Centers for Medicare and Medicaid Services have published the inaugural report for the Hospice Care Index. Are you diving into your results or delaying even taking a peek?

Think back to where you were at this time last year. Were you wondering about the changes to the Hospice Quality Reporting Program and what they might mean for your organization? Let’s take a minute to review the changes and what you learned prior to opening the envelope.

opening the envelope

July 2021: What is the Hospice Care Index?

At this time last year, hospice leaders were learning as much as they could about the new hospice quality reporting program requirement, the Hospice Care Index. Questions abounded. What is this new quality indicator? Why is CMS focusing on these areas? How will our scores compare to industry standards?

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What did CMS tell us?

The Centers for Medicare and Medicaid Services (CMS) described how they had developed 10 claims-based indicators. The indicators were designed to be meaningful measures, aligned with other health care programs, that would address high-priority areas in hospice where gaps in care might exist.

The Hospice Care Index (HCI) focused on gathering information related to the following four areas:

  • Provision of higher levels of care (Continuous Home Care and General Inpatient levels of care)

  • Visits by professional hospice staff

  • Patterns of live discharges and transitions

  • Medicare spending, reporting of per-beneficiary spending as is done in other care settings


CMS wanted to ensure that patients were receiving all levels of care to which they were entitled, that they received visits with a frequency that met their needs, that hospices were admitting and discharging patients in accordance with regulatory and industry standards, and that the cost per beneficiary was tracked in the same way it is in other health settings.

What did this level of oversight tell hospice agencies?

Hospice administrators wondered what their HCI data would show and how CMS might use the data to adjust payment structures. Hospice agencies already track metrics related to their live discharge rate, visits near death, and their reimbursement per beneficiary, but this new oversight indicated that CMS was going to be looking at this data in new ways.

Administrators wondered if CMS would be looking for patterns that might indicate the hospice was not meeting patient needs, or perhaps data trends might raise the question of fraud. Hospice agencies were nervous, wondering how their number of nursing care minutes per day or minutes of nursing care provided on the weekend would compare with other hospices in their community, state, and nationally.

Who wanted to be the low scorer there? No one!

What was CMS looking for?

CMS provided the following information on the HCI claims-based indicators designed to gather the information they needed, as well as some insight into how each indicator impacts the scoring.

(Note: To take a closer look at the image above, right-click to “open in new tab.”)

The HCI timeline & COVID-19 context

The first HCI report covers eight quarters, spanning calendar years 2019 through 2021. That includes two years of COVID-19, but every part of the health care system’s data was impacted by COVID-19, and quality data reporting requirements were suspended for Q1-2 of 2020.

There’s no discounting the data due to COVID-19; everyone was in the same boat, albeit with different challenges!

The HCI Report reveals what’s going well

The average HCI score was 8.8, and 37.9% of all hospice agencies received a score of 10! While scores were high, there was enough difference in scores for the data to be useful in identifying opportunities for improvement.

Another useful outcome was the correlation between high HCI scores and higher scores from family members on the CAHPS survey hospice question asking the family member about their willingness to recommend the hospice. Visiting patients more frequently, providing higher levels of care when indicated, discharging patients carefully and appropriately, avoiding burdensome transitions, and making skilled visits as death is nearing increased the family’s satisfaction and increased their willingness to recommend the hospice to others.

Doing the right thing while providing care in a regulatory compliant manner was the best way to meet the patient and family’s needs and improve quality scores!

Who did best?

CMS reported that overall, scores were higher among larger hospice agencies, hospices that had been around longer (lovingly called “older hospices”), not-for-profit hospices, and facility-based hospices.

So, what happens if your hospice is none of these things? What if you are a small, rural, for-profit hospice that has been in existence for 4 years? How are you supposed to compete?

Step 1: Respond to your data!

Whether you are a small hospice just starting out or a large hospice that has been around since the 1980s, your response to your quality data is the same. Identify and celebrate your strengths! Next, look at your opportunities for improvement. Is there an area where you could get a quick win? Something you could focus on and see improvement right away? Is there an area that you are concerned could lead to a survey deficiency or put you at risk for increased regulatory oversight?

Start with those areas. Be mindful that sustained performance improvement takes time and focused energy. Don’t be tempted to fix several areas at once!

The sample below is an illustration available in the Hospice Care Index Technical Report. Let’s talk about how you might respond if this was your agency’s data.

Hospice Care Index Technical Report

(Note: To take a closer look at the image above, right-click to “open in new tab.”)

This agency has an HCI score of 8. Notice the two areas where they did not meet the criteria for success: gaps in skilled nursing visits and skilled nursing care minutes per routine home care day. Both indicators reflect the amount and frequency of nursing care provided to patients.

Not visiting patients frequently enough impacts quality of care and patient and family satisfaction. The agency is also at risk during a survey if care plans indicate a weekly skilled nursing visit and those visits are not happening.

What can you do if this is you? Make sure your staff visit each patient every week, thereby increasing your nursing minutes per patient. Mandate nursing visits twice per week for all patients?

These responses would be understandable as a gut reaction to the data. No one wants to be the hospice with the fewest number of skilled nursing care minutes! However, you are encouraged to push past your gut reaction and use your quality improvement program to effect lasting change.

Quality improvement means understanding the data!

Remember our warning to avoid focusing on too many indicators at one time and avoid the temptation to lump these two indicators into one quality improvement program. This example agency could start with the gaps in skilled nursing visits.

Have your managers talk to their nurses about their perception of “skilled nursing visit once per week.” Does that mean visiting Monday this week and Wednesday next week would be okay? Many nurses think so, which leads to gaps between visits that exceed 7 days.

Gather more data. One option is to pull a daily report listing patients who have had gaps greater than 7 days. Does the challenge belong to a few providers? To one or two teams? Is it more widespread? Once you understand this, you can begin to address the issues and develop a process that can fix the problem using buy-in from the staff involved.

Once you have addressed that indicator, it is time to begin gathering data on the number of skilled nursing care minutes per routine home care day. Your agency provides 6.3 minutes per routine home care day while the national average is 16 minutes per routine home care day—just over two and a half times the number of minutes you provide!

As difficult as it might be to look at this score, think about sharing it with your nursing staff as a first step. Be careful to avoid accusations or blame. Explain how the metric is calculated: the number of direct patient care minutes logged at each visit divided by the total number of routine home care days. Ask them to write down one thing that they think contributes to such a short amount of time being spent providing direct patient care and one idea they have that might better capture the time it takes to provide good hospice care.

Look for trends in the ideas they provide. Is there information that surprises you? Ideas that you might not have considered. Avoid the temptation to apply your own reasoning for the problem. Jumping to the conclusion that the hours would be more accurate if staff would just document in the home, which is my pet peeve, might get you where you need to go. If the real issue is that patients and families still want fewer and shorter visits post-COVID, forcing the documentation issue would not help!

Going Forward

Think of the adage, “Knowledge is Power.” With the release of the initial HCI Indicator data, you have knowledge. How you decide to use it is up to you. You are encouraged to consider the following:

  • What do we do really well? Can we leverage anything from these areas to improve care overall?

  • Consider your HCI indicator data as a piece of the puzzle. Look at the data in relation to your CAHPS scores, your recent survey data, your hospice star rating data, your organization’s mission, vision, and values, and your 5–10-year plan.

  • Use your organization’s quality improvement program and processes to address opportunities for improvement. Do you need to focus on a new area? Maybe something you thought was an issue turned out not to be. Do you need to speed up a timeline, try a new approach, or even go back to the drawing board and start fresh?


As always, ground yourself, your organization, and your work in the needs of those you are privileged to care for. Quality measures are a tool to guide your processes and successes, but they can’t be the sole reason for your work.

I encourage you to spend time with BJ Miller as he shares his views in the YouTube video “What Really Matters at the End of Life.” His perspective on the role of health care systems in relieving unnecessary suffering and the importance of looking at end of life as an opportunity, “rather than just getting it out of the way, aging and dying can become a process of crescendo through to the end”.

Now, open the envelope!

opening the envelope

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