In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS)

Beginning in 2014, administration of the ICH CAHPS survey is required at all dialysis facilities that served 30 or more eligible patients in the prior calendar year. The ICH CAHPS survey focuses on gaining facility specific data on patient satisfaction and experience of care. Data is then used by the Centers for Medicare & Medicaid Services (CMS) as a measure in the ESRD QIP (Quality Incentive Program), which means that a portion of facility reimbursement is related, in part, to these scores.

In-Center Hemodialysis CAHPS Survey webpage

Things to Know

ICH CAHPS Facility Attestation

  • To determine the number of survey-eligible patients, count hemodialysis outpatients who:
    • Were 18 years or older as of 12/31/2016; were alive as of 12/31/2016; received hemodialysis as an outpatient for 3 consecutive months or more in 2016; were not in hospice care; and were not living in a nursing home, long-term facility or jail as of 12/31/2016.
  • If the facility determines there were fewer than 30 eligible patients during 2016, they must attest by choosing N/A in the appropriate field.
  • If the facility determines there were 30 or more eligible patients during 2016, they do not complete the attestation. Leave the field blank.
  • For facilities that did not offer in-center hemodialysis and/or received certification after January 1, 2017, do not complete the attestation.

Pain Assessment Screening

  • Pain Assessment and Follow-Up Plan Definitions:
    • Pain Assessment - Documentation of a clinical assessment for the presence or absence of pain using a standardized tool. A standardized tool is an assessment tool that has been appropriately normalized and validated for the population in which it is used.
    • Follow-Up Plan – A documented outline of care for a positive pain assessment.
    • Patient - Individual admitted at a facility either as permanent or transient during a performance year.
  • Eligible Patients are defined as those that are 18 years or older as of October 31, 2017 AND treated at the facility for longer than 90 days between July 1st and December 31st.
  • CROWNWeb will accept submissions for any patient. If a patient isn’t eligible using the above criteria then select ‘No documentation of pain assessment and the facility possesses documentation the patient is not eligible” from the list of available options.
  • This measure is only required of facilities with at least 11 eligible patients at the end of calendar year 2016.

Clinical Depression Screening

    • Clinical Depression Screening and Follow-Up Plan Definitions:
      • Clinical Depression Screening - Documentation of a clinical assessment for depression using a standardized tool. A standardized tool is an assessment tool that has been appropriately normalized and validated for the population in which it is used.
      • Follow-Up Plan – A documented outline of care for a positive clinical depression screening result.
      • Patient - Individual admitted at a facility either as permanent or transient during a performance year.
    • Eligible Patients are defined as:
      • Those that are 12 years of age or older as of October 31, 2017 and treated at the facility for 90 days between January 1st and December 31st.
    • Only facilities with at least 11 eligible patients at the end of calendar year 2016 and an open date before July 1, 2017 are required to complete the screening.
    • Facilities aren’t required to conduct screening; they only need to indicate whether they screen. Even if a facility does not perform (or document) its screening, it can get full points for the measure so long as it is indicated in CROWNWeb by deadline.

Tools and Resources

If you still have questions, please visit our Knowledge Base at http://help.esrd.ipro.org; there are also resources available at www.mycrownweb.org.

Project Lead

Erin Baumann, MSW
Patient Services Director
516-209-5348
ebaumann@nw2.esrd.net