Hospice Data - Part 1: What Is It; Where Does It Come From; and What Does It Mean?

Hospice Data - Part 1: What Is It; Where Does It Come From; and What Does It Mean? 

Failure to access and analyze pertinent hospice data can have significant impact on hospice providers and now is the time for hospice providers to embrace all forms of data and use it to positively influence their program. Ideally, hospice providers would access data in a timely manner and create action plans to address any areas of concern or opportunity for improvement. In doing so, providers will make great progress in mitigating payment-related scrutiny or future payment reduction. Additionally, pertinent clinical data will ultimately be publicly reported, so addressing areas of concern or areas for improvement will also pay off for hospice providers when public reporting begins later in 2018.


Hours: 1.25


Certificates provided by accrediting body (7 Match)

California Board of Registered Nursing

1.25 HOURS

Provider approved by the California Board of Registered Nursing, CEP# 13791

Nurses will receive 1.25 contact hours for participating in this course.

District of Columbia Board of Nursing


DC-RN -- District of Columbia Board of Nursing Approved Continuing Education program (CE Provider #50-290).

Nurses will receive 1.20 contact hours for participating in this course.

Florida Board of Nursing


Florida Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

American Nurses Credentialing Center

1.25 HOURS

Relias, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses will receive 1.25 contact hours for participating in this course.

Georgia Board of Nursing

1.25 HOURS

Georgia Board of Nursing CE Provider #: 50-290

Nurses will receive 1.25 contact hours for participating in this course.

South Carolina Board of Nursing

1.25 HOURS

This program was approved by the South Carolina Board of Nursing Approved Continuing Education Program (CE provider #50-290) CE Broker Course # 20-[Custom_Code]

West Virginia Board of Registered Nursing

1.25 HOURS

Course Details

Course Code: REL-HOS-WB-HDP1
Hours: 1.25
Type: Online Course
Content Expiration Date: 5/31/2021
Learning Objectives:
Recite the 4 primary sources of hospice e-specific data (E.g., HIS, CASPER, CAHPS, and PEPPER) and how to obtain each data set.
Demonstrate competence in using PEPPER target areas to determine organizational risk according to the hospice’s percentile ranking for each target area.
Verbalize the analysis and link between HIS/CASPER and CAHPS data and how non-compliance may have future payment impacts.
Recall the steps to Action Plan development based on concerning or aberrant data.

Hospice Item Set

HIS Timeliness Compliance Requirements

Consequences of Non-Compliance

Compliance Threshold Calculation

HIS and Hospice Compare

Certification and Survey Provider Enhanced Reports (CASPER)

CASPER Reports

CASPER Compliance Report

Consumer Assessment of Healthcare Providers and Systems (CAHPS®)

Hospice CAHPS®

CAHPS® Measures

CAHPS® Sampling

CAHPS® Scoring

CAHPS® Scoring, cont’d

CAHPS® Scoring, cont’d

Hospice Compare and CAHPS®

Consequences of Non-Compliance

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

PEPPER Reports

PEPPER Reports

How to Use the PEPPER

Where does PEPPER Come From?

Polling Question

PEPPER Retrieval

PEPPER Retrieval, cont’d

PEPPER Retrieval Rates

Who Gets the PEPPER

PEPPER Time Period

FY16 Release

Data Restriction & Report

PEPPER Target Areas

PEPPER Target Areas, cont’d

Percents & Percentiles

Think of the Chubby Baby…

Percents & Percentiles, cont’d

Percents vs Percentiles within PEPPER

Percents & Percentiles, cont’d

Target Area Report

Compare Report Example (22:29 left)

Target Area Report

Target Area Report

Top Terminal Diagnoses (Provider)

Top Terminal Diagnosis (CGS Compare)

Live Discharge by Type (Provider)

Live discharge by Type (CGS Compare)

DATA…data…DATA (oh my!)

All of the Data is Connected

Identifying Areas of Vulnerability


Quality OFIs (CAHPS®)

Quality OFIs (PEPPER)

Target Areas and Interventions, cont’d

Action Plan to Address Risk Areas

PEPPER and Hospice Liability

Instructor: Carrie Cooley, RN, MSN
Carrie Cooley is the Principal / Chief Executive Officer (CEO) with Weatherbee Resources. Carrie joined Weatherbee in 2009 as an Associate Consultant and was hired as the Consulting Coordinator in 2012.  In 2014, Carrie was promoted to Director of the Consulting Division and in July 2015, she assumed the Chief Operating Officer position. Carrie was promoted to CEO in February 2018.  On July 1, 2018, Carrie and her business partner, Lynn Stange, purchased Weatherbee Resources from the company's founders, Heather Wilson and Joy Barry. Together, Lynn and Carrie plan to continue the long-standing history of Weatherbee Resources' service to the hospice industry.  In her role as Principal / CEO, Carrie ensures Weatherbee's consulting services, products, and education are provided in a professional and cost-effective manner and are specifically tailored to meet each client's individual needs. As one of Weatherbee's owners, Carrie is responsible for ensuring Weatherbee is positioned to assist hospices with the ever-changing regulatory hospice environment.  
Carrie's regulatory expertise and extensive consulting experience includes forensic clinical record auditing, baseline compliance audits/mock surveys, interim management, clinical due diligence, and executive coaching. Carrie and her team also work directly with clients' legal counsel in preparation for arbitration and other hearings; Carrie frequently serves as an expert witness. Weatherbee also works extensively with clients who are under a Corporate Integrity Agreement (CIA); Carrie and her team manage the Independent Review Organization (IRO) audit activities required by the Office of Inspector General (OIG). Carrie's excellent rapport with executives and staff alike – coupled with her regulatory and clinical acumen, and knowledge of best practices – assures excellent consulting outcomes.  
Under Carrie's leadership, Weatherbee has assisted hundreds of clients under investigation by various Medicare contractors including: Targeted Probe and Educate (TPE), Zone Program Integrity Contractors (ZPIC), Unified Program Integrity Contractors (UPIC), Benefit Integrity Support Centers (BISC), Recovery Auditors (RA), the Department of Justice (DOJ), and the OIG.   As a member of Weatherbee's Speaker's Bureau, Carrie teaches a broad range of hospice, regulatory, and leadership-related topics nationally and is a member of the faculty for Weatherbee's renowned Hospice Regulatory Boot Camps. Carrie also frequently speaks at state and national hospice conferences on compliance-related topics. Carrie is a registered nurse and holds a master's degree from Samford University with a specialty in nursing leadership and healthcare finance.


Disclosure: Carrie Cooley, RN, MSN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Nurses; in the following settings: Hospice, Palliative Care.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
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All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.