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Hospice Composite Measure: Identifying Patients with Pain

nurse and patient using hospice software to document pain

Patients and caregivers rate pain management as a high priority when living with life-limiting illnesses. The consequences of inadequate screening, assessment, and treatment for pain include physical and existential suffering, diminished functional status, and development of depression. The first step in pain management that should be documented in hospice software is performing a proficient screening for the presence of pain. This is the rationale for the requirement that hospices gather information on pain screening according to the Hospice Quality Reporting Program.

Reporting Pain in the Hospice Software

The Pain Screening Quality Measure requires an agency to screen a patient for pain during the initial assessment and if pain is present, report the severity of the pain using a standardized tool in the hospice software. The measure indicates that both the screening is completed in the timeframe listed AND that a standardized tool is used to rate the severity of pain, if it is present. Standardized tools are scientifically tested on a population with characteristics like the person being assessed and include standardized response scales. In order to have this quality measure counted, the documentation of the timely pain screening and the standardized tool used to rate the pain severity need to be documented in the hospice software.

The pain severity needs to be recorded in the clinical record of None, Mild, Moderate, or Severe for the quality measure to be achieved. Rating the patient’s pain severity in J0900C as “9 – Pain not rated” will not meet quality measures as the severity of the pain being rated is one of the requirements of the quality measure. Options for types of standardized scales listed in the HIS Manual version 2.01 are Numeric, Verbal Descriptor, Patient Visual, Staff Observation, and No Standardized Tool Used. Specific standardized tools for pain severity ratings are given in the HIS Manual, but the list is not exclusive. Examples include:

  • Numeric: 10-Point Scale, Symptom Distress Scale (McCorkle), Memorial Symptom Assessment Scale (MSAS), and the Edmonton Symptom Assessment System (ESAS)
  • Verbal Descriptor: Brief Pain Inventory, McGill Pain Questionnaire, and 6-Point Verbal Pain Scale
  • Patient Visual: Wong-Baker FACES Pain Scale, Visual Analog Scale, and a Distress Thermometer
  • Staff Observation: Critical Care Pain Observation Tool (CPOT), Checklist of Nonverbal Pain Indicators (CNPI), Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), and Pain Assessment in Advanced Dementia (PAIN-AD)

Clarifying Timing of Pain Reporting

One potentially confusing part of this quality measure is the timing of the Pain Screening requirements. In the Hospice Quality Reporting Program Current Measures, CMS describes the Pain Screening Measure as the percentage of patient stays during which the patient was screened for pain during the initial nursing assessment. CMS goes on to say that this should be done within two days of admission to hospice. The apparent discrepancy between the initial nursing assessment and two days is explained by the Conditions of Participation for timing of the initial RN assessment.

The State Operations Manual Appendix M – Guidance to Surveyors: Hospice states that the agency must complete an initial assessment within 48 hours of the election of hospice care. For most agencies, the election date and date when the initial RN assessment is completed are the same, but there is an option for the RN to complete the initial assessment within 48 hours of the election. Best practice for meeting the timing requirements for the Pain Screening quality measure would be to complete the Pain Screening on the initial RN assessment for the patient, whether it is scheduled for the same day as the election date or within 48 hours of the election.

Remember, if you are the person responsible for approving the Admission HIS prior to submission, take the time to read the clinical documentation in the hospice software prior to submission. The clinician may have documented items that are key to the pain screening measure in the narrative sections of the notes, and HIS allows for changing of the responses in the HIS document based on information found in other areas of the clinical documentation.


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