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FAQs: Home Health Cardiovascular Data Registry

Most recently added FAQs are in red text.

  1. Why should my agency participate in the Home Health Cardiovascular Data Registry (HHCDR)?

    According to the Centers for Disease Control and Prevention (CDC), there are approximately 800,000 deaths caused by cardiovascular disease each year in the United States, and it has been estimated that one-quarter of them are avoidable.  The keys to shrinking that figure are assessment, education, and support, and the home health setting is ideal for all of these.  As a home health professional, you may be in the best position possible to prevent avoidable cardiovascular-related deaths, but you need tools and resources. That’s why HHQI created the HHCDR as well as two cardiovascular Best Practice Intervention Packages (BPIPs).

    The HHCDR fuels powerful new custom data reports that will help you identify opportunities for improving the cardiovascular care your patients receive and provide evidence of the impact made by your efforts. Much of the data required for these new reports is populated automatically from your OASIS-C transmissions, so additional work on your part is minimal. HHQI has developed a chart abstraction tool to make data collection a little easier.


  2. Where do we start?

    The HHCDR Process Flowchart will walk you through the process.


  3. How much does it cost to participate in the Home Health Cardiovascular Data Registry?

    As with everything HHQI-related, it’s absolutely free of cost and free of commitment.


  4. What data will we need to submit for the HHCDR Report?

    Each month, your agency will be asked on which of the topic areas (ABCS: Aspirin, Blood pressure, Cholesterol, and/or Smoking) you wish to focus/abstract.

    Much of the data for your HHCDR Report will be pre-populated from your OASIS transmissions, such as patient’s identification number, age, gender, race/ethnicity, etc. You will be asked to answer 2 to 5* simple questions.  Please download the chart abstraction tool and view the HHCDR Overview Webinar (both located here) for specifics.

    *Number of questions will be determined based upon number of topic areas (A, B, C, and/or S) your agency selects each month.


  5. We’re just starting and trying to decide the best way to proceed.  Should we focus on all four ABCS or just one per month?

    Since quality improvement is an ongoing event with different interventions being included in the patient care, it would be recommended to assess the same measures for multiple months in a row.  It is also recommended that all four areas (A, B, C, and S) be assessed each month. Understanding time restraints, it may be easier to start with two measures for a few months and then include the others after you are comfortable with the first two. If going this way, Blood Pressure and Smoking are the two we would recommend to start as they impact all body systems. Aspirin and Cholesterol are focused primarily on the cardiovascular systems. The bottom line is this decision is yours to make.  Even if you start with just one measure this month and want to add a second next month, that is fine. Getting started is the hardest part. We’ve heard overwhelmingly that once started, it’s surprisingly simple to collect and enter the information.


  6. How do we submit data for the HHCDR?

    Each agency will submit data via the HHQI Data Access System by using their HHQI Data Access account.
    1. Create or Login to your HHQI Data Access Account.*
    2. Click on the ‘HHCDR’ tab located on the gold tool bar across the top.
    3. Select the year and month of discharge for the data you want to submit.
    4. Select the ABCS on which you wish to focus this month.
    5. You will then see a list of 12 randomly selected episodes of care per topic area (A, B, C, and/or S). To strengthen your agency's HHCDR report, input data for all of these. The records can be sorted by Patient ID, SOC Date, or Discharge/Transfer Date.
    6. Click the ‘Edit’ link next to each episode of care to add your data.
    7. Once you have finished entering that month’s data, click “Close Month.” Only those months “closed” by the 14th of each month will be included in the report posted around the 23rd of the month.

You can also watch the HHCDR Overview webinar for guidance.

*Please remember that HHQI Data Access requires a separate and unique login from the one you use for general campaign access to Best Practice Intervention Packages (BPIPs) and tools. If you need assistance, please contact us at HHQI@wvmi.org.

  1. We just closed our first month of data. When will our report be available?

    It will be available around the 23rd of the following month. The HHCDR Dates to Remember document is a helpful reference tool.


  2. How many records do we need to abstract each month?

    In order to strengthen your report, you will be requested to abstract approximately 12 randomly selected records per topic area(A, B, C, and/or S) or the total number of discharges your agency has per month, whichever is smaller. After these records have been completed, all qualifying patients discharged from the agency during the selected month will be available for you to abstract. Entering this data for additional patients will strengthen your report but is optional.


  3. Twelve records per topic area means if we select to abstract all four areas, this would be a total of 48 records each month, right?

    Yes, if you select all four areas (A, B, C, and S), you will have a maximum of 48 records to abstract. However, some episodes may be randomly selected for more than one topic area. If this occurs, you will have less than 48 records. Also, if your agency didn’t have 12 episodes of care for each topic area, you will have less than 48 records.


  4. What if we decide not to abstract the 12 records per topic area?

    As long as you 'Close Out the Month', your agency will still receive the report at the end of the month but the report will be weakened due to the lower volume of records.


  5. Are these ‘patients’ or ‘episodes’?

    These are ‘episodes of care’ meaning that you may find you have the same patient listed twice if he/she was discharged twice from your agency in the same month.


  6. Most of our patients are discharged from the agency within a week or two.  We don’t really have time to address the ABCSs.  Can we exclude those patients?

    That factor has already been noted and you will only see episodes where your agency provided care for more than 14 days.


  7. How are patients selected to be in the HHCDR?

    See the Aspirin, Blood Pressure, Cholesterol, and Smoking sections.


  8. My patient was a VA patient (or ‘wasn’t admitted to our HHA’) and didn’t have an OASIS completed.
     
    All episodedata comes directly from OASIS transmission received by CMS. Please confirm with your vendor that an OASIS was not transmitted to CMS. For questions, please contact HHQI at HHQI@wvmi.org.


  9. Can we just send you our EHR data from our vendor?

    Unfortunately at this time, HHQI is not able to accept data transmission in any form other than through the HHCDR, but we have heard from many vendors that they have or are willing to create a report with the information required to be entered into the HHCDR for their subscribers.


  10. We use or vendor data and really don’t need this report.  Why should we participate?

    Having a vendor is a luxury, and your agency is very fortunate to have access to ‘real-time’ data.  But are you pulling the comparative reports the HHCDR provides?  Do you know how many of your patients with IVD have a normal/controlled cholesterol level?  Or how many of your patients who use tobacco have received minimal interventions to decrease their intake of tobacco while under the care of your agency?  Most vendors we have spoken with do not currently have these reports available.  The HHCDR will close this gap. 

    Another reason to keep an eye on the HHQI reports is for comparative values.  How is your agency progressing when compared to the other 12,000 CMS-Reporting HHAs in the country?  The HHQI Data Reports will provide this information.


  11. How do we access the HHCDR reports?

    Access these reports through HHQI Data Access the same way you access your agency’s ACH, Oral Medication, Immunizations, and Cardiovascular Risk reports.

    Log in to the Data Access website, and click on the Reports tab. You will see a dropdown menu with each report listed. Even if you just joined HHQI, if your agency has been reporting to CMS for years, you will find HHQI Data Reports dating back to 2009 waiting for you.


  12. Is the Home Health Cardiovascular Data Registry an audit?

    Absolutely not. CMS has a strict policy on agency anonymity. We will use all data to compile aggregated state and national reports to share with CMS. Only your QIN-QIO (Quality Innovation Network – Quality Improvement Organization) will have access to aggregate level agency data (never patient level data).


  13. We really don’t have time to do one more thing.  How long will this take us each month?

    We anticipate the first time you access the registry it will take approximately 2 hours per topic area and around 3 hours if you select two topic areas. It will really depend on how easy it is to navigate your records and abstract the required data. As with anything new, your speed will increase each month as you become more familiar with the process.


  14. Do we need to get our patients’ permission to do this?  What about HIPPA?  Do we need a business agreement?

    WVMI/Quality Insights is a designated Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) under a contract with the Centers for Medicare & Medicaid Services (CMS).  As part of its contract with CMS, WVMI/Quality Insights provides services for the Home Health Quality Improvement (HHQI) National Campaign. These services include supporting the HHQI National Campaign Data Access System which receives Protected Health Information (PHI) from CMS.

    As a QIN-QIO, WVMI/Quality Insights functions as a HIPAA “Business Associate” to CMS and, as such, provides satisfactory assurances to CMS regarding the confidentiality, integrity, and availability of the PHI it receives from CMS. It is under this framework, with CMS as the Covered Entity and WVMI/Quality Insights as CMS’s Business Associate, that WVMI/Quality Insights is obligated to protect the privacy and security of PHI maintained by WVMI/Quality Insights for the HHQI National Campaign.

    In its performance of QIN-QIO activities on behalf of CMS, WVMI/Quality Insights is NOT a Business Associate of, and does not require a Business Associate Agreement with home health agencies.


  15. We're just now starting. For how many months back should we abstract and enter data?

    This depends on two factors:
    1. When your agency implemented ABCS quality improvement strategies
    2. Your agency size based on number of discharges each month

The key is to establish a strong baseline of data so that you will be able to demonstrate an accurate improvement rate after you implement your strategies.  We suggest abstracting a minimum of 3 months of data prior to the implementation, if your agency is of average or larger size.  If your agency is smaller, we suggest 6+ months of abstraction for your baseline in order to have the same number of episodes. This doesn’t have to be collected all in one month – you can simply start with the most recent month of discharges available and work backwards.

  1. If a patient is a ‘Therapy Only’ case with no Skilled Nursing involved, can we exclude them from this registry?

    Technically, an abstractor can choose not to enter data on a patient, but this practice will result in the loss of strength in the monthly report. The report must represent a random sample of episodes to enhance the strength of the report. 

    Let’s look at this from a different vantage point. An expectation of any professional encounter between a patient and a healthcare professional whether in a clinic or in the home, would include receiving the basic preventative screenings such as vital signs. It is within the scope of practice of a physical therapist to assess vital signs, basic lab results and medications. HHQI encourages all agency leadership to learn the scope of practices of all disciplines employed. Please see the HHQI CardioLAN webinar, The Role of Therapists in Cardiovascular Care (April 2015), for additional resources and tips on this topic.


  2. How can we correct the information in the registry such as SOC and DC date and Race/Ethnicity?

    All data is imported into the HHCDR as it was transmitted to CMS via OASIS. Please follow your agency’s policy for correcting previously transmitted OASIS information.

    Race/Ethnicity is a unique category in the HHCDR where the field is available for editing. Remember, even though you encouraged to change this field as needed in the HHCDR, please also follow your agency’s policy for correcting previously transmitted OASIS data.


  3. When we open the month, we receive a message that says ‘No episodes available’.  Why?

    Usually, one of two things has occurred. Either the episodes of care ending in the month you selected didn’t meet the inclusion criteria (either by age, diagnosis, or episode lasting longer than 14-days), or when you selected the 'Month', you accidnetally selected the wrong 'Year'.  If you feel neither of these apply to your situation, please contact HHQI at HHQI@wvmi.org

    TIP: If your HHA has small numbers of discharged episodes per month, the topic area of ‘Smoking’ may be a good focus area because every patient over 18 years and cared for by your HHA for more than 14 days qualifies.


  4. We have completed 6 months of abstraction and are ready for Cardio Milestone 4. What is that process and how do we start it?

    The Assessment of Data Reliability is available for any agency that has submitted 6 months of data in a specific topic area. The HHQI abstractors will perform a blind abstraction on 30 randomly selected episodes your agency has already submitted. HHQI will then perform a comparison of your agency’s entries to the HHQI abstractor’s entries and provide your agency with a crude agreement rate. The purpose of this step is simply to ensure your agency is abstracting accurately and you have accurate data to drive your quality improvement strategies. This crude agreement rate will only be shared with your agency.

    To initiate the process, please visit the Cardio Milestones webpage.