The Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment at Admission (NQF #3235) also known as, the Hospice Comprehensive Assessment Measure, or the Composite Measure was implemented in the Hospice Quality Reporting Program (HQRP) on April 1, 2017. Hospices data collection for the measure from Q2 2017 thru Q4 2017 is displayed under the “HIS Comprehensive Assessment Measure” in the December 2018 Hospice Compare refresh.

The HQRP was established under section 1814(i)(5) of the Social Security Act and requires the Secretary to publicly report, on a CMS website, quality measures that relate to the care provided by hospice programs across the country. The HQRP consist of two components: the Hospice Item Set (HIS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. CMS reports quarterly through the Hospice Compare website the survey results for 8 CAHPS measures and data collected for 7 HIS quality measures. In addition, the “Hospice Comprehensive Assessment Measure” has been added to the quarterly Hospice Compare.

The “Hospice Comprehensive Assessment Measure” is a composite measure and is calculated using the existing 7 HIS data items (component measures) below:

  • NQF#1617 Patients treated with an Opioid who are Given a Bowel Regimen
  • NQF #1634 Pain Screening
  • NQF #1637 Pain Assessment
  • NQF #1639 Dyspnea Screening
  • NQF #1638 Dyspnea Treatment
  • NQF #1647 Beliefs/Values Addressed (if desired by the patient)
  • NQF #1641 Treatment Preferences

CMS began public reporting on the above measures last year individually so consumers could see how hospices performed on each individual component measure. The NEW Hospice Comprehensive Assessment Measure takes these 7 individual measures and combines them into a single metric. This measure is an “all-or-none” measure, which means that in order to receive credit, the hospice must successfully complete ALL 7 care processes for which the patient is eligible. Some Hospices are seeing the single percentage of the new composite measure lower than the lowest individual component measure due to the “all-or-none” calculation. Hospices need to make sure they understand the “all-or-none” approach with the conditional measures applied to the calculation to ensure their percentage scores reflect their quality of care.

The HIS Comprehensive Assessment Measure includes 3 conditional measures. A conditional measure is a measure where inclusion in the denominator is “dependent” or “conditional” on a response to a previous item. When calculating the Hospice Comprehensive Assessment Measure, if a patient does not meet the denominator criteria for a conditional measure, the hospice will by default “receive credit” for that conditional measure for that patient. This only applies to the Hospice Comprehensive Assessment quality measure, not the calculation of the individual component measures.

Conditional Measures in the Hospice Comprehensive Assessment Quality Measure:

  • NQF #1637 Pain Assessment
  • NQF #1638 Dyspnea Treatment
  • NQF #1617 Patients Treated with an Opioid Who Are Given a Bowel Regimen

For example, if a patient screened NEGATIVE for dyspnea:

  • The patient would be ineligible for the NQF #1638 Dyspnea Treatment above
  • The hospice would receive credit for the Dyspnea Treatment component of the Hospice Comprehensive Assessment Measure, without having conducted the dyspnea treatment care process because, based on the results of the patient’s dyspnea screening, it was appropriate for the hospice NOT to proceed with dyspnea treatment, as the patient does not have dyspnea.

The December 2018 quarterly Hospice Compare displays the “Family Experience of Care” with the 8 CAHPS measures followed by, “Quality of Patient Care” with the new “HIS Comprehensive Assessment Measure” comparing the hospice percentage with the national average. The consumer may view the 7 individual HIS quality measures but may only do so, by clicking the drop down.

It is imperative for hospices to address all 7 existing HIS components at admission for every patient with the “all-or-none” approach scoring of the new Hospice Comprehensive Assessment Measure. The Hospice Compare website’s explanation of the new measure for the hospice consumer states,

This one measure shows if the hospice staff completed all of the following when a patient was admitted to hospice care:

  • Asked patients about their treatment preferences and beliefs & values
  • Checked to see if patients were in pain
  • Thoroughly assessed patients in pain
  • Checked to see if patients had shortness of breath, and
  • Offered care for constipation for patients taking opioids

Following the above the website has this statement: “If the hospice did not complete the 7 care processes for a patient, the patient is not included in the HIS Comprehensive Assessment Measure score.”