HOPE Guidance Manual v1.02, § 1.3

Generally, hospices are required to submit up to four records for each patient admitted to their organization.

This includes a minimum of a HOPE-Admission record, a HOPE-Discharge record, and up to two HOPE

Update Visits (HUVs). Depending on the patient’s length of stay (LOS), up to two HUV records may be

required for every hospice admission, each at specified timeframes. HOPE data are collected during the

hospice’s routine clinical assessments and are based on unique patient assessment visits. However, not all

HOPE items are completed at every timepoint.

While HOPE data elements contribute to the assessment, they do not replace a thorough and ongoing

assessment of each patient1, nor do they replace clinical practice and clinical judgment. HOPE timepoints with

associated timeframes are defined in Table 1 below and depicted in Figure 1.

1 § 418.54 Condition of participation: Initial and comprehensive assessment of the patient; 42 CFR 418.54;

https://www.ecfr.gov/current/title-42/section-418.54.

Table 1: HOPE Timepoint Definitions and Timeframes

2 § 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services; 42 CFR 418.56;

https://www.ecfr.gov/current/title-42/section-418.56.

3 § 418.104 Condition of participation: Clinical records.; 42 CFR 418.104(e); https://www.ecfr.gov/current/title-42/section-418.104.

Timepoint Definition Timeframe

Admission The HOPE-Admission data

are collected as part of the

comprehensive assessment of

the patient.

No later than five calendar

days after the effective date

of the hospice election.

HOPE Update Visit 1

(HUV1)

The data for HUV1 are

collected via an in-person visit

to inform updates to the plan

of care.2

HUV1 is required on or

between days six and 15 of the

hospice stay and should not be

conducted within the first five

days after the hospice election.

The date of the hospice

election would be considered

“Day 0.”

HOPE Update Visit 2

(HUV2)

The data for HUV2 are

collected via an in-person visit

to inform updates to the plan

of care.

HUV2 is required on or

between days 16 and 30 after

the hospice election.

Discharge The data are collected at

Discharge for any reason listed

in A2115.

At the time of discharge.3

Figure 1: HOPE Data Collection Timepoints

1.3.1. Admission

For the purposes of completing HOPE, a patient is considered admitted to a hospice if the following conditions

are met:

• There is a signed election statement (or other agreement for care for non-Medicare patients).

• The patient did not expire before the effective date of the election or agreement for care.

• The hospice made a visit in the setting where hospice services are to be initiated.

All three criteria listed above must be met for the patient to be considered admitted for the purposes of HOPE

reporting (see Figure 2, below).

Figure 2: HOPE-Admission Record Flow Chart

Examples for Patient Admission

Situation A

The patient signed an election statement on Monday with an effective date of Tuesday. The nurse went to the

patient’s home on Tuesday afternoon and the patient expired before the nurse arrived, so the nurse completed a

visit with the grieving family.

Instructions

In this situation, the hospice is not required to submit the Admission or Discharge HOPE records. Although the

patient signed the election statement and survived to the effective date of the election, the patient expired before

the hospice visit could be made in the setting where the services were to be provided.

Situation B

The consents were signed on the admission date. The nurse was in the process of a visit where care was to be

provided, but the patient died during the admission assessment.

Instructions

In this situation, since the assessment was in progress, the hospice nurse should complete the Admission and

Discharge record with any HOPE data collected during the assessment visit. Due to the brief LOS, the HUV

would not be required or expected.

Situation C

The patient was being transported for admission to an inpatient hospice facility. The admission process

(including the election of the hospice benefit) was scheduled for that afternoon. The patient expired during

transport, before arriving at the inpatient facility.

Instructions

In this situation, the hospice is not required to complete or submit HOPE data since the patient expired before

electing the hospice benefit and before a visit could be made where the services were to be provided (the

inpatient hospice facility).

1.3.2. HUV Timepoints

The HUV timepoints are designed to inform updates to the patient’s written plan of care. Depending on the

patient’s LOS, up to two of these assessments are required. HUV1 should be conducted on or between days six

and 15, but not within the first five days after the date of admission (A0220.Admission Date). HUV2 should be

conducted on or between days 16 and 30. The date of the hospice election would be considered “Day 0.”

If an HUV is missed or late for any reason (e.g., HUV1 conducted on day 17 or HUV2 conducted on day 33),

conduct the visit as appropriate and submit the record once completed, including any SFV if applicable.

See Table 2 for common HUV scenarios.

Table 2: Determining the Need to Conduct the HUV Timepoints

Scenario If Then Rationale

Death/discharge

day 0 to 5

The patient dies or is

discharged within five

days after the effective

date of the hospice

election (A0220 + 5).

HUV1 is not

required.

No HUV is expected due to the

short LOS.

Day 5 of hospice

stay

It has been five days

since the effective date

of the hospice election

(A0220 + 5).

The HUV1 is not

required. It is too

early to conduct

HUV1.

HUV1 should not be conducted

within the first five days after the

effective date of the hospice

election.

Day 15 of the

hospice stay

The patient is still on

service on day 15

(A0220 + 15) and

beyond.

HUV1 is required and

accepted.

Updates to the plan of care via

HUV1 is required on or between

days six and 15.

Day 30 of the

hospice stay

The patient is still on

service on day

30 (A0220 + 30) and

beyond.

HUV2 is required and

accepted.

Updates to the plan of care via

both HUVs are required. (on or

between days six and 15 for

HUV1 and on or between days 16

and 30 for HUV2).

Death/discharge

day 10

The patient dies or is

discharged on day 10

(A0220 + 10).

HUV1 is not

required.

The HUV1 record

would be accepted if

submitted.

The hospice may not have had an

opportunity to conduct HUV1

due to the death or discharge of

the patient.

Death/discharge

day 25

The patient dies or is

discharged on day 25

(A0220 + 25 ).

HUV1 is required and

accepted.

HUV2 is not

required.

The HUV2 record

will be accepted if it

is submitted.

Updates to the plan of care via the

HUV2 would be expected if the

patient is on service for 30 days.

With a discharge or death after

day 15 and before day 30, the

hospice may not have had an

opportunity to conduct HUV2.

Examples for the HUV Timepoints

Situation A

Patient A elected hospice and was admitted on October 3. The hospice registered nurse (RN) completed the

HOPE-Admission during the initial assessment visit (as defined in the Medicare Hospice Conditions of

Participation). The HUV1 for this patient would be due sometime between October 9 and October 18,

however, the patient declines rapidly and dies within one week of admission on October 10. Is HUV1

required? See Figure 3 for the timeline in this example.

Figure 3: Hospice Discharge During the HUV1 Assessment Timeframe

Instructions for HUV completion: The HUV1 may or may not be completed.

Rationale: While there is time to conduct the HUV1 timepoint, it would not be required if the patient dies

before the October 18 deadline.

Situation B

Patient B is admitted to hospice on November 1 and the RN conducts the initial assessment visit, completing the

HOPE-Admission.

See Figure 4 for the timeline of Situation B. How soon should the nurse plan to conduct HUV1?

Figure 4: HUV1 Assessment Timeframe

Instructions for HUV1 completion: The HUV1 is required starting on November 7.

Rationale: HUV1 should occur on or between days six and 15 after the hospice election. Therefore, in this

situation, the HUV1 is due no sooner than November 7, and no later than November 16. Any visit to conduct

HUV1 within this timeframe is acceptable.

Situation C

Patient C elected hospice on February 1. The patient remained on hospice throughout their illness and died on

service 63 days later. HUV1 was conducted on February 9. See Figure 5 for the timeline. When should HUV2

be conducted?

Figure 5: Both HUV Timepoints with HUV1 Conducted and HUV2 Pending

Instructions for HUV2 completion: HUV2 is due no sooner than February 17 and no later than March 3.

Any visit within that timeframe is acceptable to conduct HUV2.

Rationale: Since the patient remained on service for 63 days, HUV2 is required on or between days 16 and 30,

after the date of the hospice election.

1.3.3. Symptom Follow-up Visit (SFV)

During the Admission or HUV, data collected for the Symptom Impact item (J2051) may trigger the need for the

Symptom Follow-up Visit (SFV).

The SFV is an in-person visit expected within two calendar days as a follow-up for any pain or non-pain

symptom impact rated as moderate or severe. The SFV must be a separate visit from the Admission or HUV. It

may occur anytime within two calendar days, or later on the same day as the assessment where the initial finding

of a moderate or severe symptom was determined during the Admission or HUV. Depending upon timing and

responses to J2051. Symptom Impact at Admission, or either of the two HUV timepoints, the SFV could stretch

beyond the assessment timeframe. For the HUV timepoints, Z0350. Date Assessment was Completed would be

the date the HUV was completed, including any SFV where applicable. Depending on the length of stay (LOS),

up to three SFVs may be required over the course of the hospice stay (Admission, HUV1 and/or HUV2). See

Figure 6. Table 3 describes common situations for the SFV.

Figure 6: Example of a Symptom Follow-up Visit Triggered at the HUV1 Timepoint

Table 3: Determining Whether the SFV is Required

Scenario If Then Rationale

Moderate or severe

symptoms

documented at a

HOPE timepoint visit

The HOPE-Admission or

HOPE Update Visit

(HUV) timepoint is

conducted and at least one

response to the Symptom

Impact item (J2051) =

moderate or severe

(J2051A-H = 2 or 3).

Symptom Follow-up

Visit (SFV) is required

within two calendar days.

A HOPE-SFV is an in-person visit expected when

any pain or non-pain

symptom impact (J2051 A

through H) is rated as

moderate or severe when

conducting the HOPE-Admission or HUV.

No moderate or

severe symptoms

were documented at

a HOPE timepoint

visit

The HOPE-Admission or

HUV timepoint is

conducted and no

response to J2051 =

moderate or severe

(J2051A-H = 2 or 3).

SFV is not required. A HOPE-SFV is only

required when any pain or

non-pain symptom (J2051

A through H) response is

moderate or severe when

completing J2051.

Symptom Impact during a

HOPE-Admission or

HUV.

Examples for SFV

Situation A

During the admission visit, the nurse assesses the impact of pain as moderate and the impact of shortness of

breath as severe. The nurse implements interventions for these symptoms and returns the next day to conduct

an SFV. During the follow-up visit, the impact of pain is mild and the impact of shortness of breath is moderate.

Instructions for SFV: An additional SFV is not required for the purpose of the HQRP.

Rationale: If there is evidence of ongoing moderate or severe symptoms during an SFV, no additional SFV is

required for HOPE. However, the hospice staff is expected to continue following up with the patient based on

their clinical and symptom management needs.

Situation B

During the admission visit, the nurse assesses the impact of nausea as moderate, triggering the need for an SFV.

The nurse returns within two days to conduct the SFV. Two weeks later, the nurse conducts the HUV1 and

assesses the impact of constipation as severe, triggering the need for another SFV. The nurse returns within two

days to conduct the SFV. On day 25, the HUV2 is conducted, and the impact of constipation is moderate. An

SFV would be required to follow up on that symptom within two days.

Instructions for SFV: An SFV is required within two calendar days in each of these instances.

Rationale: An SFV should be conducted within two calendar days as a follow-up for any moderate or severe

pain or non-pain symptom impact identified during an Admission or HUV timepoint. This may result in up to

three SFVs per patient admission over the course of the hospice stay. Although multiple SFVs are not required

for the purpose of the HQRP, it is expected that the hospice staff will continue to follow up with the patient

based on their clinical and symptom management needs.

Situation C

During the admission visit, the RN assesses the impact of a symptom as moderate. Interventions are initiated to

manage the symptoms, and the nurse (RN or LPN/LVN) returns in 2 days to follow up on the symptoms and

conduct the SFV. HUV1 is then conducted on day 11 and no further symptoms are found to have a moderate or

severe impact during that visit. The RN then conducts HUV2 on day 24 and the finding of a moderate to severe

symptom impact triggers the need for another SFV. The LPN/LVN on the hospice team returns on day 25 to

conduct the in-person SFV. Due to a decline in status, another nursing visit is conducted the next day. The

patient dies on day 27 (A0220 + 27).

Instructions for HOPE Timepoi nt Completion: For the purposes of the HQRP, HOPE-Admission and

HUVs are required based on the LOS. SFVs are only required when moderate or severe symptoms are

documented at any Admission or HUV timepoint.

Rationale: Given the LOS for this patient, the HOPE-Admission and HUV1 are required to be completed and

submitted. The submission of HUV2 is optional because the patient died before day 30. However, since the

HUV2 is complete, if the HUV2 record is submitted, this record will be accepted and ultimately count favorably

towards the HQRP QM because the SFV was conducted within two calendar days of the triggering HUV2 date.

Situation D

On day 30 after the hospice election, the primary nurse, just returning from vacation, realizes that HUV2 has

not yet been conducted. A visit is able to be arranged for that day to ensure the agency meets the requirement of

conducting an HUV2 on or between days 16 and 30. Upon visiting, the nurse hears from the patient and

caregiver that they have not been able to go out of the home recently, as the patient is experiencing diarrhea that

is preventing them from doing any outside activities. Diet suggestions are provided by the nurse along with

some medication adjustments, after consultation with the hospice physician. This symptom with moderate

impact triggers the need for an SFV within two calendar days. The nurse revisits the home within 2 days (on

day 32). The nurse determines the changes had a good effect and the impact is now slight. The nurse enters the

date and result for J2052. Symptom Follow-up Visit (SFV) and J2053. SFV Symptom Impact and Z0350.

Date Assessment was Completed to complete HUV2.

Rationale: An SFV should be conducted within two calendar days as a follow-up for any moderate or severe

pain or non-pain symptom impact identified during an Admission or HUV timepoint. Based on the timing of

the HUV2 (on or between days 16 and 30) and the results for J2051. Symptom Impact, the date of the SFV

could stretch beyond the assessment timeframe. In this situation, Z0350. Date Assessment was Completed for

this HUV2 would be when the SFV was conducted, which was two days after the HUV2 timeframe.

Figure 7: Example Calendar Depicting Completed HOPE-Admission, both HUV1 and HUV2, and SFVs

when Triggered

1.3.4. Discharge Timepoint

For the purposes of completing HOPE, a patient is considered discharged when the patient is no longer

receiving services from the hospice, or there is an interruption in care/services related to one of the reasons

listed in Item A2115. Reason for Discharge (expired, revoked, no longer terminally ill, moved out of hospice

service area, transferred to another hospice, discharged for cause).