The proportion of hospice patients who received hospice visits from a Registered Nurse or Medical Social Worker (non-telephonically) associated with the measured hospice entity during at least two of the final three days of life.
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1.5 Measure Type1.6 Composite MeasureNo1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.10 Measure Rationale
This process measure focuses on the provision of consistent professional staff visits during the last three days of life during this time of increased symptom burden. The disciplines included in this measure – registered nurse and medical social worker service visits – were selected not only because they are the focus of CMS’s payment incentive policy for end-of-life visits (the “Service Intensity Add-On”) but also empirical testing found these visits had the highest correlation with CAHPS Hospice scores (Abt, 2020). Additionally, CAHPS hospice ratings were found to be greatest when visits were provided on two of the last three days of life. Two days would seemingly be preferable to one day for providing more supportive services; as to why it would be preferrable to three days, families may prefer at least some privacy during an end-of-life vigil (and not requiring a visit every day of the last three days of life allows greater flexibility for hospice providers to achieve success at this measure).
Citation: Abt (2020). Hospice Visits When Death is Imminent: Measure Validity Testing Summary and Re-Specifications. Retrieved from: https://www.cms.gov/files/document/hqrphospice-visits-when-death-imminent-testing-re-specification-reportoctober-2020.pdf
1.11 Measure Webpage1.20 Testing Data Sources1.25 Data SourcesData are obtained from Medicare Part A Hospice Fee-For-Service Claims with dates of discharge in Calendar Years 2022 and 2023, corresponding with information used for the Fall 2024 update to the Care Compare site; access was through the CMS Research Data Assistance Center (ResDAC) Chronic Conditions Warehouse (CCW) Virtual Research Data Center (VRDC).
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1.14 Numerator
The numerator of this measure is the number of patients who received hospice visits from registered nurses or medical social workers associated with the measured hospice entity during at least two of the final three days of life.
1.14a Numerator DetailsThe numerator of this measure is the number of patient stays for which the patient and/or caregiver received hospice visits from registered nurses or medical social workers during at least two of the final three days of the patient’s life, as captured by Medicare hospice claims records. Registered nurse visits are identified by revenue code 055x (with the presence of HCPCS code G0299); Non-telephone visits by medical social workers are identified by revenue code 056x (other than 0569; HCPCP code G0155).
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1.15 Denominator
The denominator for the measure includes all Medicare hospice patient stays captured by Medicare hospice claims records where the patient expired in hospice.
1.15a Denominator DetailsThe denominator for the measure includes all the hospice's patient stays where the patient expired in hospice (i.e., patients discharged to death) except for those meeting the exclusion criteria outlined below. Patients that expired in hospice care are indicated by reason for discharge code on the claim (PTNT_DSCHRG_STUS_CD equals [40, 41, or 42]). Hospice patient dates of death must occur during the reporting period (we report analyses at the hospice level using nationwide Medicare Part A hospice claims with dates of death in Calendar Years 2022 and 2023 (corresponding with the most recent available measure calculations, also used for the CMS Care Compare public reporting site’s annual 2024 data update).
1.15d Age GroupOther1.15e Age Group OtherThe target population is all patients admitted to Medicare-certified hospice programs, regardless of patient age.
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1.15b Denominator Exclusions
Hospice patient stays are excluded from the measure if the patient (1) received any continuous home care, respite care, or general inpatient care in the final three days of life or (2) if the patient was enrolled with the hospice fewer than three calendar days.
1.15c Denominator Exclusions DetailsThe exclusion criteria are:
- Patient received any continuous home care, respite care or general inpatient care in the final three days of life (exclude if revenue codes = [0652, 0655, or 0656])
- Patient was enrolled with the hospice fewer than three calendar days.
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1.13a Data dictionary not attachedYes1.16 Type of Score1.17 Measure Score InterpretationBetter quality = Higher score1.18 Calculation of Measure Score
- The data used to calculate the measure are all Medicare Part A hospice fee-for-service claims within the relevant reporting period; this measure is calculated over two pooled years (we report analyses at the hospice level using nationwide Medicare Part A hospice fee-for-service claims with dates of discharge in Calendar Years 2022 and 2023, corresponding with information used for the Fall 2024 update to the Care Compare site).
- Identify the denominator: all Medicare hospice patient stays with the patient discharged to death within the measurement period as identified by the claims discharge status code, PTNT_DSCHRG_STUS_CD equals [40, 41, or 42].
- Remove any denominator exclusions:
- Patient received any continuous home care, respite care or general inpatient care in the final three days of life (exclude if revenue codes = [0652, 0655, or 0656])
- Patient was enrolled with the hospice fewer than three calendar days
- Identify the numerator: patient stays among the denominator in which the patient and/or caregiver received visits from registered nurses or medical social workers during at least two of the final three days of life.
- Registered nurse visits are identified by revenue code 055x (with the presence of HCPCS code G0299).
- Non-telephone visits by medical social workers are identified by revenue code 056x (other than 0569; HCPCS code G0155).
- Calculate the measure score as a proportion:
- For each hospice, divide the total number of cases in the numerator (Step 4) by the total number of cases in the denominator (Steps 2 and 3) and multiply by 100.
- Note: per CMS public reporting standards, the measure is suppressed for hospices with fewer than 20 cases in the denominator (see 1.26).
- For this process measure there is no risk adjustment or stratification of measure scores.
1.19 Measure Stratification DetailsThe measure is not stratified.
1.26 Minimum Sample SizeTo generate statistically meaningful results, the minimum CMS public reporting threshold is at least 20 denominator cases.
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization URLSteward Organization Copyright
N/A
Measure Developer Secondary Point Of ContactT.J. Christian
Abt Global
10 Fawcett Street
Cambridge, MA 02138
United StatesMeasure Developer Secondary Point Of Contact Email
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2.1 Attach Logic Model2.2 Evidence of Measure Importance
Hospice Visits in the Last Days of Life is a measure of the proportion of hospice patients who received hospice visits from a Registered Nurse or Medical Social Worker (non-telephonically) during at least two of the final three days of the patient’s life. Evidence available from clinical organizations and panels, as well as from individual studies, supports the measure’s premise that clinician visits to patients at the end of life are associated with improved outcomes for both the patients and their caregivers.
The last week of life is typically the period in the terminal illness trajectory with the highest symptom burden. Highly specific physical signs associated with death are identifiable within 3 days of death (Hui et al., 2014; Ijaopo et al., 2023). Particularly during the last few days before death, patients experience many physical and emotional symptoms, necessitating close care and attention from the integrated hospice team and drawing increasingly on hospice team resources (de la Cruz et al., 2015; Dellon et al., 2010; Kehl et al., 2013). Hospice responsiveness during times of patient and caregiver need is an important aspect of care for hospice patients (Ellington et al., 2016). Although Medicare-certified hospices do not have any mandated minimum number of required visits for patients in routine home care (RHC), the most common level of hospice care, at the end of life, hospices should be equipped to meet the higher symptom and caregiving burdens of patients and their caregivers during this critical period (Teno et al., 2016). Clinician visits to patients at the end of life are associated with decreased risk of hospitalization and emergency room visits in the last two weeks of the patients’ life, decreased likelihood of a hospital-related hospice disenrollment, and decreased odds of dying in the hospital (Seow et al., 2010; Phongtankuel et al., 2018; Almaawiy et al., 2014). In addition, clinician visits to patients at the end of life are associated with decreased distress for caregivers and higher satisfaction with home care (Pivodic et al., 2016).
Visits by staff who can assess symptoms and make changes to the plan of care as well as work with the patient and the primary caregiver to provide the appropriate palliation and emotional support (nurses, social workers, and physicians) are important to the quality of care hospices deliver, as noted by the National Quality Forum’s preferred practices on the recognition and management of the actively dying patient (Teno et al., 2016). During the development of the Family Evaluation of Hospice Care survey, families voiced the importance of visits by these staff in the last days of life (Teno et al., 2016).
Several organizations and panels have identified care of the imminently dying patient as an important domain of palliative and hospice care and established guidelines and recommendations related to this high priority aspect of care. The National Quality Forum 2006 report “A Framework and Preferred Practices for Palliative and Hospice Care Quality” recommends that signs and symptoms of impending death are recognized, communicated, and educated, and care appropriate for the phase of illness is provided (National Quality Forum, 2006). The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care also acknowledge that “care of the patient at the end of life is time- and detail-intensive, requiring expert clinical, psychological, social, and spiritual attention to the process as it evolves” and recommends that hospices continually evaluate symptom management issues in anticipation of higher needs for staff support at this time (2018). Further, the American College of Physicians Clinical Practice Guidelines recommend that clinicians regularly assess pain, dyspnea, and depression for patients with serious illness at the end of life (Qaseem et al., 2008).
Further, there is evidence of disparity in hospice staff visits at end of life. Patient characteristics associated with greater increases in visit frequency at end of life include being younger, male, white, having a spouse caregiver, and shorter hospice length of stay (Ellington et al., 2016). Another study found that hospice staff visits in the last two days of life were less likely for Medicare beneficiaries who were black, dying on a Sunday, or receiving care in a nursing home (Teno et al., 2016). Thus, measuring these visits may also reduce disparities in care.
Finally, research has shown that hospice visits by professional staff in the last days of life are correlated with higher care quality reported by caregivers. Christian et al. (2020) found that receiving visits from a registered nurse or social worker during at least two of the last three days of life was positively correlated with CAHPS Hospice outcomes, while Anhang Price et al. (2020) found that providing professional staff visits in the last two days of life to 71.1% or more of patients was associated with hospices ranking in the top quartile of both CAHPS and Hospice Item Set (HIS) performance.
Citations:
Almaawiy, U., Pond, G. R., Sussman, J., Brazil, K., & Seow, H. (2014). Are family physician visits and continuity of care associated with acute care use at end-of-life? A population-based cohort study of homecare cancer patients. Palliat Med, 28(2), 176-183. https://doi.org/10.1177/0269216313493125
Anhang Price, R., Tolpadi, A., Schlang, D., Bradley, M. A., Parast, L., Teno, J. M., & Elliott, M. N. (2020). Characteristics of hospices providing high-quality care. J Palliat Med, 23(12), 1639-1643. https://doi.org/10.1089/jpm.2019.0505
Christian, T., Teno, J., Cobb, K., Galantowicz, S., Levitt, A., & Massuda, C. (2020). Trends in the receipt of consistent hospice professional visits at the end of life and ratings of hospice care quality. Innov Aging,4(Suppl 1), 70. https://doi.org/10.1093/geroni/igaa057.228
de la Cruz, M., Noguera, A., San Miguel-Arregui, M. T., Williams, J., Chisholm, G., & Bruera, E. (2015). Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care. Palliat Support Care, 13(2), 211-216. https://doi.org/10.1017/s1478951513001144
Dellon, E. P., Shores, M. D., Nelson, K. I., Wolfe, J., Noah, T. L., & Hanson, L. C. (2010). Family caregiver perspectives on symptoms and treatments for patients dying from complications of cystic fibrosis. J Pain Symptom Manage, 40(6), 829-837. https://doi.org/10.1016/j.jpainsymman.2010.03.024
Ellington, L., Clayton, M. F., Reblin, M., Cloyes, K., Beck, A. C., Harrold, J. K., Harris, P., & Casarett, D. (2016). Interdisciplinary team care and hospice team provider visit patterns during the last week of life. J Palliat Med, 19(5), 482-487. https://doi.org/10.1089/jpm.2015.0198
Hui, D., dos Santos, R., Chisholm, G., Bansal, S., Silva, T. B., Kilgore, K., Crovador, C. S., Yu, X., Swartz, M. D., Perez-Cruz, P. E., Leite Rde, A., Nascimento, M. S., Reddy, S., Seriaco, F., Yennu, S., Paiva, C. E., Dev, R., Hall, S., Fajardo, J., & Bruera, E. (2014). Clinical signs of impending death in cancer patients. Oncologist,19(6), 681-687. https://doi.org/10.1634/theoncologist.2013-0457
Ijaopo, E. O., Zaw, K. M., Ijaopo, R. O., & Khawand-Azoulai, M. (2023). A review of clinical signs and symptoms of imminent end-of-life in individuals with advanced illness. Gerontol Geriatr Med, 9, 23337214231183243. https://doi.org/10.1177/23337214231183243
Kehl, K. A., & Kowalkowski, J. A. (2013). A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. Am J Hosp Palliat Care, 30(6), 601-616. https://doi.org/10.1177/1049909112468222
National Consensus Project for Quality Palliative Care. (2018). Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care. https://www.nationalcoalitionhpc.org/ncp
National Quality Forum. (2006). A National Framework and Preferred Practices for Palliative and Hospice Care Quality. http://www.qualityforum.org/Publications/2006/12/A_National_Framework_and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx
Phongtankuel, V., Adelman, R. D., Trevino, K., Abramson, E., Johnson, P., Oromendia, C., Henderson, C. R., Jr., & Reid, M. C. (2018). Association between nursing visits and hospital-related disenrollment in the home hospice population. Am J Hosp Palliat Care, 35(2), 316-323. https://doi.org/10.1177/1049909117697933
Pivodic, L., Harding, R., Calanzani, N., McCrone, P., Hall, S., Deliens, L., Higginson, I. J., & Gomes, B. (2016). Home care by general practitioners for cancer patients in the last 3 months of life: An epidemiological study of quality and associated factors. Palliat Med, 30(1), 64-74. https://doi.org/10.1177/0269216315589213
Qaseem, A., Snow, V., Shekelle, P., Casey, D. E., Jr., Cross, J. T., Jr., Owens, D. K., Dallas, P., Dolan, N. C., Forciea, M. A., Halasyamani, L., Hopkins, R. H., Jr., & Shekelle, P. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Ann Intern Med, 148(2), 141-146. https://doi.org/10.7326/0003-4819-148-2-200801150-00009
Seow, H., Barbera, L., Howell, D., & Dy, S. M. (2010). Using more end-of-life homecare services is associated with using fewer acute care services: A population-based cohort study. Med Care, 48(2), 118-124. https://doi.org/10.1097/MLR.0b013e3181c162ef
Teno, J. M., Plotzke, M., Christian, T., & Gozalo, P. (2016). Examining variation in hospice visits by professional staff in the last 2 days of life. JAMA Intern Med, 176(3), 364-370. https://doi.org/10.1001/jamainternmed.2015.7479
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2.6 Meaningfulness to Target Population
In interviews with former hospice caregivers in September 2024, we asked about the value and importance of a measure to assess hospice visits from registered nurses and social workers in the last three days of the patient’s life. Several caregivers reported that this information was “very important” for choosing a hospice because caregivers may not know what to expect at the very end of life and therefore may need support and guidance from hospice staff. One caregiver commented that a low score on the measure would be a red flag that a hospice was not providing high quality care because support in the last few days of life was assumed to be the standard of care.
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2.4 Performance Gap
We completed analyses at the hospice level using nationwide Medicare Part A hospice fee-for-service claims with dates of death in Calendar Years 2022 and 2023 (corresponding to information used for the Fall 2024 update to the Care Compare site). The performance scores below represent fee-for-service claims data from 1,689,061 hospice patients receiving service from 4,455 hospice entities (with measure denominators of 20+, the steward’s minimum standard for public reporting). Performance scores are listed below, calculated at the hospice-level. The nationwide average is 54.3% (standard deviation is 22.1%; interquartile range 40.7% – 58.8%). Scores in the 1st decile averaged 10.0% and in the 10th decile averaged 84.2%.
Table 1. Performance Scores by DecilePerformance Gap Overall Minimum Decile_1 Decile_2 Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9 Decile_10 Maximum Mean Performance Score 54.3 0.0 10.0 27.6 40.3 48.7 55.7 61.4 66.4 71.2 76.6 84.2 100.0 N of Entities 4,455 39 445 443 441 450 444 444 451 446 444 447 1 N of Persons / Encounters / Episodes 1,689,061 1,605 50,618 109,346 152,697 228,866 206,358 204,647 207,094 192,588 181,702 155,145 84
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3.1 Feasibility Assessment
The Hospice Visits in the Last Days of Life (HVLDL) measure is constructed entirely from hospice claims records from the Medicare Hospice Benefit, which are already collected by CMS for payment and quality purposes. Claims data are considered accurate and reliable for measure development, as they are used for payment and subject to audit. Claims data are used to calculate quality measures that are implemented and publicly reported in other CMS quality reporting programs (QRPs), including the post-acute care QRPs. The data needed to calculate this measure are readily available and require no additional data submission beyond what is already collected on claims in the normal course of business. This measure poses no additional data collection burden to hospice providers and no burden to hospice patients or their caregivers.
3.3 Feasibility Informed Final MeasureNo adjustments to the measure were necessary, as the HVLDL measure is entirely claims-based. Claims-based data are readily accessible and avoid provider, patient, and caregiver burden, and are therefore an excellent source of information for consumers.
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3.4 Proprietary InformationNot a proprietary measure and no proprietary components
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4.1.3 Characteristics of Measured Entities
Data for these analyses corresponds to 4,455 Medicare-certified hospices providing service during Calendar Years 2022-2023. These hospices were identified using 100% Medicare Part A hospice fee-for-service claims during this period. These providers correspond to the nationwide set of hospices; no sampling was used. Characteristics of these providers are reported in the table below.
During the reporting period, 4,455 hospices met the reporting standards for the CMS public reporting (1,353 additional hospices had eligible denominator stays, but fewer than the 20 total required). The majority of hospices were freestanding (84.1%), for-profit (67.9%), and in urban areas (81.2%). The number of eligible stays per hospice (for those meeting reporting requirements) ranged from 20 to 14,123. The mean hospice size was 379 eligible stays, and the median size was 196 eligible stays.
# Hospices (% Hospices*)
Decade of Medicare Certification
1980s
504 (11.3%)
1990s
847 (19.0%)
2000s
1,002 (22.5%)
2010s
1,505 (33.8%)
2020s
535 (12.0%)
Missing
62 (1.4%)
Facility Type
Facility-Based
614 (13.8%)
Freestanding
3,745 (84.1%)
Missing
96 (2.2%)
Profit Status
Government-owned
486 (10.9%)
Non-profit
847 (19.0%)
For-profit
3,026 (67.9%)
Missing
96 (2.2%)
Census Region
Northeast
419 (9.4%)
Midwest
982 (22.0%)
South
1,544 (34.7%)
West
971 (21.8%)
Outlying territories
539 (12.1%)
Urban/Rural
Urban
3,619 (81.2%)
Rural
772 (17.3%)
Missing
64 (1.4%)
* Percentages may not sum to 100 due to rounding.
4.1.1 Data Used for TestingThe dataset used for testing is nationwide Medicare Part A hospice fee-for-service claims with dates of discharge in Calendar Years (CY) 2022-2023 (January 1, 2022 through December 31, 2023; the data also includes the last couple days of December, 2021 to assess whether visits occurred in the last days of life for deaths on January 1, 2022).
4.1.4 Characteristics of Units of the Eligible PopulationAnalyses were based upon those hospice elections ending in the patient's death during the reporting period (calendar years 2022-2023). A total of 1,689,061 elections eligible for the denominator were identified. Because episodes are centered around a patient’s death, a single episode is equivalent to a single beneficiary. Characteristics of those eligible episodes/beneficiaries are reported in the table below (characteristics are missing for 3,331 beneficiaries, or 0.2% of the sample, who are omitted from below). Most beneficiaries were aged 65 and older (96.7%), 57.6% were female, and 86.9% were white. The most common primary diagnoses were cancer (27.6%) and dementia/Alzheimer’s/Parkinson’s (23.8%). Most beneficiaries lived in urban areas (81.6%).
# Beneficiaries (% Beneficiaries)
Beneficiary Age
Under 65
55,020 (3.3%)
65-69
106,721 (6.3%)
70-74
167,644 (9.9%)
75-79
230,961 (13.7%)
80-84
289,426 (17.2%)
85-89
323,635 (19.2%)
90-94
300,926 (17.9%)
95+
211,397 (12.5%)
Gender
Male
715,211 (42.4%)
Female
970,519 (57.6%)
Race/Ethnicity
White
1,465,152 (86.9%)
Black
127,532 (7.6%)
Asian
23,195 (1.4%)
Hispanic
27,910 (1.7%)
Other/Unknown
41,941 (2.5%)
Primary Diagnosis
Dementia/Alzheimer’s/Parkinson’s
400,428 (23.8%)
Cerebrovascular Accident
159,891 (9.5%)
Cancer
465,822 (27.6%)
Chronic Kidney Disease
36,108 (2.1%)
Heart Disease
299,001 (17.7%)
Lung Disease
133,713 (7.9%)
None of the Above
190,767 (11.3%)
Urban/Rural Location of Service
Urban
1,375,926 (81.6%)
Rural
309,804 (18.4%)
* Percentages may not sum to 100 due to rounding.
4.1.2 Differences in DataNone.
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4.2.1 Level(s) of Reliability Testing Conducted4.2.2 Method(s) of Reliability Testing
We followed the methodological approach to reliability testing outlined in "The Reliability of Provider Profiling: A Tutorial" (Adams, 2009), which was featured in the National Quality Forum document "What Good Looks Like" for measure submission examples. The approach entails using a hierarchical model to obtain an estimate of provider-to-provider variance, and then applying that estimate along with estimates of individual provider error to the reliability formula.
This approach calculates what's known as the "signal-to-noise ratio" or “reliability score.” As described in the Adams (2009) report: “Conceptually, it is the ratio of signal to noise. The signal in this case is the proportion of variability in measured performance that can be explained by real differences in performance. There are 3 main drivers of reliability; sample size, differences between providers, and measurement error.” In other words, the reliability score indicates the extent to which the measure distinguishes performance of one hospice facility from another. If there is a large amount of between-subject variability (i.e., “signal”) compared to within-subject variability (i.e., “noise”), then there is more evidence that it is possible to discriminate performance among facilities.
Reliability scores vary from 0 to 1, with 0 indicating all variation is attributable to noise/measurement error and 1 indicating that all variation is attributable to real differences in performance across facilities.
Citation: Adams JL. The reliability of provider profiling: a tutorial. Santa Monica, CA: RAND; 2009. http://www.rand.org/pubs/technical_reports/TR653.html.
4.2.3 Reliability Testing ResultsOur approach produces facility-level reliability scores for 4,455 facilities meeting CMS reporting thresholds (a denominator of at least 20); we present summary statistics below.
In general, the mean average reliability score was 0.96 and the median score was 0.98. There were 7.8% of hospices with signal-to-noise ratio values below 0.9, and just 14 (0.3%) had a ratio below 0.8.
Table 2. Accountable Entity–Level Reliability Testing Results by Denominator-Target Population SizeAccountable Entity-Level Reliability Testing Results Overall Minimum Decile_1 Decile_2 Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9 Decile_10 Maximum Reliability 0.96 1.00 0.97 0.95 0.95 0.96 0.96 0.97 0.97 0.97 0.97 0.98 1.00 Mean Performance Score 54.3 0.0 10.0 27.6 40.3 48.7 55.7 61.4 66.4 71.2 76.6 84.2 100.0 N of Entities 4,455 39 445 443 441 450 444 444 451 446 444 447 1 N of Persons / Encounters / Episodes 1,689,061 1,605 50,618 109,346 152,697 228,866 206,358 204,647 207,094 192,588 181,702 155,145 84 4.2.4 Interpretation of Reliability ResultsAlthough there is not a definite threshold that is considered reliable, per Adams (2009), values above 0.7 are considered sufficient to confidently detect differences between facilities. The reliability scores calculated here are almost all above 0.9 (and close to 100% are above 0.8), so reliability can be considered very good.
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4.3.1 Level(s) of Validity Testing Conducted4.3.2 Type of accountable entity-level validity testing conducted4.3.3 Method(s) of Validity Testing
We calculated (Pearson's) correlation coefficients for the association between hospice-level measure scores and responses from the CAHPS Hospice Survey. Hospice CAHPS outcome scores are an existing endorsed quality measure (CBE ID #2651) and best capture the caregiver's experiences of a patient's care. We are looking for concordance between CAHPS outcomes and Hospice Visits in the Last Days of Life; higher CAHPS scores indicate better quality hospices, so if we find facilities with higher rates of Hospice Visits in the Last Days of Life also have higher CAHPS scores, this finding would validate our process measure capturing an important aspect of care since it produced similar quality rankings of hospices. We would expect the measure to have modest positive correlations with CAHPS Hospice scores, as it captures a related (but different) construct. Note we used Medicare claims data for calculation, audited for payment purposes, and so considered complete.
4.3.4 Validity Testing ResultsCorrelation estimates are presented below. It should be noted that CAHPS Hospice data were only available for 2,999 providers (due to CAHPS suppression for minimum denominator reporting requirements); for the summary star rating, data was only available for 2,017 providers. Coefficient estimates below were all (positively) statistically significant with p-values<0.001. Note the magnitude of all correlations exceeds coefficients calculated when the measure was originally endorsed three years earlier.
Correlation Coefficients for CAHPS Quality Measures
Communication with family: 0.3088
Getting timely help: 0.2984
Treating patient with respect: 0.3110
Emotional and spiritual support: 0.3178
Help for pain and symptoms: 0.2318
Training family to care for patient: 0.2151
Rating of this hospice: 0.3242
Willing to recommend this hospice: 0.3175
Summary Star Rating: 0.2911
4.3.5 Interpretation of Validity ResultsThese findings indicate positive correlation between Hospice Visits in the Last Days of Life and CAHPS Hospice indicators and establish consistent rankings of facilities in terms of CAHPS Hospice scores and measure performance rates. In other words, the hospices which most often provide visits at the end of life by registered nurses and social workers also have the highest ratings of experience as reported by caregivers. These findings validate our process measure, in that they suggest that high-quality hospices are most often performing visits at the end of life.
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4.4.1 Methods used to address risk factorsRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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5.1 Contributions Towards Advancing Health Equity
We calculated measure performance scores across the characteristics of the eligible population listed in section 4.1.4: age, gender, race/ethnicity, diagnosis, and rurality. We did not find any meaningful differences in measure scores with respect to age, gender, or diagnosis. We do note two areas with disparities: non-white beneficiaries less often receive hospice visits in the last days of life (white 60.0% vs. black 52.3%, Asian 45.1%, Hispanic 48.8%). This finding should be further monitored to ensure that beneficiaries receive adequate care at the end of life.
Additionally, there is a slight disparity in rurality: rural patients are more likely to receive visits at the end of life. CMS had received concerns from rural providers who thought they would have unfairly lower measure scores given access issues in rural settings. The evidence seems to suggest the opposite, that hospices serving rural patients do a better job of providing visits at the end of life.
% Meeting Performance Criteria for Hospice Visits in the Last Days of Life
Beneficiary Age
Under 65
58.8%
65-69
59.2%
70-74
59.7%
75-79
59.7%
80-84
59.6%
85-89
59.0%
90-94
58.2%
95+
56.7%
Gender
Male
58.8%
Female
58.9%
Race/Ethnicity
White
60.0%
Black
52.3%
Asian
45.1%
Hispanic
48.8%
Other/Unknown
53.2%
Primary Diagnosis
Dementia/Alzheimer’/Parkinson’s
57.6%
Cerebrovascular Accident
57.4%
Cancer
60.0%
Chronic Kidney Disease
59.3%
Heart Disease
59.1%
Lung Disease
57.9%
None of the Above
59.8%
Urban/Rural Location of Service
Urban
57.8%
Rural
63.3%
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6.1.1 Current StatusYes6.1.3 Current Use(s)6.1.4 Program DetailsHospice Quality Reporting Program (HQRP); Centers for Medicaid and Medicaid Services (CMS), https://www.cms.gov/medicare/quality/hospice, The HQRP is intended to support hospice quality improvement activities and help to inform consumer choice of hospice providers., All Medicare-certified hospices in the U.S. are required to submit facility-level quality measure data to CMS., Hospice facility-level
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6.2.1 Actions of Measured Entities to Improve Performance
The intent of the measure is that collection of information about hospice staff visits near death will encourage hospices to better monitor patients’ status for signs of impending death, and, at the appropriate time, visit patients and caregivers and provide services that will address their care needs. This may lead to improved quality of care for patients and their caregivers during the patients’ last days of life. Post-pandemic hospice workforce shortages may pose a challenge to in-person visits at end of life; however, representatives from hospice provider associations noted that hospices are monitoring their HVLDL data on Care Compare and using the information for process improvement to ensure patient and family needs are met. Some hospices are also using predictive analytics to ensure staff availability for providing visits in the last days of life.
6.2.2 Feedback on Measure PerformanceCMS held a meeting with hospice provider associations in August 2024 to discuss provider feedback on the HVLDL measure, including usefulness of the measure to improve quality of care, steps hospices can take to improve performance, barriers and facilitators to performance improvement, and potential unintended consequences of measure implementation. Representatives from hospice provider associations noted that hospices are monitoring their HVLDL data on Care Compare and using the information for process improvement to ensure patient and family needs are met. Some hospices are using predictive analytics to ensure staff availability for providing visits in the last days of life. Several attendees noted concerns around visits being limited to a registered nurse or social worker; they suggested expanding the range of clinicians to include other members of the interdisciplinary team who may visit patients and families at end of life, particularly LPNs/LVNs. Another suggestion was to allow hospices to document patient/family preferences for visits at end of life, as visits to the home at end of life are not always congruent with cultural norms, and some families decline these visits. Attendees also noted concerns that the measure does not acknowledge telehealth in addition to in-person visits, as post-pandemic workforce shortages pose a challenge to in-person visits for many hospices, and in some cases families may prefer to receive visits via telehealth.
6.2.3 Consideration of Measure FeedbackRepresentatives from hospice provider associations suggested inclusion of other disciplines in the measure, particularly LPNs/LVNs, to ensure hospices can provide continuity of care at end of life with the clinicians that know patients and families best. The disciplines included in this measure – registered nurse and medical social worker visits – were selected because empirical testing found these visits had the highest correlation with CAHPS Hospice scores.Notably, in analyses completed during measure testing, LPN visits in the last days of life were negatively correlated with all CAHPS Hospice survey outcomes. These findings are described in the measure testing report (Abt, 2020). However, in the future we will continue to explore inclusion of other disciplines in the measure. In addition, in response to provider feedback that visits to the home at end of life are not always congruent with cultural norms or patient/family preferences, we will explore inclusion of an item in the HOPE assessment to allow hospices to document patient/family preferences for visits at end of life.
Citation: Abt (2020). Hospice Visits When Death is Imminent: Measure Validity Testing Summary and Re-Specifications. Retrieved from: https://www.cms.gov/files/document/hqrphospice-visits-when-death-imminent-testing-re-specification-reportoctober-2020.pdf
6.2.4 Progress on ImprovementThe measure was first publicly reported in 2022, based on eight quarters of data from April-December 2019 and July 2020 – September 2021 (note at the time CMS was not publicly reporting data from the first two quarters of 2020 due to the Public Health Emergency); measure performance was 50.5%. As noted in Section 2.4 (Performance Gap), current performance (based on Calendar Years 2022-2023) is 54.3% – about a four percentage point increase in two years. We will continue to monitor whether these improvement trends continue.
6.2.5 Unexpected FindingsFeedback on measure implementation was positive overall; hospice provider associations noted that hospices are using HVLDL performance data for process improvement to ensure patient and family needs are met in the last days of life. Representatives from provider associations also noted that the goal of this measure should be to ensure that hospices meet the individualized needs of patients and families, so a potential unintended consequence is that hospices may make visits at end of life to ensure they meet expectations for the measure, rather than developing a plan of care purely focused on patient/family wishes. In addition, hospice care teams often include other interdisciplinary team members who know the patient and family best, so hospices may be forced to choose between meeting the measure criteria and ensuring the best quality and continuity of care in the last days of life. We have taken this feedback into consideration and will continue to explore inclusion of other disciplines in the measure. We will also explore inclusion of an item in the HOPE assessment to allow hospices to document patient/family preferences for visits at end of life.
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CBE ID: 3645 Hospice Visits in Last Days of Life
On behalf of the National Alliance for Care at Home (Alliance) we appreciate the opportunity to submit feedback on the Hospice Visits in Last Days of Life measure currently under maintenance review. The Alliance is the unified voice for providers delivering high-quality, person-centered healthcare to individuals, wherever they call home. Our members are providers of sizes and types – from small rural agencies to large national companies - and including government-based providers, nonprofit organizations, systems-based entities, and public corporations. Formed through the joint affiliation of the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO), the Alliance is dedicated to advancing policies that support care in the home for millions of Americans at all stages of life, individuals with disabilities, persons with both chronic and serious illnesses as well as dying Americans who depend on those supports.
The Alliance wholeheartedly supports the use of hospice interdisciplinary group visit data in the Hospice Quality Reporting Program (HQRP). The Meaningful Measure area for the Hospice Visits in Last Days of Life measure is “Person Centered Care” and the Healthcare Priority is “Strengthen Person & Family Engagement as Partners in their Care”. We believe that, as currently constructed, the proposed measure does not fit within this area or priority, and it should not be maintained with the current measure specifications.
Arguably the central tenet of hospice care is patient and family-centered care. The HVLDL measure as currently constructed does not consider the wishes of the patient. Rather, it incentivizes hospices to impose Registered Nurse (RN) and medical social worker (MSW) visits on patients and families when a different discipline of the hospice interdisciplinary group may be most appropriate and/or when the patient and family do not desire a visit. Furthermore, the HVLDL measure does not allow the virtual telehealth visits that some families prefer and discourages hospices from meeting the end-of-life spiritual and religious needs of patients and families by focusing heavily on only the medical portion of the interdisciplinary team. This measure as currently specified does not serve the Meaningful Measure or Healthcare Priority intended.
It is our strong belief that analysis utilizing data that includes whether the patient/family desired a visit from the disciplines that are part of a measure or exclusion criteria that removes patients/caregivers who refuse visits offered by these various disciplines in the last days of life from the measure denominator would better reflect quality of care and better serve the Meaningful Measure and Healthcare Priority. The Alliance appreciates the reasons for measurement of visits in the last days of life and strongly urges CMS to consider visit data in the context of an individualized plan of care reflective of patient and family wishes.
For the 2020 Abt Associates report, Hospice Visits When Death is Imminent: Measure Validity Testing Summary and Re-Specifications Report, hospice claims data was analyzed to determine the correlation coefficient between the number of visits from hospice interdisciplinary (IDG) staff and the CAHPS Hospice Survey outcomes. All correlation coefficients were generally low (0.28 and below), including the HVLDL measure which showed a correlation coefficient of 0.24 and 0.26 for the CAHPS Hospice Survey “would you recommend” and “rating of hospice” questions, respectively. Even though the HVLDL correlation was higher than some of the alternative visit specifications, it is still a generally low correlation. Specifically, the data shows a correlation between RN and MSW visits and CAHPS Hospice Survey outcomes of less than 0.3 reflecting a weak relationship. None of the visit types had a moderate (0.5-0.7) or strong (0.7-1) correlation with the CAHPS Hospice Survey outcomes. The fact that the data does not show even a moderate relationship between visits and CAHPS Hospice Survey outcomes begs the question of the purpose of the HVLDL and its value.
In addition, available data reflects national trends and does not consider regional or cultural trends. Significant differences across hospices may be highlighted with such an analysis which could inform risk adjustment. As an example, a strong emphasis in some cultures on spiritual care and rituals could reveal a moderate to strong correlation between spiritual care counselor visits and CAHPS Hospice Survey results.
The literature is clear that spiritual needs are prevalent at the end of life and rise in importance as death approaches. There are indications that spiritual well-being buffers the potential impact of end-of-life despair. Most religious traditions also have important end-of-life rituals performed by a spiritual counselor. The National Consensus Project Clinical Guidelines for Quality Palliative Care propose that maximizing the benefits of supporting spiritual and religious needs requires a trained professional health care spiritual care counselor-a spiritual care specialist. The current HVLDL measure is effectively a barrier to the delivery of that spiritual/religious care by not permitting spiritual care counselor visits to be included in this measure, even if this is what the family chooses and desires at the end of life.
The HVLDL focuses on whether visits are made as opposed to the quality of those visits. As stated above, limiting the disciplines to only RN and MSW visits does not capture all services delivered by the hospice interdisciplinary group. Many hospices utilize Licensed Practical Nurses/Licensed Vocational Nurses (LPN/LVN) in the delivery of nursing care. Hospices are required in the conditions of participation to have an RN as a member of the IDG and it is the RN that is responsible for ; however, hospices are not limited to utilizing only RNs as part of the IDG (§418.56(a)(1)). Per the Medicare hospice conditions of participation, an RN who is a member of the IDG must provide coordination of care and ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care (§418.56(a)), but again, the RN can utilize an LPN/LVN to assist in delivering care to the patient. The workforce challenges faced throughout healthcare in nursing are well documented and were exacerbated by the COVID-19 pandemic. As a result, hospices are utilizing LPNs/LVNs in addition to RNs. Considering the allowance in the Medicare conditions of participation and the current healthcare workforce challenges and hospice operations, it remains unclear as to why CMS, the measure steward, is interested in only measuring RN visits. Visits from physicians, aides, spiritual care counselors, marriage and family therapists and licensed mental health counselors are absent from the HVLDL. Also missing are visits made via telehealth, which is sometimes preferred and requested by families to minimize intrusions during a sacred time. Coding on hospice claims identifying telehealth visits and visits made by non-medical interdisciplinary team members are glaringly absent. There are, however, CMS-approved spiritual care counselor codes available for use on VA claims. It seems a reasonable and fairly straightforward process for expanding allowed use of these codes on hospice claims to facilitate the collection of data on the prevalence of these visits at the end of life.
It is not uncommon for an RN and a MSW to make a joint visit to a patient during the final days of life. The HVLDL does not recognize these types of visits. Patients and families have found them helpful in addressing symptoms and issues as well as potentially preventing crises. For example, nurses can focus on physical patient symptom management while medical social workers can assist with psychosocial and emotional symptoms. The current HVLDL only credits one visit per day per RN or MSW as it focuses on the number of days on which a visit from an RN or MSW was made as opposed to the total number of visits made by these disciplines. At the time the HVLDL was incorporated into the HQRP, there were not many measures that looked at aspects of visits. While there are now only four HQRP measures, one of the measures, the Hospice Care Index, is a composite measure consisting of ten indicators. Of these ten indicators, four address an aspect of visits making a total of five visit related items in the HQRP.
Furthermore, the Hospice Outcomes & Patient Evaluation (HOPE) tool, to be implemented in 2025, has two associated measures that address visits. This begs the question of whether the HVLDL still holds value in the HQRP that outweighs its reporting burden. Again, the Alliance strongly supports gathering visit data and the development of meaningful measures around these visits. However, as stated throughout this comment letter, there are opportunities to improve the HVLDL measure, increase its value and that of visit date in the HQRP.
Another concern about the HVLDL measure is that it requires a hospice to identify the ‘final days’ of a patient’s life. This is not an exact science and the difficulty in identifying these days can be exceptionally difficult in situations where the patient does not exhibit symptoms that require an RN visit or MSW visit. Hospice providers have reported that they have invested significantly in platforms to allow rapid communication of patient status to assist with making timely visits and to improve HVLDL performance. However, national performance data indicates that hospice performance has improved little since implementation of the HVLDL. In Calendar Year 2021, the share of hospice care days with nurse visits in the last seven days of life rose to 63%, up from 62% year over year. Medical social worker visits in the last days of life also rose to 9% in 2021, up from 7% in 2020. In 2019, prior to the COVID-19 pandemic, the share of hospice care days with nurse visits in the last seven days of life was 66%. Overall, this seems to be a lower-than-expected percentage considering how much hospices have invested to accurately identify patients at the end of life and increase the number of RN and MSW visits.
The precipitous drop in HVLDL performance during the pandemic highlights the strain HVLDL compliance creates on hospices already facing significant staffing challenges exacerbated by the pandemic. Expanding the measure to include allowable visits by LPN/LVN, spiritual care providers, and hospice aides and other members of the IDG would better reflect the full scope of interdisciplinary care that patients and families receive in the last days of life, as well as relieve staffing burden on RNs and medical social workers.
In summary, hospice care visits are critical to care and must be of the highest quality. The HQRP should include measures that incentivize appropriate visits consistent with patient and family wishes, that measure all visits delivered and are of value in the HQRP. The HVLDL can meet this by
- removing the restrictions on the disciplines of the staff whose visits count,
- allowing virtual visits, and
- inserting an exception to the denominator for patients and families who are documented to not want a visit of any kind at this time.
Sincerely,
Katie Wehri Sarah Simmons, RN, MSN, CHPN
Vice President, Regulatory Affairs, Quality & Compliance Senior Director, Quality
OrganizationNational Alliance for Care at Home
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General information: My impression is that this is a crazy measure. Measure Rationale was so insensitive to the end of life process and I wanted to stop before even reading the measure text. If hospice is not actively involved when there are signs of decline, something substantially has failed in the process.Perhaps it is daily caregivers, perhaps it is family. Measuring whether hospice nurses attend is not helpful to this process.
I read further and my comments stand as is. My mother in law receives hospice care at an extended care facility. The family has a privately hired caregiver who monitors the care and is in contact with her family when she feels a hospice visit is needed. Most people in hospice are not so fortunate.