In the first three months since the implementation of the Hospice Item Set (HIS), all but one of the 7 CMS Quality Measures have improved since July 2014.
The measure creating the most challenge is Comprehensive Pain Assessment. The scores for this measure have declined each month since July 2014. The most common reasons for this measure not to be met are a) No comprehensive pain assessment was completed, or b) Only 1-4 of the required attributes were assessed – or at least documented.
Table 1 shows performance for July, August, and September for each of the measures. Note that Pain Assessment has gotten worse over time, but this can be easily corrected. Table 2 shows the percentage of time that each attribute is utilized.
As part of HRQP education, hospices should reinforce to staff that at least 5 of the following must be included in the pain assessment:
- What relieves or worsens the pain
- The effect on function or quality of life