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«DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 409, 424, and 484 [CMS-1560-F] RIN 0938-AP55 Medicare ...»

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• “Short term episode of care”: Implementation process measures report whether a care process was “implemented since the last OASIS assessment”. These measures will be calculated

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Short-term episodes are those in which the time frame from Start of care (SOC)/Resumption of Care (ROC) to Transfer (TRF)/Discharge (DC) is less than or equal to 60 days (and DO NOT contain a 60 day follow-up assessment). Long-term episodes are those in which the time frame from SOC/ROC to TRF/DC is longer than 60 days (and DO contain a 60 day follow-up assessment). In response to industry and NQF concerns that measures might not accurately reflect care for longer stay patients, episodes that exceed 60 days will not be included in publicly reported measures on implementation of evidence based practices.

• The phrase “at start of episode” does not refer to payment episodes and does not mean that this information will be collected and reported for each 60-day episode. The phrase means that the measure reports on best care practices that occur when a patient is admitted to home care. It is used to distinguish this measure from others that report on best practices that are implemented over the course of the home health stay (rather than at the time of home health admission) and are collected at transfer or discharge.

• “Timely physician contact” is defined as communication to

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telephone, voicemail, electronic means, fax, or any other means that appropriately conveys the message of patient status.

• “High risk medications” are defined as those identified by quality organizations (Institute for Safe Medication Practices, Joint Commission, etc.) as having considerable potential for causing significant patient harm when they are used erroneously.

• In the OASIS-C Guidance Manual, clinically significant medication issues are defined as those that, in the care provider’s clinical judgment, pose an actual or potential threat to patient health and safety, such as drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, medication omissions, dosage errors, or nonadherence to prescribed medication regimen. Potential clinically significant medication issues include adverse reactions to medications (for example, rash), ineffective drug therapy (for example, analgesic that does not reduce pain), side effects (for example, potential bleeding from an anticoagulant), drug interactions (for example, serious drug-drug, drug-food and drug-disease interactions), duplicate therapy (for example, generic name and brand name drugs that are equivalent both prescribed), omissions (missing drugs from an ordered regimen),

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noncompliance (for example, regardless of whether the noncompliance is purposeful or accidental) or impairment or decline in an individual’s mental or physical condition or functional or psychosocial status.

Comment: One commenter expressed concern with our proposal (set out at 74 FR 40960) regarding home health care quality improvement. We proposed to “reconcile the OASIS submissions with claims data in order to verify full compliance with the quality reporting requirements.” The commenter thought this process was new and requested that it be defined in more detail.

Response: This proposal is not new. Identical language was proposed in our May 4, 2007, CY 2008 HH PPS proposed rule (72 FR 25450) and in our CY 2009 HH PPS update notice (73 FR 65356). These proposals were subsequently implemented. Details regarding the process are available in the Medicare Claims Processing Manual, Chapter 10, section 120.

Comment: One commenter was concerned that pay for performance does not differentiate between traditional Medicare patients and those participating in waiver programs. Waiver patients have long term chronic needs, unlikely to be shown in discharge data, or to improve in the same manner as traditional

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Response: We thank the commenter for the comment on this topic, and will consider his concerns related to differences in outcomes for dually eligible waiver patients as plans for pay for performance are developed.

Reporting of Home Health Care Quality Data through CAHPS Survey In the Home Health Prospective Payment System Rate Update for Calendar Year 2010 (August 13, 2009), we proposed to expand the home health quality measures reporting requirements to include the CAHPS® Home Health Care (HHCAHPS) Survey, as initially discussed in the May 4, 2007 proposed rule (72 FR 25356, 25452) and in the November 3, 2008 Notice (73 FR 65357, 65358). As part of the U.S. Department of Health and Human Services (DHHS) Transparency Initiative, we proposed to implement a process to measure and publicly report patient experiences with home health care using a survey developed by the Agency for Healthcare Research and Quality’s (AHRQ’s) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program. The HHCAHPS survey is part of a family of CAHPS® surveys that asks patients to report on and rate their experiences with health care. The HHCAHPS survey presents home

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home health care providers and about the quality of their home health care. Prior to this survey, there was no national standard for collecting information about patient experiences that would enable valid comparisons across all home health agencies (HHAs).

In this Final Rule, we intend to move forward with the implementation of the HHCAHPS. However, we intend to link the survey to the CY 2012 payment update rather than to the CY 2011 payment update. We still intend to implement the survey on a voluntary basis beginning in October 2009.

Background and Description of the HHCAHPS AHRQ, in collaboration with its CAHPS grantees, developed the CAHPS® Home Health Care Survey with the assistance of many entities (for example, government agencies, professional stakeholders, consumer groups and other key individuals and organizations involved in home health care). The HHCAHPS survey was designed to measure and assess the experiences of those persons receiving home health care with the following three

goals in mind:

To produce comparable data on patients’ perspectives

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To hold health care providers accountable by informing the public about the providers’ quality of care.

The development process for the survey began in 2006 and included a public call for measures, review of the existing literature, consumer input, stakeholder input, public response to Federal Register notices, and a field test conducted by AHRQ.

AHRQ conducted this field test to validate the length and content of the CAHPS® Home Health Care Survey. We submitted the survey to the National Quality Forum (NQF) for consideration and endorsement via their consensus process. NQF endorsement represents the consensus opinion of many healthcare providers, consumer groups, professional organizations, health care purchasers, federal agencies and research and quality organizations. The survey received NQF endorsement on March 31, 2009.

The HHCAHPS survey includes 34 questions covering topics

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providers, communication with providers, interactions with the home health agency, and global ratings of the agency. For public reporting purposes, we will utilize composite measures and global ratings of care. Each composite measure consists of four or more questions regarding one of the following related


1. patient care;

2. communications between providers and patients; or

3. specific care issues (medications, home safety and pain).

There are also two global ratings; the first rating asks the patient to assess the care given by the HHA’s care providers, and the second asks the patient about his/her willingness to recommend the HHA to family and friends.

There are two options for administering the HHCAHPS survey.

The agency can choose to administer the existing HHCAHPS survey, or the HHA can integrate additional questions within the HHCAHPS survey. If an agency chooses to implement an integrated survey, the core questions from the HHCAHPS survey (questions 1 through

25) must be placed before any specific/supplemental questions that the home health agency wishes to add to the survey.

Questions 26 through 34 (the “About You” survey questions) must

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before or after any supplemental questions that the HHA wishes to add to the HHCAHPS survey. If no HHA-specific questions are to be added to the HHCAHPS survey, the “About You” questions should follow the core questions (numbered 1 through 25) on the HHCAHPS survey. In addition, there are nine optional supplemental HHCAHPS questions that are available for HHAs to use (in addition to the 34-item HHCAHPS survey). These optional supplemental HHCAHPS questions will not be publicly reported and are not required. The supplemental questions are listed in the Protocols and Guidelines Manual available at https://www.homehealthcahps.org.

The survey is currently available in both English and Spanish translations. We proposed that HHAs and their survey vendors will not be permitted to translate the HHCAHPS survey into any other languages on their own. However, it was proposed that CMS will provide additional translations of the survey over time. The website https://www.homehealthcahps.org will provide information about the subsequent availability of additional translations. In the proposed rule, we asked for suggestions for any additional language translations. Such suggestions should be submitted online to the HHCAHPS Survey Coordination

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Home health agencies interested in learning about the survey are encouraged to view the HHCAHPS survey website, at https://www.homehealthcahps.org. Agencies can also call tollfree (1-866-354-0985), or send an email to the HHCAHPS Survey Coordination Team at HHCAHPS@rti.org for more information.

The following types of home health care patients were proposed

as eligible to participate in the HHCAHPS survey:

Current or discharged patients who had at least one skilled care home health visit at any time during the sample month;

Patients who were at least 18 years of age at any time during the sample period, and are believed to be alive;

Patients who received at least two skilled care visits from HHA personnel during a 60-day look-back period. (Note that the 60-day look-back period is defined as the 60-day period prior to and including the last day in the sample month);

Patients who have not been selected for the monthly sample during any month in the current quarter or during the 5 months immediately prior to the sample month;

Patients who are not currently receiving hospice care;

Patients who do not have “maternity” as the primary reason for receiving home health care; and

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To collect and submit HHCAHPS data to CMS, Medicarecertified agencies will need to contract with an approved HHCAHPS survey vendor. Beginning in summer 2009, interested vendors applied to become approved HHCAHPS vendors. The application process was (and still is) delineated online at https://www.homehealthcahps.org. Vendors are required to attend training conducted by CMS and the HHCAHPS Survey Coordination Team, and to pass a post-training certification test.

Home health agencies that are interested in participating in the HHCAHPS survey may do so on a voluntary basis beginning in October 2009. Such agencies must select a vendor from the list of HHCAHPS approved survey vendors. This listing was made available on the website https://www.homehealthcahps.org on September 14, 2009. The listing will be updated on an ongoing basis to reflect the current approved list of survey vendors.

Participation Requirements for CY 2011: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care Survey In the proposed rule, we proposed that beginning in the first quarter of CY 2010, all Medicare-certified home health

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(HHCAHPS) survey data in accordance with the Protocols and Guidelines Manual located on the HHCAHPS website https://www.homehealthcahps.org. Home health agencies would contract with approved HHCAHPS survey vendors (posted on https://www.homehealthcahps.org)that are to conduct the survey.

We proposed that participating home health agencies would conduct a dry run of the survey for at least one month in the first quarter of 2010 (January, and/or February, and/or March 2010), and submit the dry run data to the Home Health CAHPS® Data Center by 11:59 p.m. EST on June 23, 2010. The dry run data would not be publicly reported on the CMS Home Health Compare website. This dry run would provide an opportunity for vendors and HHAs to acquire first-hand experience with data collection, including sampling and data submission to the Home Health CAHPS® Data Center, with no public reporting of the results. We proposed that all Medicare-certified home health agencies continuously collect HHCAHPS survey data every quarter beginning in the second quarter (April, May and June) of 2010, and submit these data for the second quarter of 2010 to the Home Health CAHPS® Data Center by 11:59 p.m. EST on September 22,

2010. We proposed that these data submission deadlines be firm

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Medicare-certified HHAs would need to provide their respective survey vendors with information about their surveyeligible patients (either current or discharged) every month in accordance with the Protocols and Guidelines Manual posted on https://www.homehealthcahps.org. Details about selecting the HHA sample are also delineated in the Protocols and Guidelines Manual.

In the proposed rule, we proposed that the HHCAHPS survey data be submitted and analyzed quarterly, and that the sample selection and data collection occur on a monthly basis. HHAs would target 300 HHCAHPS survey completes annually. Smaller agencies that were unable to reach 300 survey completes by sampling would survey all HHCAHPS eligible patients. We proposed that survey vendors initiate the survey for each monthly sample within 3 weeks after the end of the sample month.

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