Strategies to Boost Hospice CAHPS Scores

Profitability is becoming inseparable from quality in today’s health care marketplace. Consequently, strong performance on publicly reported quality and caregiver satisfaction data is becoming increasingly crucial to hospice business performance.

Among the most important sources of data is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Patients and families in increasing numbers are using this information when choosing a hospice. Likewise, referral organizations such as hospitals, primary care physicians, and nursing homes are using the data to guide referral and contracting decisions.

“Referral sources are looking at these numbers, and patients and families are looking at them as well,” said Shelly Cartwright, administrator for Apex Hospice and Palliative Care in Chicago. “They are using the CAHPS scores to choose the provider that is going to have the highest quality of care.”


CAHPS participation is not budget neutral. The U.S. Centers for Medicare & Medicaid Services (CMS) requires hospices to use a vendor to send and collect the surveys and report the results to CMS, and improvement projects to raise scores tend to come with their own costs.

But experts are increasingly seeing quality measurement and improvement as an investment in future business growth.

“If you are improving health care, opportunities and profits will follow,” said Chris Booker, partner at the Nashville-based health care investment firm Frist Cressey Ventures. “If you are truly improving outcomes, then the returns on the investments you are making will follow.”


Quality could become even more key to profitability as payment models continue to evolve. Hospices now are preparing for CMS’ test of a hospice carve-In for Medicare Advantage plans. Those payors could take quality scores into account during contracting with hospices, as could Accountable Care Organizations.

“Right now hospices are not reimbursed based on their scores,” Kerri Ervin, MS, RN, chief compliance officer and senior vice president of engagement for Avow Hospice in Naples, Fla., told Hospice News. “We anticipate that in the future that this would change. I would think that the government will move towards that direction.”

Currently, CMS can reduce payments to hospices that don’t participate in CAHPS by 2 percent, though hospices that care for less than 50 patients in a given year can apply for an exemption. The agency reports hospice scores via Hospice Compare.

For hospice, CAHPS surveys are sent to the family after the patient has passed away to gauge their satisfaction with the care their family member received. The survey vendor contacts the family by phone or mail approximately 42 days after the end of the month in which the patient died.

The survey’s 47 questions indicate the family’s perception of hospice performance on 11 metrics such as hospice team communication, symptom management, emotional and spiritual support, patient and caregiver training, and whether the family would recommend the hospice, among other data points.

“The survey certainly gives us a picture of how well we are performing as viewed by patients and families, and we have used that information to improve the quality of care—which ultimately is the goal of CAHPS,” Ervin said.

Avow Hospice uses CAHPS data to develop and prioritize performance improvement goals. If the company scores are lower than expected on a particular measure, they design an improvement project to bring them back up. These projects are led by the patient experience of care manager, a post that Avow created specifically to lead efforts to enhance CAHPS performance.

Hospices should look not only at their most recent results but benchmark those against previous years’ to identify trends, declines or improvements in caregiver satisfaction. Some survey vendors also provide access to comparison norms so providers can benchmark their performance against other companies.

In addition to robust staff education on factors affecting quality, Avow uses a tool called Gap Analysis to guide improvement strategies. A gap analysis is designed to compare a company’s actual performance with their desired performance, using these steps:

  • Identify the existing process
  • Identify the existing outcome
  • Identify the desired outcome
  • Identify and document the gap
  • Identify the process to achieve the desired outcome
  • Develop the means to fill the gap
  • Develop and prioritize requirements to bridge the gap

Another consideration in addition to the hospice’s own performance is an examination of results that have the greatest impact on the overall scores.

According to a white paper by Massachusetts-based consulting firm Fazzi Associates, improvement on these four survey questions correspond with improvement on overall CAHPS results:

  1. How often did you feel that the hospice team really cared about your family member?
  2. How often did the hospice team keep you informed about your family member’s condition?
  3. How often did the hospice team listen carefully to you?
  4. How often did the hospice team explain things in a way that was easy to understand?

In addition to supporting an organization’s business interests, the data also provides insights into the hospice’s mission, giving a picture of how clinicians and staff can better serve patients and their families.

“If hospice providers don’t use the information available to them through CAPHS and other quality data, then they are really losing an opportunity to improve. The best practice is really looking at those results and setting goals for where you want to be,” Ervin told Hospice News. “Because behind each of those numbers is a life we touched. It’s important to look at the numbers, but also the stories behind the numbers and what they represent.”

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