Hospice Special Focus, IDR, and Quality Reporting Program – 2024

Somewhat buried within the Home Health Final Rule (PPS) was an update on a CMS initiative to identify hospice agencies requiring additional regulatory oversight for poor care performance (poor quality, unsafe care practices).

Back in 2021, CMS began the Special Focus initiative and in the 2024 Hospice Final Rule, CMS indicated that the recommendations for the program would be in the Home Health Final Rule. To facilitate the program development, CMS convened a Technical Expert Panel to provide program recommendations. The background for the panel is here:

According to the 2022 Medicare Payment Advisory Commission (MedPAC), more than 1.7 million
patients received hospice services in 2020 at a cost of $22.4 billion to Medicare (MedPAC, 2022). The
hospice industry is growing rapidly, with the number of Medicare-participating hospices increasing by
more than 44 percent in the past decade (5,058 in 2020 compared to 3,498 in 2010; MedPAC, 2022).
Quality hospice care at the end of life is associated with better patient satisfaction, pain control, decreased
intensive care unit use, and decreased hospital mortality (Kleinpell et al., 2019). However, a recent report
indicated that 18 percent of hospices fail to meet the health and safety standards Medicare requires for
participation in the hospice program (OIG, 2019), potentially endangering patients.

Implementation of the SFP includes the following steps.  These steps are found within the TEP Report that is available for download here: 2023 HQRP TEP Summary Report

  1. To identify hospices providing poor quality or unsafe care, CMS will use the most recent Medicare hospice data from the following data:
    • 1) Hospice surveys (recertification and complaint)
    • 2) Hospice Care Index Overall Score, based on Medicare claims data
    • 3) Four CAHPS Hospice Survey measures, aligned with caregiver experience
  2. Hospices will be ranked from highest to lowest in aggregated score, and the group of the ten percent of hospices with the highest scores (lowest-performing hospices), will be considered for the SFP.
  3. CMS will identify the ten percent of hospices with the highest aggregated scores and the SFP selections from that group, which will be determined annually.  Minimally, the general information, program guidance, the target ten percent, SFP selections, and current and past SFP status will be available on the CMS SFP webpage by the end of the first quarter of each calendar year.
  4. While in the SFP, a hospice will be surveyed “not less than once every six months” over 18 months. 
  5. Once in the SFP, a hospice must meet certain conditions to be released from the program.
    • No condition-level deficiencies for two of the standard surveys, which are conducted every six months during the SFP.
    • No pending complaint investigations staged as immediate jeopardy or condition, or
    • Have returned to substantial compliance with all requirements, during the 18-month timeframe to complete the SFP successfully.
  6. A hospice that was unable to achieve substantial compliance for surveys conducted during the SFP would be considered for termination from the Medicare program.

With respect to IDR (Informal Dispute Resolution) and the above SFP, the IDR would allow hospices an informal opportunity to refute one or more condition-level deficiencies cited in the Statement of Deficiencies survey report, which would be similar to the established IDR for Home Health Agencies.

 The Hospice QRP consists of four different quality measures: Hospice Care Index, Hospice Visits in the Last Days of Life, Hospice Item Set and Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Through fiscal year 2023, hospices can earn a 2% reduction in reimbursement for failure to meet requirements for HIS and CAHPS data submission, and in fiscal year 2024 the penalty doubles.

The Hospice QRP Quarterly Q&A for Q3 2023 is now available via CMS. This Q&A includes selected questions received by the Hospice Quality Help Desk during the third quarter of 2023 (July 1 to Sept. 30). A link to the document can be found in the Downloads section of the HQRP Requirements and Best Practices page. 

CMS convened a TEP (Technical Expert Panel) for the Hospice QRP movement to the HOPE quality measure.  The summary TEP Report is available here: 2023 HQRP TEP Summary Report

The name of the hospice patient assessment instrument (HOPE) was finalized in the 2020 Hospice Final Rule. This tool is supposed to help hospices better understand patient care needs through the dying process and then, input to the patient’s plan of care. It is supposed to assess patients in real-time, based on interactions with the patient, as opposed to the Hospice Item Set (HIS) chart review.  

More on the HOPE Assessment is available at the CMS homepage on HOPE at https://www.cms.gov/medicare/quality/hospice/hope

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