PC measures must be applicable across variety of illnesses, settings
While the Affordable Care Act (ACA) mandates quality reporting for hospices, the same is not true for palliative care delivery in other settings.
"One core benefit of palliative care is that it can be delivered to seriously ill patients with a variety of illnesses and across multiple settings," says Sally A. Norton, PhD, RN, FPCN, FAAN, co-director of research in the Department of Medicine’s Palliative Care Division and associate professor in the School of Nursing at University of Rochester (NY).
As a result, palliative care clinicians have been challenged to find measures of quality that are applicable to all patients in a variety of settings. The Hospice and Palliative Nurses Association and the American Academy of Hospice and Palliative Medicine are moving forward with a project to recommend a set of measures that are cross-cutting, says Norton, which will begin to measure quality across populations and settings.
The goal of the Measuring What Matters project is to recommend a set of five to 10 quality measures that are not site- or disease-specific. "That will provide us a foundation to establish quality measures and benchmarks for palliative care," says Norton. (For more detailed information, go to http://bit.ly/1nFINal.)
"The ethical considerations involving assessment center on what constitutes quality, and for whom," says Norton. "Performance measures drive care practices."
As a geriatrician, Christine Cassel, president and CEO of the National Quality Forum (NQF), cared for many patients who were experiencing serious illness or were in need of end-of-life care.
"I know firsthand how important this type of care is and how vital it is to see continued improvements in the quality of care in this area," she says. Performance measurement and public reporting in this area is still relatively new, acknowledges Cassel. In 2006, NQF released its National Framework and Preferred Practices for Palliative and Hospice Care Quality.
"This framework served as a foundation upon which quality measurement and reporting could be built, offering practices designed to improve hospice and palliative care," says Cassel. A total of 38 preferred practices were endorsed as suitable for implementation by palliative care and hospice programs, based on eight domains. These are structures and processes of care; physical aspects of care; psychological and psychiatric aspects of care; social aspects of care; spiritual, religious, and existential aspects of care; cultural aspects of care; care of the imminently dying patient; and ethical and legal aspects of care.
"Since then, the field of measurement has progressed," says Cassel. NQF has endorsed several end-of-life care measures, including a measure related to whether pain is brought to a comfortable level within 48 hours of initial assessment, and a post-death survey for families to answer questions about their perception of care.
"Additional NQF-endorsed measures related to end-of-life care specifically focus on patients with cancer," says Cassel. "Discussions have encouraged an exploration of expanding these beyond this patient population."
Until now, data on hospice program quality have primarily been collected on a voluntary basis, and aggregated to report on quality at a national level. Here are some recent developments:
• The Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs provide financial incentives for meaningful use of certified EHR technology, including a measure that encourages hospitals and eligible providers to record whether patients 65 years of age and older have an advance directive stored in the record.
• Section 3004 of the ACA directs the Department of Health and Human Services (HHS) to establish reporting requirements for hospice programs through the Hospice Quality Reporting Program. Beginning fiscal year 2014, hospice programs are required to submit quality data or incur a financial penalty.
• In 2012, NQF, through its multistakeholder Measure Applications Partnership (MAP), provided input to HHS on performance measures for hospice and palliative care, with an eye toward aligning measures across various settings.
Recognizing that measurement in this area is new, says Cassel, MAP suggested a phased approach to emphasize clinically focused measures at first. This will expand to measures that assess a patient’s full set of experiences across time and settings.
"At this time, this is a pay-for-reporting program, and the submission of data establishes compliance with the requirements — not the performance level," says Cassel. "No date has been specified to begin the public reporting of the data."
- Sally A. Norton, PhD, RN, FPCN, FAAN, Co-Director of Research, Palliative Care Division, Department of Medicine, University of Rochester (NY) Medical Center. Phone: (585) 275-9814. E-mail: Sally_Norton@URMC.Rochester.edu.