Getting Timely Help

Identifying Attributes

Care Settings
Palliative Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Hospice Quality Reporting Program
Type of Quality Indicator
Outcome
IOM Quality Dimension
Person-Centredness
Domain
Structure and Processes of Care

Defining Attributes

Definition

Multi-item measure included as part of the CAHPS® Hospice Survey.. Both items have response options of "Never," "Sometimes," "Usually," and "Always." Survey question (P1): "While your family member was in hospice care, when you or your family member asked for help from the hospice team, how often did you get help as soon as you needed it?"; Survey question (P2): "How often did you get the help you needed from the hospice team during evenings, weekends, or holidays?"

Numerator

CAHPS® Hospice Survey measures are calculated using top-box scoring. The top-box score refers to the percentage of caregiver respondents that give the most positive response. The top box numerator is the number of respondents who answer "Always." Top box scores for each survey question within the measure are adjusted for the mode of survey administration (at the individual respondent level) and case mix (at the hospice level), and then averaged to calculate the overall hospice-level measure score.

Denominator

The top box denominator is the number of respondents who answer at least one question in the multi-item measure (i.e., one of question P1 or P2).

Exclusions

The hospice patient is still alive; The decedent's age at death was less than 18; The decedent died within 48 hours of his/her last admission to hospice care; The decedent had no caregiver of record. -The decedent had a caregiver of record, but the caregiver does not have a U.S. or U.S. Territory home address; The decedent had no caregiver other than a nonfamilial legal guardian; The decedent or caregiver requested that they not be contacted (i.e., by signing a no publicity request while under the care of hospice or otherwise directly requesting not to be contacted); The caregiver is institutionalized, has mental/physical incapacity, has a language barrier, or is deceased; The caregiver reports on the survey that he or she "never" oversaw or took part in the decedent's hospice care.

Use of Risk Adjustment
Yes
Risk Adjustments

Documents describing the case-mix adjustment process are available on the Scoring and Analysis page of the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org). Unable to locate full details because the CAHPS website access if forbidden.

Stratifications

Data Attributes

Type of Data Collection
Surveys
Data Collection Methods

The CAHPS Hospice Survey is conducted monthly (hospices are required to participate on an ongoing monthly basis in order to receive their full Annual Payment Update from CMS). Survey vendors select monthly samples of all decedents/caregivers who meet survey eligibility criteria for each contracted hospice. Data collection for sampled decedents/caregivers must be initiated two months following the month of patient death. The data collection process must be completed within 42 calendar days after initial contact. Submission of the data to the CAHPS Hospice Survey Data Warehouse occurs quarterly. There are three allowed modes of administration for the CAHPS Hospice Survey: Mail Only, Telephone Only and Mixed Mode (mail with telephone follow-up). The CAHPS Hospice Survey mail materials are available in English, Spanish, Chinese, Russian, Portuguese, Vietnamese, Polish, and Korean. The CAHPS Hospice Survey telephone script is available in English, Spanish, and Russian.

Frequency of Data Collection
Monthly
Frequency of Data Collection in Days
30
Reporting Methods

Public reporting.

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
Indicator Has Recommended Targets
No

Source and Reference Attributes

Evidence Source

Partnership for Quality Measurement. (2023). Available from: p4qm.org/measures/2651 CMS website: https:/www.cms.gov/medicare/quality/hospice/public-reporting-cahps-preview-reports-and-requests-cms-review-cahps-data. Dated cited 18/10/2023. CMS current measures: www.cms.gov/medicare/quality/hospice/current-measures. Dated cited 18/10/2023. Example Medicare public reporting: www.medicare.gov/care-compare/details/hospice/311563?city=New%20York&state=NY&zipcode=&measure=hospice-family-caregiver-experience Unable to access main CAHPS website: web.archive.org/web/20250104211132/https://www.hospicecahpssurvey.org/. Access is forbidden. CAHPS Quality Assurance Guidelines (September 2020 version): www.cms.gov/files/document/cahps-hospice-survey-quality-assurance-guideline-v70-september-2020.pdf. Date cited 18/10/2023.

Link to Measurement Tools

This measure is endorsed under Consensus Based Entity (CBE) #2651 (last endorsed 20 November 2020)

Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025