Hospice Visits in the Last Days of Life (HVLDL)

NQF ENDORSEMENT STATUS: Not Endorsed  |  NQF ID: 9999  |  MEASURE TYPE: Process  |  INFO AS OF: Not available  |  CMIT ID: 6111  |  REVISION: 3
This measure assesses hospice staff visits to patients at the end of life. This measure is constructed from Medicare hospice claims records. It indicates the hospice provider’s proportion of patients who have received in person visits from a registered nurse or medical social worker on at least two out of the final three days of the patient’s life.
Info As Of Not available
Description This measure assesses hospice staff visits to patients at the end of life. This measure is constructed from Medicare hospice claims records. It indicates the hospice provider’s proportion of patients who have received in person visits from a registered nurse or medical social worker on at least two out of the final three days of the patient’s life.
Numerator The number of patient stays in the denominator in which the patient and/or caregiver received in person visits from registered nurses or medical social workers on at least two of the final three days of the patient’s life, as captured by hospice claims records.
Denominator All hospice patient stays except those meeting exclusion criteria as identified below.
Denominator Exclusions Patients are excluded from the denominator if: • They did not expire in hospice care as indicated by reason for discharge • They received any continuous home care, respite care or general inpatient care in the final three days of life • They were enrolled in hospice for fewer than three days Note: HVLDL looks at visits in the last three days of life; patients must receive hospice services for at least three days to be included in the measure.
Rationale There is evidence available from clinical organizations and panels, as well as from individual studies, supporting the measure's basis that clinician visits to patients at the end of life are associated with improved outcomes for both the patients and their caregivers. The last week of life is typically the period in the terminal illness trajectory with the highest symptom burden. Particularly during the last few days before death, patients experience many physical and emotional symptoms, necessitating close care and attention from the integrated hospice team and drawing increasingly on hospice team resources (de la Cruz 2014, Dellon 2010, Kehl 2013). Highly specific physical signs associated with death were identified within 3 days of death (Hui et al., 2014). Hospice responsiveness during times of patient and caregiver need is an important aspect of care for hospice patients (Ellington 2016). Although Medicare-certified hospices do not have any mandated minimum number of required visits for patients in routine home care (RHC), the most common level of hospice care, at the end of life, hospices should be equipped to meet the higher symptom and caregiving burdens of patients and their caregivers during this critical period (Teno 2016). Clinician visits to patients at the end of life are associated with decreased risk of hospitalization and emergency room visits in the last 2 weeks of the patients' life, decreased likelihood of a hospital-related disenrollment, as well as decreased odds of dying in the hospital (Sewo 2010, Phongtankuel 2018, Almaawiy 2014). In addition, clinician visits to patients at the end of life is also associated with decreased distress for caregivers and higher satisfaction with home care (Pivodic 2016). Visits by staff who can assess symptoms and make changes to the plans of care as well as work with the patient and the primary caregiver to provide the appropriate palliation and emotional support (nurses, social workers, and physicians) are important to the quality of care hospices deliver, as noted by the NQF's preferred practices on the recognition and management of the actively dying patient (Teno 2016). During the development of the Family Evaluation of Hospice Care survey, families voiced the importance of visits by these staff in the last days of life (Teno 2016). Citations: de la Cruz, M., et al. (2015). Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care. Palliative & Supportive Care, 13(2): 211-216. doi: 10.1017/S1478951513001144 Dellon, E. P., et al. (2010). Family caregiver perspectives on symptoms and treatments for patients dying from complications of cystic fibrosis. Journal of Pain & Symptom Management, 40(6): 829-837. doi: 10.1016/j.jpainsymman.2010.03.024 Kehl, K. A., et al. (2013). A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. American Journal of Hospice & Palliative Care, 30(6): 601-616. doi: 10.1177/1049909112468222 Hui D et al. (2014). Clinical Signs of Impending Death in Cancer Patients. The Oncologist. 19(6):681-687. doi:10.1634/theoncologist.2013-0457. Ellington, L., et al. (2016). Interdisciplinary Team Care and Hospice Team Provider Visit Patterns during the Last Week of Life. Journal of Palliative Medicine, 19(5), 482-487. doi: 10.1089/jpm.2015.0198 Teno, J. M., et al. (2016). Examining Variation in Hospice Visits by Professional Staff in the Last 2 Days of Life. JAMA Internal Medicine, 176(3): 364-370. doi: 10.1001/jamainternmed.2015.7479 Seow, H., Barbera, L., Howell, D., & Dy, S. M. (2010). Using more end-of-life homecare services is associated with using fewer acute care services: A population-based cohort study. Medical Care, 48(2): 118 124. doi: 10.1097/MLR.0b013e3181c162ef
Evidence This measure addresses a high priority area by assessing hospice staff visits to patients and caregivers during the final days of life when patients and caregivers typically experience higher symptom and caregiving burdens, and therefore a higher need for care. Collecting information about hospice staff visits for measuring quality of care will encourage hospices to visit patients and caregivers and provide services that will address their care needs and improve quality of life during the patients' last days of life. We conducted testing using 100% of Medicare hospice users discharged to death in FY2018 (n=1.1 million beneficiaries) for previously developed Measures 1&2 and the new measure, RN or MSW visits each day in the last three days of life, allowing for one missed day. There 3,594 hospices with reportable data for Measure 1, 3,579 hospices with reportable data for Measure 2, and 3,569 hospices with reportable data for the newly specified measure. The previously developed Measures 1 & 2 had mean scores of 89.3% and 72.9% (medians 14.9% and 16.6%, respectively); IQRs 86.5%-98.7% and 64.8% and 84.6%. Validity was assessed by calculating the correlation between the measure scores and the hospice's percentage of caregivers who would recommend the hospice; the Pearson correlation coefficients were 0.2166 and -0.0984 for Measures 1 & 2, respectively. We assessed reliability using split-half reliability analysis and the intraclass correlation coefficients were 0.861 and 0.817 for Measures 1 & 2, respective. For the new measure, the mean measure score across hospices was 64.8% (median 70.2%; IQR 53.0%-80.9%. Validity was again assessed by calculating the correlation between the measure score and the hospice's percentage of caregivers who would recommend the hospice; there was high evidence of validation with a (Pearson's) correlation of 0.2418. We also again assessed reliability using split-half reliability analysis and there was also high evidence; the intraclass correlation coefficient on this test was 0.893, indicating high evidence for reliability (the minimum threshold of acceptability is often given as 0.80).
Steward Centers for Medicare & Medicaid Services (CMS)
Contact Not available
Measure Developer Abt Associates
Development Stage Fully Developed
Measure Type Process
Meaningful Measure Area End of Life Care according to Preferences
Healthcare Priority Strengthen Person & Family Engagement as Partners in their Care
eCQM Spec Available Not Available
NQF Endorsement Status Not Endorsed
NQF ID 9999  (NQF Website )
Last NQF Update Not available
Target Population Age Not Specified
Target Population Age (High) Not available
Target Population Age (Low) Not available
Reporting Level Hospice
Conditions
Subconditions
Care Settings Hospice

  Core Measure Set  :   Not available


Measure Group Group Identifier Actions
Hospice and Palliative Care Not available
There are no relationships associated with the measure at this time.
Info As Of Not Available
Program / Model Notes
Data Sources Claims Data
Purposes Not available
Quality Domain Making care safe through timeliness and responsiveness of care
Reporting Frequency Not available
Impacts Payment No
Reporting Status Active
Data Reporting Begin Date 2021-10-01
Data Reporting End Date Not Available
Milestone Effective Date Comments Links Other Data Actions
Implemented 2021-10-01 Not available

https://www.govinfo.gov/content/pkg/FR-2021-08-04/pdf/2021-16311.pdf

Finalized 2021-08-04 Not available

https://www.govinfo.gov/content/pkg/FR-2021-08-04/pdf/2021-16311.pdf

Considered 2019-12-01 Not available

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Measures-under-Consideration-List-for-2018.pdf

MUC ID MUC2019-33
Development 2019-01-01 Not available
There are no links associated with the measure at this time.