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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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We proposed that all data collection for each monthly sample be completed within 6 weeks (42 days) after data collection began.

We have approved three modes of the survey to be used: mail only, telephone only, and mail with telephone follow-up (the “mixed mode”). We proposed that for mail-only and mixed-mode surveys, data collection for a monthly sample would end 6 weeks

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telephone-only surveys, data collection would end 6 weeks following the first telephone attempt.

In the proposed rule we wrote that we were aware that there was a wide variation in the size of Medicare-certified home health agencies. We proposed that the requirement to collect HHCAHPS survey data be waived for agencies that served fewer than 60 HHCAHPS eligible patients annually. The HHCAHPS eligible, unduplicated patient counts for the period of October 1 through September 30 for a given year would be used to determine if the HHA had to participate in the HHCAHPS survey in the next calendar year.

We also proposed that newly Medicare-certified home health agencies (that is, those certified on or after January 1, 2010 for payments to be made in CY 2011) be excluded from the HHCAHPS reporting requirement for the first year, as data submission and analysis would not be possible for an agency this late in the reporting period.

In the proposed rule, we strongly recommended that home health agencies participating in the HHCAHPS survey promptly review the required Data Submission Summary Reports that are described in the Protocols and Guidelines Manual posted on

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home health agency to ensure that its survey vendor has submitted their data on time, and that the data have been accepted/received by the Home Health CAHPS® Data Center. We received no comments on this proposal, and are finalizing it as proposed.

Oversight Activities: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care Survey We proposed that vendors and HHAs be required to participate in HHCAHPS oversight activities to ensure compliance with HHCAHPS protocols, guidelines and survey requirements. The purpose of the oversight activities is to ensure that HHAs and approved survey vendors follow the Protocols and Guidelines Manual. It was proposed that all approved survey vendors develop a Quality Assurance Plan (QAP) for survey administration in accordance with the Protocols and Guidelines Manual. The QAP

would include the following:

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As part of the oversight activities the HHCAHPS Survey Coordination Team would conduct on-site visits and/or conference calls. The HHCAHPS Survey Coordination Team would review the survey vendor’s survey systems, and would assess administration protocols based on the Protocols and Guidelines Manual posted on https://www.homehealthcahps.org. We proposed that all materials relevant to survey administration would be subject to review.

The proposed systems and program review would include but not be limited to: (a) survey management and data systems; (b) printing and mailing materials and facilities; (c) data receipt, entry and storage facilities; and (d) written documentation of survey processes. Organizations would be given a defined time period in which to correct any problems and provide follow-up documentation of corrections for review. Survey vendors would be subject to follow-up site visits as needed.

We did not receive any comments regarding the proposed oversight activities and therefore, the proposed recommendations are considered to be final for this rule.

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It is strongly recommended that all home health care agencies participating in the HHCAHPS survey regularly check the website, https://www.homehealthcahps.org for program updates and information.

We proposed that all HHAs, unless covered by specific exclusions, meet the quality reporting requirements or be subject to a 2 percent reduction in the home health market basket percentage increase in accordance with section 1895(b)(3)(B)(v)(I) of the Act. A reconsideration and appeals process is being developed for HHAs who fail to meet the HHCAHPS reporting requirements. We proposed that these procedures would be detailed in the proposed CY 2012 home health payment rule, the period for which HHCAHPS will be linked to the home health market basket percentage increase.

Comment: We received a comment endorsing the proposed addition of the HHCAHPS patient perspectives of care survey, stating that it would be a useful supplement to existing performance measures.

Response: We appreciate this comment in support of adding the Home Health Care CAHPS (HHCAHPS) measures to the quality reporting program of the agency.

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field-tested and the survey results need to be statistically reliable before such results are incorporated into quality reports, published on Home Health Compare, or counted in the consideration of the annual payment update for home health agencies.

Response: The Home Health Care CAHPS has been field-tested by AHRQ and the CAHPS grantees and the final survey is currently being used in a national, randomized mode experiment. A rigorous, scientific process was used in the development of the survey, including: a public call for measures; literature reviews; focus groups with home health patients; cognitive interviews with home health patients; stakeholder input; public response to Federal Register notices; and a field test.





Comment: We received feedback from commenters asking how HHCAHPS would be adjusted to account for variation in quality scores which is unrelated to agency behavior. One commenter noted that this would require matching of demographic and insurance data into a risk adjustment methodology. The commenter asked CMS to articulate how this adjustment will be achieved to prevent the release of spurious quality measures.

Response: We appreciate this feedback and would like to

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HHCAHPS, the prevention of spurious variables on the data was viewed as essential in the implementation of HHCAHPS. To further achieve this goal, we have additionally revised our protocols for the HHCAHPS based on comments that were sent to us. We are now including only Medicare and/or Medicaid patients in the HHCAHPS survey. For public reporting of the data, the data will be adjusted for mode of survey administration. The HHCAHPS measures will also be adjusted for patient mix.

Patient-mix adjustments are made when certain patient characteristics that are beyond home health agencies’ control impact how a patient responds to the survey. The patient-mix characteristics that have been identified for possible inclusion cover variables such as overall health status, diagnosis information, age, education, managed care indicator, whether the patient lives alone, and insurance coverage. Although the patient-mix adjusters included in the model are constant over time, the exact values of patient-mix adjustment coefficients are re-estimated each reporting period based on the empirical relationship observed between the patient-mix adjustment variables and HHCAHPS outcomes in that period.

Comment: We received comments that the HHCAHPS survey is

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completion of consumer satisfaction surveys are typically low, particularly when the instrument is long.

Response: The version of the HHCAHPS that was used in the AHRQ field test had 58 items, and the length of that survey did not appear to influence the completion of the survey. However, as a result of intensive data analysis and input from the stakeholders and the Technical Expert Panel, over 20 questionnaire items were eliminated from the field test survey.

The current 34-item questionnaire (that ultimately received NQF endorsement) was the outcome of this development process. We believe that the length of the survey represents an effective compromise and achieves the goal of providing key quality measures of the patient perspectives of care while at the same time keeping the survey as short as possible. CMS is not shortening the survey in this Final Rule.

Comment: We received feedback from a commenter concerned that many HHA patients were not sufficiently educated to interpret the HHCAHPS correctly.

Response: We appreciate the sensitivity to the home health patients by asking about the readability of the HHCAHPS survey.

The Flesch-Kincaid reading test showed that the HHCAHPS survey

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if patients are unable to answer the survey due to decrease capacities, a family or friend may assist the patient and answer the questions on behalf of the selected home health patient in the HHCAHPS home health agency sample.

Comment: We received comments asking how the HHCAHPS survey would be administered to patients suffering from dementia or psychiatric disorders.

Response: We appreciate comments sensitive to concerns about how HHCAHPS would be administered to patients suffering from dementia, or other disorders that might present challenges to respondents. Early on, we recognized the importance of allowing proxy respondents for this population even though proxy respondents are not always used in other CAHPS surveys. Proxy respondents answer the HHCAHPS survey on behalf of the patient respondent. We analyzed the field test data and found that proxy respondents do not respond differently from home health patients; thus, proxy respondents (that is, family members) are allowed. However, home health agency staff cannot serve as proxy respondents for patients.

Comment: We received feedback from one commenter that the existing survey timelines could result in patients being

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ended, resulting in an inability to recall or evaluate services accurately.

Response: We appreciate this comment concerning surveying patients too long after they received services. We received comments from the home health agencies in our mode experiment that the earliest that they can deliver a patient list from the end of the month is about two weeks after the close of the month. Therefore, we have emphasized to the HHAs to send their patient lists to their respective vendors in time to begin data collection within 21 days after the close of any month. In most data collection scenarios, we believe that patients will be surveyed within 60 days from the time that they last received services from the home health agency. In certain circumstances, it may be that patients will be surveyed later than 60 days if they were seen the very beginning of the sample month and do not respond to the initial mail or telephone attempts. Overall, the goal of the data collection process is to survey the patients as soon as possible.

Comment: We received comments that there is a need for additional language translations of the HHCAHPS besides English and Spanish. Several commenters mentioned the difficulties in

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who speak either English or Spanish.

Response: We appreciate these concerns regarding the need for additional language translations and strongly encourage that these suggestions and specific requests be submitted as soon as possible to the HHCAHPS Survey Coordination Team at HHCAHPS@rti.org. Currently, CMS is creating a Chinese translation of the questionnaire and will produce additional translations in the coming year. CMS is not allowing vendors or individual HHAs to independently translate the survey into other languages on their own because of the need to assure comparable (if not identical) wording in every language, and thus ensure comparability of the survey data on a national basis.

Comment: We received several comments about how we chose the particular criteria on who is eligible/ineligible to participate in the survey.

Response: Based on input received through stakeholder meetings, AHRQ and CMS agreed that patients 18 and older needed to have 2 or more skilled visits in order to evaluate an agency’s care. Additionally, maternity and hospice patients were excluded due to (1) the unique circumstances surrounding maternity care; and (2) the sensitivity associated with

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Comment: We received several comments concerning the inclusion of all patients, rather limiting the survey to Medicare and/or Medicaid patients only. Commenters were concerned about the burden and validity of including nonMedicare or non-Medicaid patients as respondents.

Response: In this Final Rule we are recommending that the submission of HHCAHPS data be initially applied to Medicare and Medicaid patients only. Only Medicare and/or Medicaid patients are included in the HHCAHPS survey. All other eligibility criteria are being implemented as proposed.

Comment: We received comments asking why Home Health Agencies cannot conduct the HHCAHPS survey themselves (that is, self-administer the survey).

Response: Agencies are not allowed to conduct the survey on their own. Since many of patients have a continuing relationship with their home health agency, we believe that an independent third party will be better able to solicit an unbiased response. Since they receive care in their homes, this population is particularly vulnerable and dependent upon their home health agency caregivers.

Comment: We received a comment asking CMS to clarify what

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patient lists and submit them to vendors.

Response: We thank the commenter for this inquiry and respond that we will be conducting oversight activities for the HHCAHPS vendors. As part of the oversight activities, we will monitor information about the number of patients eligible per month and may ask the vendor to provide sampling frame counts for a sample of agencies. If we are seeing unusual numbers of eligible patients counts compared against OASIS counts, we may work with the vendor and agency to determine if there are any systematic issues.

Comment: We received comments concerning the costs involved in contracting with an approved Home Health Care CAHPS vendor to collect and submit data. These costs represent an additional expenditure for agencies without additional compensation from CMS. These commenters stated vendor cost estimates have been provided, ranging anywhere from $5 per completed survey, up to $9,000 a year.



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