Hospice Evaluation & Assessment Reporting Tool (HEART): - PowerPoint Presentation

Hospice Evaluation & Assessment Reporting Tool (HEART):Summary of the Pilot A Preliminary Findings Report April 2018

Acronyms in Presentation Average daily census (ADC) Centers for Medicare & Medicaid Services (CMS) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice SurveyElectronic Health Record (EHR)Hospice Evaluation and Assessment Reporting Tool (HEART)Hospice Quality Reporting Program (HQRP) Hospice Item Set (HIS)Lengths of stay (LOS)Special Open Door Forum (SODF) 1

Purpose of this slide deck: The following slides provide a summary of the HEART Pilot A The work of Pilot A was based on stakeholder input as discussed in the HEART Technical Expert Panel Report The assessments tested were based on TEP input. 2

Background Section I 3

HEART Background The Centers for Medicare & Medicaid Services (CMS) is developing and testing a standardized patient assessment tool for hospices entitled the Hospice Evaluation & Assessment Reporting Tool (HEART). As a comprehensive patient assessment tool, HEART’s goal is to understand the care needs throughout the end of life process. It will provide hospices with important information to help them understand and address patient and family needs while ensuring the delivery of high quality care throughout the patient stay. HEART is intended to be multifunctional, such that it is used by hospices as part of their plan of care and by CMS for quality measure development. 4

HEART Intended Use To meet its goals: HEART will include interim assessments, standard of practice checklists, and additional clinical items that can be used to develop new quality measures, in addition to admission and discharge assessments. HEART will complement existing requirements set forth in the Medicare Hospice Conditions of Participation, such as the initial and comprehensive assessment. It would be designed to complement data collected as part of high-quality clinical care. HEART will replace the current HIS if implemented, it will not replace other Hospice Quality Reporting Program (HQRP) data collection efforts (that is, the CAHPS® Hospice Survey). HEART will not replace regular submission of claims data; HEART might consider future payment refinements as a secondary goal, but this is not planned at this time. 5

HEART Intended Use Cont’d HEART is envisioned to capture quality, clinical, and resource intensity information throughout the patient stay, by collecting assessments at various times during a patient’s hospice episode of care from any Medicare-certified hospice provider. HEART is subject to change as we test it and receive stakeholder input. 6

HEART Pilot Testing Focus Feasibility: Pilot tests evaluate the feasibility of implementing the HEART instrument by examining provider data collection methods, disruption of current clinical practice, and experiences of undue provider burden. These evaluation areas will give insight into issues that could impact the reliability and validity of HEART data items (and thus any quality measures that could be developed using HEART items), prior to national testing.Usability: Pilot tests ascertain the usability of the piloted items to capture the key concepts integral to HEART’s purpose. Pilot A was designed to identify issues associated with item wording that may require refinements of HEART data items to best capture the item concepts. Based on findings from Pilot A, HEART will be re-designed and tested during a future pilot testing. 7

Pilot Site Recruitment and Testing 9 hospice pilot sites were chosen based on a variety of characteristics to promote diversity including: Geographic Location (variation by region of the country and by metropolitan area); Urban and Rural; Size (Average daily census (ADC)); Patients of various Lengths of stay (LOS);Care in different settings; Business status; Clinical records system (EHR vs. paper-based) Each pilot site participated in a pilot test and data collection training led by a CMS contractor. 8

Pilot Site Demographics 9 Hospice State Region of Country Urban (U)/ Rural (R) Profit Status Clinical Record System Average Daily Census (ADC) Average Length of Stay (ALOS) in Days A CA West U For Profit EHR 172 80.17 B CO West U/R Nonprofit EHR 226 68 C CT Northeast U Nonprofit EHR 22 27 D LA Southeast U/R For Profit EHR 78.7 82 E NC Southeast U Nonprofit EHR 536 62.77 F ND Midwest R Nonprofit Paper 6.1 47 G NJ Northeast U Nonprofit EHR 371 57.6 H TX Southwest R For Profit EHR 57.2 101.9 I WI Midwest U/R Nonprofit EHR 796 98

Pilot A Testing Based on TEP RecommendationsPilot A designed to test the recommendations from the Technical Expert Panel (TEP)TEP was held for two days beginning on November 2, 2017 TEP Report: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/HEART-Webinar-TEP-Report.pdf 10

HEART Status– Inter-related Activities 11 TEP Nov 2-3, 2017 Pilot A January-March 2018 SODF September 26, 2018 And December 5, 2018 Continue to develop a hospice assessment tool based on stakeholder input, including TEP Further Pilot Testing Continue Quarterly SODF’s: March June September December Plan for Rulemaking and Implementation

Key Findings from TEPGoal: Provide Assessments to determine the care needs of hospice patients over the complete hospice stayAdmission AssessmentInterim Assessment Imminently Dying Assessment Discharge Assessment Assess for Distress12

Pilot Site Qualitative Data Collection—General Overview 13 Pilot sites were asked to collect data and complete 8 to 12 assessments of each type (listed below), and upload their data collection forms to the contractor, via a secure website, on a rolling basis. All pilot sites participated in a total of 6 weekly check-in calls, during which their experiences collecting HEART data were discussed. HEART—Admission New admissions throughout the duration of the pilot test. HEART--Discharge Recently and newly discharged patients through the first two weeks of the pilot test. HEART—Interim (60-Day) Patients admitted for at least 60 days throughout the duration of the pilot test. HEART—Interim (Imminently Dying) Patients that transition to imminently dying throughout the duration of the pilot test

Pilot Item Sets as Determined by the Technical Expert Panel HEART-Admission : provides a comprehensive picture of patient and family care needs at admission, quality of care related to identifying and beginning to meet those needs, and the resources the hospice anticipates it will need to deploy. HEART-Discharge: retrospectively captures the care that was delivered toward the end of the patient’s hospice stay, and is an expanded HIS Discharge to capture a broader view of hospice patent care at discharge. 14

Pilot Item Sets as Determined by the Technical Expert Panel HEART- Interim (60-Day): a new assessment for hospice, captures care needs every 60 days after admission to capture major changes in patient and family care needs during the hospice stay to enable a more-comprehensive view of hospice care. HEART- Interim (Imminently Dying): a new assessment for Hospice, focuses on patient physical and psychosocial symptoms, as well as family and caregiver needs, once a patient is transitioning to imminently dying. 15

Pilot Site Quantitative Data Collection Pilot sites were asked to complete 8 to 12 assessments of each type. Pilot sites uploaded their Data Collection forms to CMS’s contractor via a secure website on a rolling basis. Pilot Site Qualitative Data Analysis All pilot sites participated in a total of 6 weekly check-in calls, during which their experiences collecting HEART data were discussed. Each of the check-in calls focused on a particular item set (i.e. HEART-Discharge assessment, HEART-Interim Imminently Dying assessment, etc.); specific item sections (e.g., Section M: Skin Conditions); or implementation.

HEART PILOT A DATA COLLECTION: Feedback from Pilot Sites Section 2 17

HEART Admission Assessment The pilot sites used three main approaches for HEART Admission Assessment data collection: The bedside nurse filled out HEART Admission in the field, concurrent with regular care processes; An administrator abstracted most of the data from the EHR and interviewed the bedside nurse for the remaining data; or An administrator abstracted most of the data from the EHR and gave worksheets to bedside nurses for additional data collection in the field. The majority of the pilot sites used approach 1 instead of approach 2 or 3, as it met their needs and was less burdensome on their clinical staff. 18

HEART Admission Assessment cont’d In general, HEART Admission Assessment was reflective of the hospices’ current assessment processes, with the exception of some details such as patient distress. 19

HEART Discharge Assessment Pilot sites were able to retroactively obtain the information via chart abstraction. Data came from a mixture of sources including assessment data, administrative data, and clinician notes. Data collectors were chart abstractors rather than bedside clinicians. 20

HEART Interim-60-day Assessment Pilot sites used the same three approaches for completing HEART Interim-60-day as HEART Admission Assessment. Pilot sites were instructed to complete the 60-day assessment as close to the 60-day mark as possible. Pilot sites advised that a long-stay interim assessment is feasible but the content and timing of the 60-day assessment should align with current workflows.Because patient needs can change, the HEART Interim Assessment should be done during re-certification and other times, such as when there is a change in the plan of care. Skip patterns should be used to identify the decline in function or focus on the POC. 21

HEART Interim-Imminently Dying Assessment Among sites that had formal processes to identify patients eligible for the Imminently Dying Assessment, the following strategies were used: Existing systems alerted staff when patients transitioned.Initiated short-stay care plans when patients transition to imminently dying. Altered workflows to ensure an administrator paid special attention during interdisciplinary team (IDT) meetings to identify transitioning patients when appropriate (One pilot site). Some sites had no formal processes in place to notify staff when a patient transitioned to imminently dying . 22

Pilot sites provided the following feedback about the Imminently Dying Assessment:When patients are identified as imminently dying, pilot sites focus on providing support to the family rather than filling out standardized assessments. Large proportion of patients are minimally responsive at the time of imminent death and cannot respond to questions. Content should fit with current workflows and processes so as to not require additional time or resources to complete. A checklist to identify Imminently Dying would be more useful than an assessment. 23 HEART Interim-Imminently Dying Assessment cont’d

OVERARCHING ITEM DEVELOPMENT CONSIDERATIONS Section 3 24

Distress Items Patient distress items were included throughout HEART to assist with care planning through identification of physical symptoms that were of the highest priority to the patient. Hospices’ experiences during the pilot suggest that: Distress was a difficult concept for patients to understand, and the pilot sites did not find these items useful for care planning.Scale used for distress (no distress, a little bit, somewhat, quite a bit, very much) had too many choices that were not clearly distinct. Hospices suggested asking questions to probe for the source of distress (e.g. related to spiritual/emotional) rather than ask specifics about the distress itself. In lieu of the distress items, a majority of hospices expressed a preference for quality of life items, which they felt would be more meaningful to clinicians and patients, although there was no clear consensus on how to best conceptualize quality of life. 25

Scripted Items Several items throughout HEART included prompts for the clinicians to “Ask the patient…,” followed by a script. Scripted items are intended to facilitate cross-setting standardized data collection to permit data exchange and creation of more valid quality measures. Hospices’ experiences during the pilot suggest that: Majority felt scripted items were awkward for the clinicians and impeded the clinician’s ability to therapeutically discuss important topics with patients.Sites recommended that HEART be less prescriptive regarding conversations with patients. 26

Defining Caregiver—Setting Specific Challenges Several HEART items request information related to the caregiver or allow for “caregiver report”. Hospices’ experiences during the pilot suggest that: When patients reside in non-hospice facilities (i.e. assisted living facilities, skilled nursing facilities, or hospitals), it can be challenging to collect the necessary information from families and caregivers.There are instances where families are not present, and/or do not live in the area; in these cases, the primary caregivers consist of the facility staff. Several hospices requested a clear definition be developed of who qualifies as a caregiver. Several hospices recommended a “not applicable” option be created for caregiver items when a caregiver is not present. 27

Item Framing for Interim Assessments Selected items from HEART-Admission were repeated on the interim assessments. Hospices’ experiences during the pilot suggest that: Items were burdensome and sometimes awkward. Items requesting dates of discussions were confusing because it was not clear whether the date referred to a conversation that was previously had by another clinician or on a different day. Gateway items could be added to determine if something had changed since the last HEART assessment, or that items could be reworded to indicate the “most recent” occurrence of events. 28

Skip Patterns/Flexible Assessments for Special Populations Two special populations were identified that might require a shorter set of items: Those who are minimally responsive; and Those who are imminently dying at the time of admission or at the 60-day assessment.Hospices’ experiences during the pilot suggest that: Skip patterns need to be available and inserted on the assessment for ease of usage.A shorter set of items would be appropriate for patients that are imminently dying at admission or at time of 60-day assessment. Inclusion of a “not applicable” response option would be beneficial where questions would be inappropriate for a particular patient. A clear definition of “Minimally Responsive” may be needed to distinguish between patients responsive only to significant stimuli (e.g., pain, repositioning) and those unable to interact during the assessment (e.g., unable to answer questions or track conversation in a meaningful way). 29

HEART IMPLEMENTATION FEEDBACK RELEVANT TO FUTURE TESTING AND IMPLEMENTATION Section 4 30

Feedback Relevant To Future Testing And Implementation Training and Messaging Sites want more communication about how to volunteer for future pilot studies. Sites desire that the intent/benefit of the assessment be more clearly emphasized during trainings for future pilot testing. Make clear what appropriate personnel must be present at training, and distribute materials well in advance of the training. If HEART were to become a new HQRP requirement, sites supported a training approach that includes resources similar to those available for the HIS, including a manual and webinar trainings. Burden Data collection for Pilot A was time consuming, and data needed for HEART were often spread across structured and unstructured (i.e., narrative notes) fields of the clinical record. Suggest if we are to ask similar questions to information already in their EHR like their comprehensive assessments, there needs to be a way to extract the data from their EHR and make it interoperable so as to reduce burden and fit their business model. Integration into Current Systems and Workflows Due to previous experiences with implementing the HIS, sites felt that integration into EHR would be necessary and preferably during pilot testing. 31

Feedback Relevant To Future Testing And Implementation cont’d Rollout To mitigate burden in EHR integration and transition, sites suggested a dry run period for HEART and/or to consider a phased implementation approach. Impact- Clinical WorkflowSites noted that HEART should fit into their business model so focus is on clinician’s ability to provide care that patients need. Impact- Patients and families Sites believed HEART may benefit family interactions by ensuring that important information is collected to improve quality care, specifically mentioning that HEART includes items on all symptoms rather than focusing on only a few. Sites noted that during the admission process, families are focused on getting their loved one admitted and may become frustrated with a large series of questions. 32

ITEMS AND SECTIONS Included in Pilot Test A Section 5 33

The following Assessment Sections were included as part of HEART Pilot Test A: Section A. Administrative Information Section AA. Living Situation, Caregiver Availability, and Capability Section I. Active DiagnosesSection II. Prognoses Section B. Communication, Hearing, & VisionSection C. Cognitive PatternsSection F. PreferencesSection D. Mood 34 Assessment Sections

Assessment Sections cont’d Section E. Behavior Section G/GG. Function Section H. Bladder and BowelSection J. Health ConditionsSection K. Swallowing and Nutrition StatusSection M. Skin ConditionsSection N. MedicationsSection O. Special Treatments, Procedures, and Programs 35

Next StepsConduct Quarterly SODFs Quarterly: December, March, June, September Provide regular updates on CMS webpages, including how to get involved .Design an hospice assessment tool that reflects the lessons learned from HEART and includes TEPs and testing. 36

Get Involved 37