CAHPS® Hospice Survey

Hospice-specific FAQs
     
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CAHPS Hospice Survey
Hospice-specific Frequently Asked Questions (FAQs)

Does my hospice need to participate?

In general, all Medicare-certified hospices (identified by CMS Certification Number [CCN]) must participate in the CAHPS Hospice Survey in order to receive their full Annual Payment Update (APU). However, certain exemptions are granted by CMS for size or newness.

Exemption for Size

  • If your hospice has served fewer than 50 survey-eligible decedents/caregivers during the “reference period” (see table below) you can apply for an exemption from the CAHPS Hospice Survey
  • Exemptions on the basis of size are active for one year only. If your hospice remains eligible for this exemption in subsequent years, your organization will need to request this exemption on an annual basis.

"Reference Period" or Decedent Date of Death

Exemption Form Deadline

Exemption Request Review by CMS

Affects APU

Jan 1 to Dec 31, 2014

Aug 15, 2015

2016

FY 2017

Jan 1 to Dec 31, 2015

Dec 31, 2016

2017

FY 2018

Jan 1 to Dec 31, 2016

Dec 31, 2017

2018

FY 2019

Jan 1 to Dec 31, 2017

TBD

2019

FY 2020

FY – Fiscal Year

Exemption for Newness

  • The exemption for newness is based on how recently the hospice received its CCN, also known as the Medicare Provider Number. The criterion for this exemption is that the hospice must have received its CCN on or after the first day of the performance year for the CAHPS Hospice Survey.
    • For the calendar year (CY) 2017 data collection period, hospices who received their CCN on or after January 1, 2017 are eligible for a one-time exemption for newness. For example, if a hospice receives its CCN in March 2017, then the hospice would receive an exemption for newness for CY 2017.
  • This is a one-time exemption for each hospice as identified by CCN
  • Hospices eligible for this exemption will be identified by CMS, as this exemption is based on when the hospice’s CCN is assigned. There is no form for hospices to submit.

Does my hospice need to have a contract with a survey vendor? 

  • If your hospice is exempt from participation because of size or newness, you will not need to contract with a survey vendor
  • If your hospice does not meet the exemptions for size or newness, then your hospice will need to select a survey vendor, negotiate a contract with the survey vendor, and authorize the survey vendor to collect and submit data on your hospice’s behalf. The approved survey vendor list is located under the left hand Approved Vendor List navigation button on the CAHPS Hospice Survey Web site.

How does my organization authorize our survey vendor?

  • Your hospice needs to fill out the CAHPS Hospice Survey Vendor Authorization Form which can be found on the Technical Specifications page of the CAHPS Hospice Survey Web site. This form will authorize the survey vendor you have chosen to collect and submit data on your hospice’s behalf. This serves as your notification to CMS of the survey vendor with whom your hospice has contracted.
  • This form must be submitted to the RAND Corporation one calendar quarter (90 days) prior to the data submission deadline. If you have questions, contact the CAHPS Hospice Survey Data Coordination Team via email at: cahpshospicetechsupport@rand.org.

How does my organization submit a sample file to the survey vendor? 

  • Your hospice will work with its contracted survey vendor to determine a date each month to submit the monthly decedents/caregivers list and counts of cases ineligible due to live discharges and voluntary requests for no contact (“no publicity”)
  • There is specific information that the hospice will need to provide to its survey vendor. This information can be found in Appendix E of the CAHPS Hospice Survey Quality Assurance Guidelines V3.0. This manual is available on the CAHPS Hospice Survey Web site, under the left hand Quality Assurance Guidelines navigation button.

How is the “primary informal caregiver” identified?

  • The hospice is responsible for identifying the primary informal caregiver that may be eligible to receive and respond to the CAHPS Hospice Survey. Please note, hospices should not necessarily prioritize a primary informal caregiver that is a family member over a friend, as one caregiver category does not automatically have preference over another. The CAHPS Hospice Survey is designed to be administered to the person most knowledgeable about the care the decedent received at the hospice. Staff members or employees of the hospice or care setting in which the patient received care should not be considered primary informal caregivers.

How will my hospice access the CAHPS Hospice Survey Data Warehouse?

  • Your hospice will need user accounts to access and review the data submitted by your survey vendor via the CAHPS Hospice Survey Data Warehouse. This gives your hospice an opportunity to check the quality of the work of your survey vendor.
  • Your hospice will need to complete the CAHPS Hospice Survey Data Warehouse Form, which is located on the Technical Specifications page of the CAHPS Hospice Survey Web site. Your hospice will not be required to install any special software or pay a licensing fee to access the Data Warehouse.
  • It is important to designate two people from your hospice to have access to the CAHPS Hospice Survey Data Warehouse in order to be able to review quarterly data submission reports. Make sure to notify the CAHPS Hospice Survey Data Coordination Team of any staff changes by sending an updated CAHPS Hospice Survey Data Warehouse Form to cahpshospicetechsupport@rand.org.
  • The CAHPS Hospice Survey Data Warehouse can be found online at: https://kiteworks.rand.org  
  • Your form must be received one calendar quarter (90 days) prior to the first time data will be submitted to the CAHPS Hospice Survey Data Warehouse. If you have questions, contact the CAHPS Hospice Survey Data Coordination Team via email at: cahpshospicetechsupport@rand.org.

What reports are available to my hospice on the CAHPS Hospice Survey Data Warehouse?

Below is a brief overview of what is presented in your hospice’s reports. These reports will be posted to your hospice’s data warehouse folder no later than 5:00 PM Eastern Time on the business day following an upload by your survey vendor. The four reports are:

  • Data Submission Detail Report (Part I): This report indicates whether or not the data submitted by your survey vendor was accepted and processed. If the uploaded file fails to meet the required standards, the file will not be processed and the remainder of the reports will not be generated. A correct file will need to be resubmitted prior to the deadline.
  • Data Submission Detail Report (Part II): This report indicates if the submitted data passed data quality checks. If any values are out of range, ‘Data Value Checks Status’ will show as ‘Rejected’ and survey vendors must submit a new file. If all data values pass the data quality checks, ‘Data Value Checks Status’ will show as ‘Accepted,’ and no further action is needed.
  • Survey Status Summary Report: This report lists the number of records and number of completed surveys for your organization contained within the file. These are listed separately by month of death, and overall. The column ‘# Administrative Data Records’ is the number of records within the file, and the column ‘# Survey Results Records’ is the number of completed surveys.
  • Review and Correction Report: This report lists the number of valid and invalid responses to each variable in the file.

When does the survey take place? 

Hospices are now required to participate in the CAHPS Hospice Survey on an ongoing monthly basis.

  • Data collection for sampled decedents/caregivers must be initiated two months following the month of patient death
    • For example, if a patient dies in January 2017, a hospice may begin surveying that patient’s primary caregiver starting April 1, 2017
  • For more information on the survey administration timeline, refer to the left hand FAQs navigation button on the CAHPS Hospice Survey Web site

Can our hospice discuss the CAHPS Hospice Survey with decedents/caregivers?

  • If your hospice wants to let caregivers know that they may receive a survey and to encourage them to complete it, you must tell all caregivers. However, your hospice must not attempt to influence the caregivers to answer the CAHPS Hospice Survey questions in any particular way.

Are there guidelines for conducting quality improvement activities in conjunction with the CAHPS Hospice Survey?

It is permissible for patients and/or their caregivers to be asked questions about their care during their hospice stay or during bereavement calls where this is a normal part of quality improvement activities.

Activities and encounters that are intended to provide or assess clinical care or promote patient/family well-being are permissible. If patients or their caregivers are asked questions during their hospice care, we suggest that such questions be worded in a neutral tone and not slanted toward a particular outcome. In addition, questions must not resemble CAHPS Hospice Survey items or their response categories. Hospices should focus on overall quality of care rather than the measures reported to CMS.

Caregivers should not be given any formal, CAHPS Hospice Survey-like, patient experience/satisfaction survey during their family member’s hospice stay or after the death of the patient. A formal survey, regardless of the mode employed, is one in which the primary goal is to ask standardized questions of a significant portion of a hospice’s patient/caregiver population.

  • When asking non-CAHPS Hospice Survey questions, do not use CAHPS Hospice Survey-like response categories (for instance, “Always,” “Usually,” “Sometimes” or “Never”)
  • The following are examples of the types of questions that are not permissible:
    • “On a scale of 0 to 10, how would you rate your family member’s hospice care?”
    • “Is there a way we could always….?”
    • “Did the hospice team explain things in a way you could understand?”
    • “Overall, how would you rate the care you received from the hospice?”

Activities and encounters that are primarily intended to influence how caregivers, or which caregivers, respond to CAHPS Hospice Survey items must be avoided.


How can my hospice receive identified data?

If your hospice wishes to view the survey responses linked to respondents’ name and other identifying information, you must work with your approved CAHPS Hospice Survey vendor to include the Consent to Share Responses supplemental question in the mail questionnaire and/or in the telephone questionnaire. If you’d like to receive identified data, please refer to the left hand Survey Instruments navigation button for Consent to Share Responses language.


 

This page was last modified on 01/24/2017