is the day of the transfer to the new level of provider, there is a potential for the admission day to be a day or days later for HH. The concern is how the quality measures will capture the same timeframes with the differences and lapses in when the assessment is made among the settings. (Submitted by: National Association for the Support of Long Term Care (NASL))
  
  
• The American Health Care Association (AHCA) represents more than 12,000 non-profit and proprietary skilled nursing centers, assisted living communities, sub-acute centers and homes for individuals with intellectual and developmental disabilities. By delivering solutions for quality care, AHCA aims to improve the lives of the millions of frail, elderly and individuals with disabilities who receive long term or post-acute care in our member centers each day. AHCA appreciates the opportunity to submit comments on MUC 16-142 Application of Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay). We do not support the use of this modified measure and in the comments below, we address key focus areas with recommendations and rationale for those recommendations. Issue 1: The addition of unstageable pressure ulcers due to slough or eschar, unstageable pressure ulcers due to non-removable dressing or device, and unstageable pressure ulcers presenting as deep tissue injuries in the numerator AHCA recommends: • Do not add unstageable pressure ulcers due to slough or eschar, unstageable pressure ulcers due to non-removable dressing or device or unstageable pressure ulcers presenting as deep tissue injury to the measure. These MDS items do not indicate a worsened pressure ulcer nor clearly represent a new pressure ulcer acquired in the SNF, which are what the measure is intended to capture. Rationale: We do not support the addition of unstageable pressure ulcers because these types of pressure ulcer coding of unstageable by nature do not indicate worsening of the pressure ulcer. Another example of a reason to oppose including unstageable pressure ulcers, such as "Unstageable –Non-removable dressing/device (M0300E1) –(M0300E2) > 0” because the presence of a non-removable dressing/device does not necessarily indicate a worsened pressure ulcer. There are times when a person has a pressure ulcer with non-removable dressing/device during the MDS assessment window, thus this item would be coded. The measure specifications as proposed, would indicate this pressure ulcer as new or worsened, which is not necessarily accurate. In addition, deep tissue injuries take time to appear and in some cases may have occurred before admission to the SNF due to the time it takes to be present to the naked eye. Supporting references include A. Gefen, PHD; K. Farid, DNP, MA, CWON; and I. Shaywitz, MD – in Ostomy Wound Management February 2013 “by the time dead skin becomes a more detectable black eschar, the original DTI at the level of bone (the death of the underlying tissues) is approximately 2 weeks old. Regardless of whether the patient has been in the facility 2 weeks or less, the pressure ulcer then is classified facility-acquired “unstageable,” even though it most likely was present underneath on admission.” Issue 2: The use of M0300 (M1311 OASIS) items instead of M0800 (M1313 OASIS) items to calculate the quality measure. This modification is intended to reduce redundancies in assessment items and facilitate cross-setting quality comparison as specified by the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act). AHCA Recommends: • Do not use M0300 items instead of M0800 items to calculate the quality measure. M0800 provides the most accurate reconciliation of pressure ulcers for the purposes of what this measure is intended to capture. Rationale: M0800 provides an opportunity to reconcile pressure ulcers to verify which of current pressure ulcers were not present or were at a lesser stage on prior assessment or last entry. The CMS RAI Version 3.0 Manual also states on page M-26 under Coding tips: “Coding this item will be easier for nursing homes that document and follow pressure ulcer status on a routine basis.” Neglecting use of M0800 for this measure, will undermine accuracy of the measure. In summary, we do not support the use of this modified measure. The already existing measure for this topic, is used by CMS as a nursing home quality measure, used on Nursing Home Compare and Five Star Rating System, and recently added to the CMS SNF Quality Reporting Program. Modifying this measure for SNF QRP use, will not bring value to quality of care, rather will add unnecessary complexity, burden and confusion which will only detract from the National Quality Strategy priority of making care safer. Thank you for inviting our feedback and considering these recommendations. (Submitted by: American Health Care Association)
  
  

• AOTA supports the inclusion of this measure across PAC settings with the updated specifications provided by CMS and the contractor RTI which is found at the link below. The updated language standadrizes terminology utliizing the recommendations from the National Pressure Ulcer Advisory Panel (NPUAP) from 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Refinement-of-Percent-of-Residents.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the IRF QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. A review of the UDSMR IRF database indicates that a change to the new items would increase the number of cases identified as having a new or worsened pressure ulcer by 60%, bringing into question the reliability and validity of the item set utilized for this purpose. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 1% for IRFs, as detailed in the most recently published CMS IRF Provider Preview Reporting. While the measure may be able to differentiate value amongst some of the IRFs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of IRF performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the PAC/LTC workgroup consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• MUC 16-143 IRF QRP Application of Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (short-stay). AMRPA has historically supported clear, clinically accurate pressure ulcer measures. A similar measure is currently used in the IRF QRP. However, before this measure under consideration is adopted we recommend NQF consider the following comments. AMRPA has made similar recommendations to CMS which we believe would enhance the value of the measure and patient outcomes. All IRFs are currently using a similar measure. However, with respect to amending the measure we recommend the following: 1. Numerator A. Pressure Ulcers Due to Slough or Eschar AMRPA supports the inclusion in the numerator of unstageable pressure ulcers due to slough or eschar or due to a non-removable dressing/device, which AMRPA also supported when it was proposed in the FY 2016 IRF PPS proposed rule. Furthermore, CMS does not propose to include suspected deep tissue injuries (sDTIs) in the numerator which AMRPA supports. We do not think it is appropriate to include sDTIs because much is still unknown about including whether there is an actual deep tissue injury. Many sDTIs heal without opening and it would be unfair to penalize a provider for these. B. Measure Specifications CMS proposed refinements that would also change how the measure is calculated. It would use IRF PAI Item M0300, “Current Number of Unhealed Pressure Ulcers at Each Stage” to calculate new or worsened pressure ulcers by subtracting the number of pressure ulcers that were present on admission from the total number of pressure ulcers for each stage, all of which is contained in M0300 assessment data. Presently, the measure is calculated using IRF PAI Item M0800A-F, “Worsening in Pressure Ulcer Status Since Admission” which is assessed at discharge. This item requires providers to “indicate the number of current pressure ulcers that were not present at admission or were at a lesser stage at admission” for Stage 2-4 pressure ulcers and three types of unstageable pressure ulcers. In other words, the present method requires providers to do the calculation for Item M0800 themselves and then enter the data into an additional assessment item. AMRPA supports modifying the measure calculation to using M0300 items directly. We commended CMS and its contractors for proposing to simplify the measure calculation process. We also requested that CMS clarify whether M0800 would still be included on the IRF PAI if it no longer feeds into the pressure ulcer measure (NQF #0678) calculations. If M0800 does not serve quality reporting purposes, AMRPA recommends that it be eliminated from the IRF PAI. This would reduce the number of items providers must report and thus decrease burden. However, we have heard concerns raised that replacing M0800 A-F with a calculation derived from M0300 would overestimate the number of new/worsened pressure ulcers (and subsequently the number of patients with new/worsened pressure ulcers) and should not be considered for IRFs until the data can be considered consistent and reliable. This issue may also call into question the validity and reliability of the derived M0300 calculation as currently used in other settings to indicate new/worsened pressure ulcers. Given the discrepancy between the items, we believe this type of change would need to be reviewed through the NQF measure endorsement process. (Submitted by: American Medical Rehabilitation Providers Association (AMRPA))
  
  

• AOTA supports the inclusion of this measure across PAC settings with the updated specifications provided by CMS and the contractor RTI which is found at the link below. The updated language standadrizes terminology utliizing the recommendations from the National Pressure Ulcer Advisory Panel (NPUAP) from 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Refinement-of-Percent-of-Residents.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the IRF QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. A review of the UDSMR IRF database indicates that a change to the new items would increase the number of cases identified as having a new or worsened pressure ulcer by 60%, bringing into question the reliability and validity of the item set utilized for this purpose. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 1% for IRFs, as detailed in the most recently published CMS IRF Provider Preview Reporting. While the measure may be able to differentiate value amongst some of the IRFs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of IRF performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the PAC/LTC workgroup consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the inclusion of this measure across PAC settings with the updated specifications provided by CMS and the contractor RTI which is found at the link below. The updated language standadrizes terminology utliizing the recommendations from the National Pressure Ulcer Advisory Panel (NPUAP) from 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Refinement-of-Percent-of-Residents.zip (Submitted by: American Occupational Therapy Association)
  
  

• While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: Association of Rehabilitation Nurses)
  
  
• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet MAP Measure Selection Criterion #1 or #3. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". While this measure is already implemented for the IRF QRP based upon NQF Endorsed measure #0678, the changes made to the endorsed measure as presented to the PAC/LTC Workgroup come without reference to any testing and without consideration for whether the changes to the items being utilized provide reliable and valid measure information. These changes are significant enough that they should require the measure to go back through the NQF Consensus Development Process to determine whether or not this measure should continue to receive an endorsed status. To detail the specific changes to this measure, CMS has made 3 significant changes to this measure: 1. Language/descriptions for the items utilized in the measure are now consistent with NPAUP guidelines. We agree with this change for the purpose of consistency within the industry, but question whether these changes will impact the currently collected data and understanding of the value of the quality measure. 2. The numerator will now include unstageable pressure ulcer data, instead of just Stage 2-4 pressure ulcers. Currently, data collection for the unstageable pressure ulcer items is voluntary, suggesting that data available to CMS for testing of the impact of this change may be incomplete and/or inconsistent. This should bring into question the reliability and validity of the item set and therefore impacts the measure values. We believe this alone should require a full review for endorsement consideration as part of the NQF CDP. 3. The numerator statement will also change as a result of a change in the items being utilized for this measure. Currently, post-acute care providers enter data into fields M0800A-C to define pressure ulcers that are new or worsened at time of discharge. CMS has provided extensive training and documentation related to how to code these fields. The proposal under consideration changes the measure to utilize different items that do not explicitly indicate new or worsened pressure ulcers, nor do they provide the same level of training material or documentation that is consistent with the existing new or worsened items. A review of the UDSMR IRF database indicates that a change to the new items would increase the number of cases identified as having a new or worsened pressure ulcer by 60%, bringing into question the reliability and validity of the item set utilized for this purpose. We once again suggest that this change alone should require review for measure endorsement as part of the NQF CDP. UDSMR would further note that current statistics for this measure indicate that the national average for this measure is less than 1% for IRFs, as detailed in the most recently published CMS IRF Provider Preview Reporting. While the measure may be able to differentiate value amongst some of the IRFs, we wonder whether this measure is close to being "topped out" for this setting. While an ideal state would suggest that this measure approach 0%, the differentiation of IRF performance on such a small percentage of cases may not be as indicative of quality differentiation between providers as desired. We would suggest that the PAC/LTC workgroup consider advising CMS to look to the information collected on Healed Pressure Ulcers as a potential next step for the measurement of the domain of skin integrity. Based upon the information presented above, we ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• Home Health is not a 24-hour care setting in which our clinicians can more closely supervise and intervene/provide timely hands-on patient care for patients with a high risk for skin breakdown. For example: get the patient out of bed; repositioning the patient frequently. Home Health can provide the right support surfaces for bed and wheelchairs, instruct and develop schedule for repositioning and assess whether the plan is being followed. The measure must be adjusted for agencies that have a high volume of patients that are either not engaged in self-care or do not have the caregiver and/or resources to implement or follow the home health care plan for preventing worsening/new pressure ulcers. Suspected DTI should be excluded in this measure due to the fact that when identified it is too early in the assessment to confirm whether or not it truly is a pressure ulcer. (Submitted by: Armstrong Institute for Patient Safety and Quality)
  
  

• AOTA supports the inclusion of this measure to better understand the transfer of information. We recommend the admission measure to be harmonized with a QRP for acute care/inpatient hospitalization. The measure is meant to identify a gap in practice for improvement. In the this case, the discharging institution is best positioned to improve the transfer of information at PAC admission; however, the measure is completed on the PAC assessment. this may present an attribution problem, especically with reporting programs. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities, impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• We support continued development of this measure as described in the List of Measures under Consideration. (Submitted by: American Health Care Association)
  
  

• AOTA supports the inclusion of this measure to better understand the transfer of information. We recommend the admission measure to be harmonized with a QRP for acute care/inpatient hospitalization. The measure is meant to identify a gap in practice for improvement. In the this case, the discharging institution is best positioned to improve the transfer of information at PAC admission; however, the measure is completed on the PAC assessment. this may present an attribution problem, especically with reporting programs. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities, impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• The collecting route of information exchange does not add to quality, this is a collection burden and is not necessary. For facilities with a large geographic reach, this is highly variable and would not provide useful data. For units within a hospital this would more likely be within an EMR system. The potential impact and any unintended consequences of the measures (either positive or negative) include: 1. Redundancy – The Caregiver Advise, Record, Enable (CARE) Act requires caregivers be provided written documentation on discharge planning and care needed at discharge; The Commission on Accreditation of Rehabilitation Facilities (CARF) requires patient portable profile which requires much of the same data; the Joint Commission also has standards for discharge summaries. 2. Needs clarification for settings – as IRF and SNF settings are required to screen patients for appropriate admission – is this expected to be information obtained which is exclusive or inclusive of the screening data? 3. Requiring only 1 of the 11 categories to meet the regulation may lead to "doing the minimum". 4. Eliminate the burden of collecting 4.1 admission measure specifications – this is not under the control of the receiving PAC setting. This is not a measure of the quality care provided by the PAC. (Submitted by: Association of Rehabilitation Nurses)
  
  
• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of admission, did your facility/agency receive from the referring/sending/ discharging provider the patient’s health information and/or care preferences that were needed to plan and provide care?”. The responses to this question are “Yes”, “No”, or “NA– Patient was not under the care of another provider immediately prior to this admission/SOC/ROC”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information received from the referring/sending/ discharging provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the receipt of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is not on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. While the admitting provider can request a transfer of information from the referring/sending/discharging provider, the admitting provider’s performance on this measure could be completely outside their control and dependent on the ability of the referring/sending/discharging provider to produce the required information. Given the fact that the admitting provider is already collecting this information as part of a pre-admission screening process without requiring the referring/sending/discharging provider to transfer this information, should the admitting provider be measured on the performance of the other provider? Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 3 items and another page to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the inclusion of this measure to better understand the transfer of information. We recommend the admission measure to be harmonized with a QRP for acute care/inpatient hospitalization. The measure is meant to identify a gap in practice for improvement. In the this case, the discharging institution is best positioned to improve the transfer of information at PAC admission; however, the measure is completed on the PAC assessment. this may present an attribution problem, especically with reporting programs. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities, impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of admission, did your facility/agency receive from the referring/sending/ discharging provider the patient’s health information and/or care preferences that were needed to plan and provide care?”. The responses to this question are “Yes”, “No”, or “NA– Patient was not under the care of another provider immediately prior to this admission/SOC/ROC”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information received from the referring/sending/ discharging provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the receipt of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is not on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. While the admitting provider can request a transfer of information from the referring/sending/discharging provider, the admitting provider’s performance on this measure could be completely outside their control and dependent on the ability of the referring/sending/discharging provider to produce the required information. Given the fact that the admitting provider is already collecting this information as part of a pre-admission screening process without requiring the referring/sending/discharging provider to transfer this information, should the admitting provider be measured on the performance of the other provider? Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 3 items and another page to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the inclusion of this measure to better understand the incidence of the transfer of information. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities., impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• Withdraw previous request regarding MUC16-314. (Submitted by: University of Colorado, Anschutz Medical Campus)
  
  
• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of admission, did your facility/agency receive from the referring/sending/ discharging provider the patient’s health information and/or care preferences that were needed to plan and provide care?”. The responses to this question are “Yes”, “No”, or “NA– Patient was not under the care of another provider immediately prior to this admission/SOC/ROC”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information received from the referring/sending/ discharging provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the receipt of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is not on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. While the admitting provider can request a transfer of information from the referring/sending/discharging provider, the admitting provider’s performance on this measure could be completely outside their control and dependent on the ability of the referring/sending/discharging provider to produce the required information. Given the fact that the admitting provider is already collecting this information as part of a pre-admission screening process without requiring the referring/sending/discharging provider to transfer this information, should the admitting provider be measured on the performance of the other provider? Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 3 items and another page to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• The FAH supports the intent of this measure as it focuses on promoting care coordination and may lead to reductions in patient harm and overuse of services. This measure should be tested for reliability and validity and reviewed by NQF for endorsement prior to support from the MAP and subsequent implementation in the SNF QRP, particularly since similar care transition measures in the inpatient setting have proven challenging to collect and report. (Submitted by: Federation of American Hospitals )
  
  

• AOTA supports the inclusion of this measure to better understand the incidence of the transfer of information. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities., impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. has the potential to show positive performance for circumstances that do not lead to improved quality of care. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of discharge or transfer, did your facility/agency provide the patient’s health information and/or care preferences to the receiving/admitting provider?”. The responses to this question are “Yes”, “No”, or “NA – Patient was not discharged to the care of another provider at the time of this discharge or transfer”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information provided by your facility/agency to the receiving/admitting provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the transfer of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure has the potential to show positive performance for circumstances that do not lead to improved quality of care. While a referring/sending/discharging provider may provide any and all information to the admitting provider, processes are not currently in place to ensure that the information provided by the referring/sending/discharging provider is received and/or reviewed by the admitting provider. Furthermore, the referring/sending/discharging provider could send over incomplete or non-standardized information that does not assist the admitting provider with the ability to properly plan or provide care for the patient. And finally, as we noted above, the information from referring/sending/discharging provider could differ from the information the admitting provider receives from completing their pre-admission process, potentially causing further issues with determining the proper planning and provision of care. We would recommend that CMS and measure developers provide information related to whether or not resulting measure values for transferring providers will represent the opportunity to show an improvement in the quality of care. Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 5 items and another 2 pages to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Of these items, only 2 will actually be utilized for quality measure purposes, while the other 3 are stated to be utilized for additional data collection purposes only. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. has the potential to show positive performance for circumstances that do not lead to improved quality of care. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of discharge or transfer, did your facility/agency provide the patient’s health information and/or care preferences to the receiving/admitting provider?”. The responses to this question are “Yes”, “No”, or “NA – Patient was not discharged to the care of another provider at the time of this discharge or transfer”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information provided by your facility/agency to the receiving/admitting provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the transfer of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure has the potential to show positive performance for circumstances that do not lead to improved quality of care. While a referring/sending/discharging provider may provide any and all information to the admitting provider, processes are not currently in place to ensure that the information provided by the referring/sending/discharging provider is received and/or reviewed by the admitting provider. Furthermore, the referring/sending/discharging provider could send over incomplete or non-standardized information that does not assist the admitting provider with the ability to properly plan or provide care for the patient. And finally, as we noted above, the information from referring/sending/discharging provider could differ from the information the admitting provider receives from completing their pre-admission process, potentially causing further issues with determining the proper planning and provision of care. We would recommend that CMS and measure developers provide information related to whether or not resulting measure values for transferring providers will represent the opportunity to show an improvement in the quality of care. Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 5 items and another 2 pages to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Of these items, only 2 will actually be utilized for quality measure purposes, while the other 3 are stated to be utilized for additional data collection purposes only. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• MUC 16-325 IRF QRP Transfer of Information at Post-Acute Care: Discharge or End of Care to Other Providers/Settings 1. General Comments AMRPA supports collection of data of this nature. Furthermore, we support efforts to delineate the information to be included at the time of transfer from the post-acute care provider and to the families/ patient/ caregivers as well. 2. Use as a Quality Measures AMRPA believes this proposed measure lends itself more readily to being characterized as a quality measure as the information was in the control of the PAC provider, in this case an IRF. 3. Specific Information Requested to be Transferred Again, as noted with respect to MUC 16-319, various categories are redundant and burdensome. In reality IRFs generally provide this information. However, to pull it from the record and double check these categories by these definitions may be an extra burdensome tasks. The MUC report provided by NQF references eight categories yet we did not see a list. Hence these comments reflect our observations on the RAND proposal: a. Several of the items are redundant and therefore increase the reporting burden. Items such as “Administrative Information: should be reexamined and narrowed. b. Functional status should be retained and encompass mobility and self-care at a minimum c. Cognitive function and mental status should be retained. d. Special services should be retained e. Medical conditions and co-morbidities should be retained. f. Impairments should be retained. g. Medication instruction should be retained and explained. h. Patient care preferences should be retained and also expanded to include preference regarding types of nurses, language used, and religion as examples. i. Goals of care needs to be clarified—was this the goals of care in the IRF or the projected goals of care for the receiving PAC provider? j. Diet/nutrition could be eliminated. 4. Denominator Specifications AMRPA understand that one of the objectives of the IMPACT Act is to collect comparable data across all the four post-acute care providers encompassed within the Act. To do so implies that items utilized are essentially identical if there is to be a true comparison. For this proposed measure the populations to be used in the denominators for the various providers are different. For example, for IRFs the population for the denominator is Medicare Part A (traditional fee for service Medicare) and Part C (Medicare Advantage) patient stays. For SNFs it is only Part A resident stays. The final data collected will be comparable within provider types but not across provider type. AMRPA recommends this approach be reconsidered. (Submitted by: American Medical Rehabilitation Providers Association (AMRPA))
  
  

• AOTA supports the inclusion of this measure to better understand the incidence of the transfer of information. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities., impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. has the potential to show positive performance for circumstances that do not lead to improved quality of care. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of discharge or transfer, did your facility/agency provide the patient’s health information and/or care preferences to the receiving/admitting provider?”. The responses to this question are “Yes”, “No”, or “NA – Patient was not discharged to the care of another provider at the time of this discharge or transfer”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information provided by your facility/agency to the receiving/admitting provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the transfer of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure has the potential to show positive performance for circumstances that do not lead to improved quality of care. While a referring/sending/discharging provider may provide any and all information to the admitting provider, processes are not currently in place to ensure that the information provided by the referring/sending/discharging provider is received and/or reviewed by the admitting provider. Furthermore, the referring/sending/discharging provider could send over incomplete or non-standardized information that does not assist the admitting provider with the ability to properly plan or provide care for the patient. And finally, as we noted above, the information from referring/sending/discharging provider could differ from the information the admitting provider receives from completing their pre-admission process, potentially causing further issues with determining the proper planning and provision of care. We would recommend that CMS and measure developers provide information related to whether or not resulting measure values for transferring providers will represent the opportunity to show an improvement in the quality of care. Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 5 items and another 2 pages to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Of these items, only 2 will actually be utilized for quality measure purposes, while the other 3 are stated to be utilized for additional data collection purposes only. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the inclusion of this measure to better understand the transfer of information. We recommend the admission measure to be harmonized with a QRP for acute care/inpatient hospitalization. The measure is meant to identify a gap in practice for improvement. In the this case, the discharging institution is best positioned to improve the transfer of information at PAC admission; however, the measure is completed on the PAC assessment. this may present an attribution problem, especically with reporting programs. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities, impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of admission, did your facility/agency receive from the referring/sending/ discharging provider the patient’s health information and/or care preferences that were needed to plan and provide care?”. The responses to this question are “Yes”, “No”, or “NA– Patient was not under the care of another provider immediately prior to this admission/SOC/ROC”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information received from the referring/sending/ discharging provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the receipt of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is not on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure potentially penalizes the admitting provider for issues present at the referring/sending/discharging provider. While the admitting provider can request a transfer of information from the referring/sending/discharging provider, the admitting provider’s performance on this measure could be completely outside their control and dependent on the ability of the referring/sending/discharging provider to produce the required information. Given the fact that the admitting provider is already collecting this information as part of a pre-admission screening process without requiring the referring/sending/discharging provider to transfer this information, should the admitting provider be measured on the performance of the other provider? Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 3 items and another page to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the inclusion of this measure to better understand the incidence of the transfer of information. AOTA would encourage more conversation related to requiring only 1 of the 8 areas of information. While this may be appropriate as providers acclimate to this process measure, it may not be meaningful. AOTA fully supports balancing the burden of reporting with the utility of the measure, but we are not currently convinced that only 1 of 8 is the right balance. Furthermore, the full specification of "Draft Specifications for the Transfer of Health Information and Care Preferences for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Home Health Agencies" found at the link below includes 11 areas of information: "1. Functional status, 2. Cognitive function and mental status, 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use), 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain), 5. Impairments (e.g., incontinence, sensory), 6. Medication information, 7. Patient care preferences (e.g., advance directives), 8. Goals of care, 9. Diet/nutrition, 10. Administrative information, 11. Discharge instructions". More discussion is warranted to define the 8 areas included in the MUC in comparison to the 11 areas proposed by RTI and CMS. We would recommend including the following areas for discussion related to the numerator statement: Functional status, cognitive function and mental status, medical conditions and co-morbidities., impairments, medication information, and diet/nutrition. AOTA would also recommend the consideration of implantable devices. This may be accomplished by including this important element in the special services or another category. LINK: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Percent-of-Home-Health-Episodes-with-Admission-and-Discharge-Functional-Assessment-and-Care-Plan.zip (Submitted by: American Occupational Therapy Association)
  
  

• In reference to the slides provided as part of the All-MAP Pre-Rulemaking process, the measure as it has been presented would not meet the criteria that it is fully developed and tested, and would not meet many of the MAP Measure Selection Criterion. Accordingly, we suggest that the PAC/LTC Workgroup consider the decision category of "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". We would also like to note that this measure has not completed a full stakeholder input process prior to consideration for rule-making by the MAP PAC/LTC Workgroup. While a Technical Expert Panel was constructed and met to discuss the potential for a quality measure in late September, a Public Comment period is currently open with a deadline of December 11th for providers and other industry experts to provide feedback to CMS and their measure developer about the measure as it is proposed. We are very concerned that a measure that is very early in the development stage and has not been through a thorough stakeholder review process has been added to the MUC List, and that CMS has not provided adequate time to industry stakeholders to provide feedback prior to consideration for rule-making by the NQF MAP PAC/LTC Workgroup. Furthermore, while UDSMR believes that care transitions can be enhanced through care coordination and the enhanced flow of patient information, the measure presented for consideration: 1. does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care, 2. does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers, 3. does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes, and 4. has the potential to show positive performance for circumstances that do not lead to improved quality of care. To provide additional context to our concerns above: 1. The proposed measure does not ensure that the information that is to be transferred is standardized or provided in a sufficient manner to benefit the patient’s care. According to proposed measure specifications, the assessment of this measure begins by asking the post-acute care provider “At the time of discharge or transfer, did your facility/agency provide the patient’s health information and/or care preferences to the receiving/admitting provider?”. The responses to this question are “Yes”, “No”, or “NA – Patient was not discharged to the care of another provider at the time of this discharge or transfer”. A “Yes” response to this question would then prompt another question asking the provider to “Indicate the types of health information provided by your facility/agency to the receiving/admitting provider”, with a “Check all that apply” response list containing the following options: 1. Functional status 2. Cognitive function and mental status 3. Special services, treatments, and/or interventions (e.g., ventilator support, dialysis, IV fluids, parenteral nutrition, blood product use) 4. Medical conditions and co-morbidities (e.g., pressure injuries and skin status, pain) 5. Impairments (e.g., incontinence, sensory) 6. Medication information 7. Patient care preferences (e.g., advance directives) 8. Goals of care 9. Diet/nutrition 10. Administrative information 11. Discharge instructions 12. None of these types of health information were provided CMS does not provide any additional context or requirements as to what information is necessary to satisfy any of the options above, potentially providing the opportunity for referring/sending/discharging providers to transfer information that is not standardized and may not assist the admitting provider in planning or providing care to the patient. For example, a patient’s functional status can be measured on a number of different self-care and mobility items using many different assessment tools or documentation notes. Would the transfer of one functional status item be sufficient to meet the requirements of this measure, or is a full functional status assessment required based upon a standardized set of items? Without these details or requirements, providers may not receive the information necessary to properly plan and provide care to the patient. Additionally, as the proposed measure specifications currently state, “The numerator for the admission measure is the number of patient/resident stays/episodes with an admission/start of care/resumption of care assessment indicating that health information and/or care preferences were received at admission/start of care/resumption of care, and the information transferred was from at least one of eleven categories of information.” This suggests that in order to meet the measure, the referring/sending/discharging provider needs only to provide information from one of the information types noted above. While we do not expect this to happen in practice, exclusion of any of the information types above may prohibit the admitting provider from providing the necessary planning and provision of care needed for improved outcomes. We would recommend that should CMS continue consideration of this measure, that the requirement be for the transfer of all the information types noted above based upon a standardized set of data elements in order to provide post-acute care providers with information sufficient to properly care for their patients. And finally, we would suggest that for quality measurement purposes it is not necessarily the amount of the information that is transferred, but whether the quality of the information that is transferred leads to an improved patient experience or outcome. CMS and the measure developers should ensure that the information to be included as part of this measure has been shown to impact quality of care and outcomes. 2. The proposed measure does not take into consideration pre-admission screening requirements that are already in place for most post-acute care providers. Part of the requirements for participation in the Medicare program is that the post-acute care providers complete a pre-admission assessment prior to admission, and maintain documentation of that pre-admission assessment within the medical record. The current requirements within the pre-admission assessment guidelines also mirror the information types noted previously, placing the post-acute providers responsible for obtaining this information rather than requiring the transfer of this information from the prior provider. Post-acute care providers are also subjected to audits and/or pre-authorization practices where the medical records are reviewed to determine whether a pre-admission screening was done, and payment potentially withheld or recouped from the provider should a pre-admission screening be missing or inadequately done prior to admission. With this practice in place today, we question the methodology for the measure being proposed and the duplication of efforts that may result from the implementation of this measure. We ask CMS to consider whether the transfer of this information should come from the referring/sending/discharging provider, or through a standardized pre-admission assessment completed by the admitting provider. We also ask CMS to consider whether implementation of this proposed measure should remove pre-admission screening requirements from those providers who are currently subjected to these conditions as part of their participation in the Medicare program. 3. The proposed measure does not contain any evidence that the proposed measure has been tested and can be shown to be reliable and valid towards better care transitions or improved patient outcomes. We recognize that this measure is on the MUC List as being in the “Early development” stage, but without testing the item set for reliability and validity, and not analyzing whether the collection of these items will lead to improved care transition and/or patient outcomes, we do not believe that this measure is ready for implementation into any of the quality reporting programs. While CMS and the measure developer cite various articles and studies that show that improved communication and transfer of information lead to better care transitions and care coordination, none of the articles or studies utilize the proposed measurement items or methodology to determine whether or not the proposed measure will lead to the desired results. We recommend that CMS consider piloting the collection of this information to determine whether or not the items are reliable and valid and produce the desired results for improved care transitions, care coordination and patient outcomes. 4. The proposed measure has the potential to show positive performance for circumstances that do not lead to improved quality of care. While a referring/sending/discharging provider may provide any and all information to the admitting provider, processes are not currently in place to ensure that the information provided by the referring/sending/discharging provider is received and/or reviewed by the admitting provider. Furthermore, the referring/sending/discharging provider could send over incomplete or non-standardized information that does not assist the admitting provider with the ability to properly plan or provide care for the patient. And finally, as we noted above, the information from referring/sending/discharging provider could differ from the information the admitting provider receives from completing their pre-admission process, potentially causing further issues with determining the proper planning and provision of care. We would recommend that CMS and measure developers provide information related to whether or not resulting measure values for transferring providers will represent the opportunity to show an improvement in the quality of care. Finally, we would also like to note the additional burden to be placed upon the providers to collect and submit this information. As proposed, this measure will add an additional 5 items and another 2 pages to existing assessment tools that are already extensive and continually expanding due to the additional requirements CMS is implementing for quality and payment purposes. Of these items, only 2 will actually be utilized for quality measure purposes, while the other 3 are stated to be utilized for additional data collection purposes only. Implementation of this measure will not only require administrative burden to collect and record this information, but will also require updates to technology as well as training for staff in order to adequately and accurately record the information. We ask CMS and the NQF MAP PAC/LTC workgroup to consider whether this additional burden, and the potential increased costs to the Medicare program, will result in the improvement in quality of care desired. Based upon the information presented above, we again ask that the PAC/LTC workgroup consider the decision categories "Refine and Resubmit Prior to Rulemaking" or "Do Not Support for Rulemaking". (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  

• AOTA supports the effort to align functional data elements collected across PAC settings. CMS should weigh provider burden as data elements from the CARE tool are implemented in each setting. The OASIS currently includes functional data elements in section M. As CMS works to standardize data elements, it is important to remove potentially duplicative elements as appropriate to reduce burden. (Submitted by: American Occupational Therapy Association)
  
  

• AOTA submitted comments to CMS and the contractor Abt Associates related to this measure. We support an outcome measure examining the fall with major injury across PAC settings; however, we would recommend further refinement of or development of a new process measure which may fill a gap left by recently removed process measures related to falls. A process measure which identifies evidence-based areas which should be assessed related to falls, potentially including this list from the CDC: Lower body weakness, Poor vision, Difficulties with gait and balance, Problems with feet and/or shoes, Use of psychoactive medications, Home hazards,and Postural dizziness. Other evidence-based areas of intervention related to falls include functional cognition as well as community and environmental hazards. (Submitted by: American Occupational Therapy Association)
  
  

Navigating the Discussion Guide

• How do I get back to the section I was just looking at?
  The easiest way is to use the back button on your browser. Other options are using your backspace button (which works for many browsers on laptops), or using the permanent links at the upper right hand corner of the discussion guide. But the back button is the best choice in most situations.
  
  
• Can I print the discussion guide out?
  You can, but we don't recommend it. Besides using a lot of paper (probably a couple hundred pages at least), you'll lose all the links that allow you to move around the document. For instance, if you're scrolling through the agenda and want to see more information about a particular measure, the electronic format will allow you to click a link, read more, and then bo back. If you're on paper, there will be a lot of flipping through paper.
  
  
• If I can't print this out, how can I read it on the plane?
  We will send you a pdf/Adobe Acrobat file a few days before the meeting, which will hopefully be useful when you're reviewing the discussion guide as you travel to Washington, DC.
  
  
• How do I know that I'm looking at the most recent version?
  At the top left corner of the discussion guide is a version number. At the beginning of the in person meetings, the NQF staff will ask everyone to load the most recent discussion guide version and will check that everyone has the same version loaded.
  
  
• What electronic devices can I use to view the discussion guide?
  We tried to make this as universal as possible, so it should work on your laptop (PC, Mac, Linux), your tablet (iPad, Android), or your phone (iPhone, Android). It should also work on many types of browsers (IE, Firefox, Chrome, Safari, Opera, Dolphin,....). Please let us know if you have any problems, and we'll troubleshoot with you (and improve the discussion guide for the next go around).
  
  
• Why do I see weird characters in some places?
  Because we're joining data from many different sources, we do find some technical challenges. This generally shows up as strange characters--extra question marks, accented characters, or otherwise unusual items. We've been able to fix many of these problems, but not all. We ask that you bear with us as we improve this over time!
  
  

Content

• What is included in the discussion guide?
  There are four sections within this document:
  • Agenda, with summaries of each measure under consideration
  • Full information about each measure, including its specifications, preliminary analysis of how this measure can advance the program's goals, and the rationale by HHS for being included in the list
  • Summaries for each federal health program being considered
  • Public comments that have been received to date (Note that the discussion guide may be released before the public comment period is finished, in which case there will just be a placeholder for where comments will go)
  
  
• How are the meeting discussions organized?
  The meeting sessions are organized around consent calendars, which are groups of measures being considered for a particular program or groups of measures for a particular condition or topic area. For each measure being discussed, this document will show you the description, the public comments (if any), the summary of the preliminary analysis, and the result of the preliminary analysis algorithm.

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