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Hospice and Palliative Care Composite Process Measure—Comprehensive Assessment at Admission

CBE ID
3235
Project
Geriatric and Palliative Care
Endorsed
New or Maintenance
Maintenance
Endorsement and Maintenance (E&M) Cycle
Fall 2020
Is Under Review
No
Measure Description

The Hospice Comprehensive Assessment Measure assesses the percentage of hospice stays in which patients who received a comprehensive patient assessment at hospice admission. The measure focuses on hospice patients age 18 years and older. A total of seven individual NQF endorsed component quality will provide the source data for this comprehensive assessment measure, including NQF #1634, NQF #1637, NQF #1639, NQF #1638, NQF #1617, NQF #1641, and NQF #1647. These seven measures are currently implemented in the CMS HQRP. These seven measures focus on care processes around hospice admission that are clinically recommended or required in the hospice Conditions of Participation, including patient preferences regarding life-sustaining treatments, care for spiritual and existential concerns, and management of pain, dyspnea, and bowels.

  • Measure Type
    Composite
    Electronic Clinical Quality Measure (eCQM)
    No
    Level Of Analysis
    Facility
    Care Setting
    Other Care Setting (Please specify)
    Numerator

    The numerator of this measure is the number of patient stays in the denominator where the patient received all 7 care processes which are applicable to the patient at admission, as captured by the current HQRP quality measures. To be included in the comprehensive assessment measure numerator, a patient must meet the numerator criteria for each of the individual component quality measure (QM) that is applicable to the patient. The numerator of this measure accounts for the three conditional measures in the current HQRP (NQF #1637 Pain Assessment, NQF #1638 Dyspnea Treatment, and NQF #1617 Bowel Regimen) as described below.

    Denominator

    The denominator for the measure includes all hospice patient stays enrolled in hospice except those with exclusions.

    Exclusions

    Patient stays are excluded from the measure if they are under 18 years of age, or are a Type 2 (discharged stays missing the admission record) or Type 3 patient stay (active stays).

    Testing Data Sources
    Other Data Source
  • Most Recent Endorsement Activity
    Endorsed Geriatrics and Palliative Care Fall Cycle 2020
    Initial Endorsement
    Next Planned Maintenance Review
    Geriatrics and Palliative Care Fall 2024
    Endorsement Status
    Endorsed
    Last Updated