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CAHPS Hospice FAQs

What is the CAHPS Hospice Survey?

The CAHPS Hospice Survey is an experience of care survey that evaluates the experiences of hospice patients and their caregivers. The survey is sent to hospice patients’ primary informal caregivers (i.e., family members and friends) after the death of the hospice patient. The CAHPS Hospice Survey is used in a CMS pay-for-reporting program which started with the fiscal year (FY) 2017 Annual Payment Update (APU) and continues for subsequent APU periods.

 

For a more detailed overview, please see the CAHPS Hospice Survey page and review the other resources available to you using the left-side menu.

Who must participate in the CAHPS Hospice Survey?

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 APU. However, certain exemptions are granted by CMS for size or newness.

 

Exemption for Size:

 

 

Reference Period

(Decedent Death)

Exemption Form Deadline Exemption Request Review by CMS Affects APU
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 Dec 31, 2018 2019 FY 2020
Jan 1 to Dec 31, 2018 Dec 31, 2019 2020 FY 2021
Jan 1 to Dec 31, 2019 Dec 31, 2020 2021 FY 2022

 

FY – Fiscal year

 

Exemption for Newness:

 

 

For the calendar year (CY) 2018 data collection period, hospices who received their CCN on or after January 1, 2018 are eligible for a one-time exemption for newness. For example, if a hospice receives its CCN any time in 2018 whether it is in January 2018 or December 2018, it is exempt from survey administration for the remainder of 2018. A hospice that receives its CCN any time in 2018 is required to start participating in the CAHPS Hospice Survey beginning with January 2019 decedents.

 

How is CAHPS Hospice Survey compliance determined?

The CAHPS Hospice Survey is a pay-for-reporting program, which means that the submission of required data by specified deadlines determines compliance. Data submission requirements include the following:

 

 

How does a hospice find a CMS-approved CAHPS Hospice Survey vendor?

CMS provides an Approved Vendor List on the official CAHPS Hospice Survey website. Clicking the hyperlink will open the page in a new tab so you can keep your place in the Axxess Help Center.

 

(After contracting with an approved survey vendor, complete and submit a CAHPS Hospice Survey Vendor Authorization Form. Click the link or use the menu on the left side of the screen to access forms and instructions.)

 

How can I receive updates/more information related to the CAHPS Hospice Survey?

CAHPS Hospice Survey Website

CMS’ official website for the CAHPS Hospice Survey provides comprehensive information on CAHPS survey requirements for hospice agencies, compliance, and additional information including the following sections:

 

Hospice Quality Reporting Program (HQRP)

The HQRP website provides provides consumer and provider information regarding the HQRP (mandated by the Affordable Care Act of 2010) and analytic information on CMS’ public reporting of HIS and CAHPS Hospice Survey data.

Hospice professionals can subscribe to the PAC QRP listserv for the latest hospice quality reporting information including training, stakeholder engagement opportunities, and general updates on the following items:

 

How can I contact the CAHPS Hospice Survey Project Team?

 

When is the survey administered?

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. Please see the schedule outlined in the table below.

 

Month of Death Initial Contact with Sampled Decedents/Caregivers Data Submission to the CAHPS Hospice Survey Data Warehouse
January 2019 April 1, 2019 August 14, 2019
February 2019 May 1, 2019
March 2019 June1, 2019
April 2019 July 1, 2019 November 13, 2019
May 2019 August 1, 2019
June 2019 September 1, 2019
July 2019 October 1, 2019 February 12, 2020
August 2019 November 1, 2019
September 2019 December 1, 2019
October 2019 January 1, 2020 May 13, 2020
November 2019 February 1, 2020
December 2019 March 1, 2020

 

What was the dry run?

What topics are included in the CAHPS Hospice Survey?

Topics include:

How many decedents/caregivers will be sampled?

Who pays to administer the CAHPS Hospice Survey?

Participating hospices will contract directly with, and pay, a CMS-approved CAHPS Hospice Survey vendor to administer the survey on behalf of the hospice.

Who will the survey be administered to?

The CAHPS Hospice Survey will be administered to eligible decedents/caregivers from all payer sources.

Who is eligible to be a “primary informal caregiver?”

The CAHPS Hospice Survey is designed to be administered to the person who is most knowledgeable (primary informal caregiver) about the hospice care received by the decedent. The caregiver relationship to the decedent should fall into one of the following categories: spouse/partner, parent (or step parent), child (or step child), other family member, friend, or other. A non-familial legal guardian who does not fall into one of these categories cannot be considered a primary informal caregiver for the purposes of the CAHPS Hospice Survey. The hospice is responsible for identifying the primary informal caregiver that may be eligible to receive and respond to the CAHPS Hospice Survey.

What is meant by the data element “Facility Name?”

A caregiver may associate their family member’s care with the facility where hospice care was received, rather than the actual name of the hospice organization. Therefore, “Facility Name” refers to the name of the facility (e.g., name of the assisted living facility, nursing home, hospital, or hospice house) where care was received. For example, if the decedent received care from Hospice ABC while in Facility XYZ, Facility XYZ is the “Facility Name.”

How do you determine the eligibility of decedents/caregivers?

Decedents/Caregivers who initiate or voluntarily request at any time during their stay that the hospice 1) not reveal the patient’s identity and/or 2) not survey him or her will be excluded from the sample frame. Patients whose last admission to hospice resulted in a live discharge will also be excluded.

Note: Decedents/Caregivers must be included in the CAHPS Hospice Survey sample frame unless the survey vendor has definitive evidence that a decedent/caregiver is ineligible. If information is missing on any variable that affects survey eligibility when the sample frame is constructed, the decedent/caregiver must be included in the sample frame. The only exception to this guideline is the date of death; if any part (i.e., day, month or year) of the decedent’s date of death is missing, the case must not be included in the sample frame, and the case must be included in the count of “Missing Date of Death” submitted by the survey vendor to the CAHPS Hospice Survey Data Warehouse.

Note: If a hospice or survey vendor becomes aware that the caregiver is under 18 years old prior to drawing the sample, the caregiver should be excluded from the sample frame.