Hospices, NHPCO prepare for anticipated CPs

Experts offer advice on how to plan for the change

Time is running out for hospices to prepare for the new Medicare conditions of participation (CPs), and experts say the best strategy is to make quality improvement changes now and not wait until sometime in 2008 when it will become the law.

The major change hospice industry leaders expect to find in the final rule for Medicare CPs involves the quality assessment and performance improvement (QAPI) requirement.

The Centers for Medicare & Medicaid Services (CMS) will ask providers to put together a comprehensive assessment of where their organization is in business, as well as in clinical practice. Then they'll be asked to do some performance improvement projects, including analyzing data and making certain they're measuring improvement, says Judi Lund Person, MPH, vice president of quality for the National Hospice & Palliative Care Organization (NHPCO) of Alexandria, VA.

"The whole idea of collecting data is not new," Person says. "The whole idea that you will measure your performance against yourself and other hospices in the country is a new area."

These quality improvement (QI) measures will be more challenging for hospices than they are for other health care entities, Person notes.

"You have the challenge of having at least half of our patients who are not responsive enough to answer questions directly," Person says. "So hospices will need to get information and data from family members."

Another challenge is that patients won't be enrolled with hospices for very long. Many patients may be in the program for less than a week, and this makes it difficult to track QI, she adds.

NHPCO launched its Quality Partners program a year ago to help hospice providers incorporate QI into their process, Person says.

"Quality Partners is very tied to CPs, and it helps providers get ready for this process, and it's one of the reasons why we have over 2,000 individual providers who have signed up for it and 250 hospice providers who have signed up," Person says.

CMS published the proposed CPs in the Federal Register on May 27, 2005, and the final rule is expected to be published in May 2008. While the final CPs will be changed somewhat from what was proposed two and a half years ago, hospice experts say they likely will include the major changes, such as the QI requirement.

The new CPs likely will focus on quality performance measures, as did the proposed CPs, says Cordt Kassner, PhD, executive director of the Colorado Hospice Organization of Colorado Springs.

"Many hospices have their own internal quality/performance improvement process, but they aren't specifically required through the CPs, and in the new CPs, they'll be required," Kassner says. "So the hospices that don't have an FTE [full-time equivalent] dedicated to quality assurance are in for a change and need assistance on how to develop these programs and how to be in compliance with the new CPs."

It's important to put the changes in context.

Current hospice rules are 25 years old, and the proposed new CPs will update the existing rules, as well as provide more consistency and clarity, Kassner says.

"I believe this is a reasonable request to show the good work that hospices do," he adds.

When the Medicare agency changed the rules for home care organizations more than five years ago, it led to many organizations closing their doors. But this is unlikely to happen with hospices because the changes are not onerous, Kassner says.

"It doesn't seem like these new CPs are really out to significantly shrink the hospice industry, as other fields have experienced," he says. "I think there are some factors out there and some issues and concerns that we're monitoring that may have some impact on hospices, but it's nothing in the CPs."

Hospice leaders express some concerns about implementing the required changes, but none of them express fear that the changes may force them to go out of business, Kassner says.

"People aren't necessarily excited about it, but most hospices see how this is a good requirement in the new COPs," Kassner says. "Even for smaller hospices that don't have specific quality assessment programs in place, do not think it will be an overwhelming burden."

On the positive side, smaller hospices may be able to implement the new CP changes more quickly and more smoothly than larger hospices because they won't have as much staff to train or as complex communication systems to adjust, Kassner notes.

Colorado Hospice Organization (CHO), like other state hospice organizations, has joined NHPCO's Quality Partners program and is offering services and resources to hospices that need help in preparing for the CP changes.

There have been two statewide telephone conferences on the proposed CPs, Kassner says.

And CHO's annual fall conference, held Oct. 11-12, 2007, in Vail, CO, will focus on the quality initiative, and four of the 10 quality components will be addressed in plenary sessions and workshops, Kassner notes.

"We selected the following components: patient and family-centered care, workforce excellence, clinical excellence and safety, and performance measurement," Kassner says.

For some hospices, quality performance has long been a focus.

"We have been preparing for this long before there were new CPs," says Janet L. Jones, RN, BSN, CFO of Alive Hospice Inc. of Nashville, TN.

As a large hospice with more than 400 patient visits per day, Alive Hospice has been measuring quality performance organizationally for the past decade, Jones says.

"We attend to not just the clinical quality measures, but also the financial and other operational measures," Jones says. "So in preparing for the new CPs, it was a matter of pulling together things we were already doing and focusing on these a little differently."

The hospice was one of the first to participate in the NHPCO Quality Partners program, says Tamara Royse, RN, BS[Ed], MSQA, director for quality improvement and training at Alive Hospice.

"That helped us learn new techniques for improvement, and it was a fantastic learning experience," Royse says.

Royse works with other hospices as a faculty coach, assisting them with their performance improvement projects.

Another major change hospice leaders made in preparing for the CPs was to assess the hospice's overall education and leadership training, notes Karen York, MA, CPHQ, executive vice president of organizational excellence and mission at Alive Hospice.

They started off with broad staff education, followed by updates on quality assurance plans, and incorporating changes suggested by the proposed CPs, York says.

At Family Hospice and Palliative Care in Pittsburgh, part of the preparation for the new CPs involves having a detailed assessment done on all patients, says Virginia Valentine, RN, MS, CHPN, director of performance improvement.

"We evaluate right up front what their ability is to communicate," Valentine says. "We have tools for measuring pain in patients who are cognitively impaired or non-communicative, and we used guidelines in relation to non-cancer diagnoses."

Through using these tools, hospice leaders guide staff in making individual adjustments as needed, Valentine says.

Hospice leaders also hold discussions about the anticipated CPs and what these will mean to hospice professionals' daily work.

"We talk about current regulations related to the care planning and setting goals, and we looked at the proposed regulations out there because there are major changes in that whole area of care planning," Valentine says. "We've looked at doing care planning that would yield a focus on outcomes we could measure."

There are weekly team conferences in which staff review an individual patient's case and see how fast the patient's care is moving forward with regard to goals and outcomes, Valentine adds.

It takes time for staff to adjust to this change in how they think about patients and cases, she notes.

"I try to point out there will be a heavy focus on those outcomes," Valentine says. "If the goal is to achieve a certain level of comfort in terms of pain control, then you really need to monitor that and look at that."

Then at a two-week review, staff will have to see how the hospice is doing with regard to this outcome, Valentine says.

"We have to document that we have evaluated those outcomes and that we've moved on to developing new strategies for developing those outcomes," Valentine says.

It comes down to one word: documentation.

"When you talk to hospice professionals, you find that we all feel like we're doing a good job," Valentine says.

"But quality is a nebulous thing," she says. "We have to document with some measurable outcomes that we're in fact doing what we say we're doing."

So how do hospices do this?

The first step is conducting a comprehensive assessment for every patient at admission, Person says.

"It's not that different a process than what providers do now," Person explains. "It's goal setting and identifying each patient's needs."

The initial assessment is the beginning point for starting a quality assessment/performance improvement project, Person adds.

Basically, hospice organizations need to look within themselves to identify which areas need improving, and then they should start a clear and distinct process to make these improvements and measure their success, Jones says.

"Every organization will have to designate someone to be responsible for this process," Jones adds. "It doesn't have to be an additional person, but it has to be someone who has the key responsibility for helping with the process."