Form CMS-10390 Hospice Outcome and Patient Evaluation

HOPE All Items

OMB Control Number XXXX-XXXX
Expiration XX/XX/XXXX

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. HOPE is a patient assessment instrument that
intends to collect data during a hospice patient’s stay. Data collected using this instrument will be used to
measure the quality of care provided by a hospice provider. The valid OMB control number for this information
collection is XXXX-XXXX. Submission of this data is required by Section 1814(i)(5) of the Social Security Act.
The time required to complete this data collection is estimated to average XX minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and
review the data collected. Submitted patient-level data will remain confidential and is protected from public
dissemination in accordance with the Privacy Act of 1974, as amended. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will
not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Jermama Keys, National Coordinator, Hospice Quality Reporting Program Centers
for Medicare & Medicaid Services, at Jermama.Keys@cms.hhs.gov.

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HOSPICE OUTCOME AND PATENT EVALUATION (HOPE) VERSION 1
All Items

Section A

Administrative Information

A0050. Type of Record
Enter Code

1. Add new record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers
A. National Provider Identifier (NPI):

CMS Certification Number (CCN):

B.

A0215. Site of Service at Admission
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
99.

Patient’s Home/Residence
Assisted Living Facility
Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)
Skilled Nursing Facility (SNF)
Inpatient Hospital
Inpatient Hospice Facility (General Inpatient (GIP))
Long Term Care Hospital (LTCH)
Inpatient Psychiatric Facility
Hospice Home Care (Routine Home Care (RHC)) Provided in a Hospice Facility
Not listed

A0220. Admission Date

 Month    Day      Year
A0250. Reason for Record
Enter Code

1.  Admission (ADM)
2.  HOPE Update Visit 1 (HUV1)
3.  HOPE Update Visit 2 (HUV2)
9.  Discharge (DC)

A0270. Discharge Date

 Month    Day      Year

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A0500. Legal Name of Patient
A. First name:

B.

Middle initial:

C.

Last name:

D. Suffix:

A0550. Patient Zip Code

-

A0600. Social Security and Medicare Numbers
A. Social Security Number:

-

B.

-

Medicare Number:

A0700. Medicaid Number
Enter “ +“ if pending, “N” if not a Medicaid Recipient

A0800. Gender
Enter Code

1. Male
2. Female

A0900. Birth Date

 Month    Day      Year

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A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓ Check all that apply
A.

No, not of Hispanic, Latino/a, or Spanish origin

B.

Yes, Mexican, Mexican American, Chicano/a

C.

Yes, Puerto Rican

D.

Yes, Cuban

E.

Yes, Another Hispanic, Latino, or Spanish origin

X.

Patient unable to respond

Y.

Patient declines to respond

A1010. Race
What is your race?
↓ Check all that apply
A.

White

B.

Black or African American

C.

American Indian or Alaska Native

D.

Asian Indian

E.

Chinese

F.

Filipino

G.

Japanese

H.

Korean

I.

Vietnamese

J.

Other Asian

K.

Native Hawaiian

L.

Guamanian or Chamorro

M. Samoan
N.

Other Pacific Islander

X.

Patient unable to respond

Y.

Patient declines to respond

Z.

None of the above

A1110. Language
A. What is your preferred language?
Enter Code
B.

Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9.   Unable to determine

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A1400. Payer Information
↓  Check all existing payer sources that apply at the time of this assessment
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care)
G. Other government (e.g., TRICARE, VA, etc.)
H. Private Insurance/Medigap
I.  Private managed care
J.  Self-pay
K. No payer source
X. Unknown
Y. Other
A1805. Admitted From
Enter Code

Immediately preceding this admission, where was the patient?
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living,
other residential care arrangements)
02. Nursing Home (long-term care facility) 
03. Skilled Nursing Facility (SNF, swing beds) 
04. Short-Term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
99.  Not Listed

A1905. Living Arrangements
Enter Code

Identify the patient’s living arrangement at the time of this admission.
1.
2.
3.
4.
5.

Alone (no other residents in the home)
With others in the home (e.g., family, friends, or paid caregiver)
Congregate home (e.g., assisted living or residential care home)
Inpatient facility (e.g., skilled nursing facility, nursing home, inpatient hospice, hospital)
Does not have a permanent home (e.g., has unstable housing or is experiencing homelessness)

A1910. Availability of Assistance
Enter Code

Code the level of in-person assistance from available and willing caregiver(s), excluding hospice and facility staff,
at the time of this admission.
1.
2.
3.
4.
5.

Around-the-clock (24 hours a day with few exceptions)
Regular daytime (all day every day with few exceptions)
Regular nighttime (all night every night with few exceptions)
Occasional (intermittent)
No assistance available

A2115. Reason for Discharge
Enter Code

1.
2.
3.
4.
5.
6.

Expired
Revoked
No longer terminally ill
Moved out of hospice service area
Transferred to another hospice
Discharged for cause

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Section F

Preferences for Customary Routine and Activities

F2000. CPR Preference
Enter Code

A. Was the patient/responsible party asked about preference regarding the use of cardiopulmonary
resuscitation (CPR)? - Select the most accurate response
0. No — Skip to F2100, Other Life-Sustaining Treatment Preferences
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B.

Date the patient/responsible party was first asked about preference regarding the use of CPR:

      Month    Day      Year
F2100. Other Life-Sustaining Treatment Preferences
Enter Code

A. Was the patient/responsible party asked about preferences regarding life-sustaining treatments other
than CPR? - Select the most accurate response
0. No — Skip to F2200, Hospitalization Preference
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B.

Date the patient/responsible party was first asked about preferences regarding life-sustaining
treatments other than CPR:

  Month    Day      Year
F2200. Hospitalization Preference
Enter Code

A. Was the patient/responsible party asked about preference regarding hospitalization? - Select the most
accurate response
0. No — Skip to F3000, Spiritual/Existential Concerns
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B.

Date the patient/responsible party was first asked about preference regarding hospitalization:

  Month    Day      Year
F3000. Spiritual/Existential Concerns
Enter Code

A. Was the patient and/or caregiver asked about spiritual/existential concerns? - Select the most accurate
response.
0. No — Skip to I0100, Principal Diagnosis
1. Yes, and discussion occurred
2. Yes, but the patient/caregiver refused to discuss
B.

Date the patient and/or caregiver was first asked about spiritual/existential concerns:

  Month    Day      Year

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Section I

Active Diagnoses

I0010. Principal Diagnosis
Enter Code

01. Cancer
02. Dementia (including Alzheimer’s disease)
03. Neurological Condition (e.g., Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS))
04. Stroke
05. Chronic Obstructive Pulmonary Disease (COPD)
06. Cardiovascular (excluding heart failure)
07. Heart Failure
08. Liver Disease
09. Renal Disease
99.   None of the above

Comorbidities and Co-existing Conditions
↓ Check all that apply
Cancer
I0100. Cancer
Heart/Circulation
I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema)
I0900.  Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
I0950. Cardiovascular (excluding heart failure)
Gastrointestinal
I1101. Liver disease (e.g., cirrhosis)
Genitourinary
I1510. Renal disease
Infections
I2102. Sepsis
Metabolic
I2900. Diabetes Mellitus (DM)
I2910. Neuropathy
Neurological
I4501. Stroke
I4801. Dementia (including Alzheimer’s disease)
I5150. Neurological Conditions (e.g., Parkinson’s disease, multiple sclerosis, ALS)
I5401. Seizure Disorder
Pulmonary
I6202. Chronic Obstructive Pulmonary Disease (COPD)
Other
I8005. Other Medical Condition

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Section J

Health Conditions

J0050. Death is Imminent
Enter Code

At the time of this assessment and based on your clinical assessment, does the patient appear to have a life
expectancy of 3 days or less?
0. No
1. Yes

J0900. Pain Screening
Enter Code

A. Was the patient screened for pain?
0. No — Skip to J0905, Pain Active Problem
1. Yes
B. Date of first screening for pain

Month    Day      Year

Enter Code

C. The patient’s pain severity was:
0. None
1. Mild
2. Moderate
3. Severe
9. Pain not rated

Enter Code

D. Type of standardized pain tool used:
1. Numeric
2. Verbal descriptor
3. Patient visual
4. Staff observation
9. No standardized tool used

J0905. Pain Active Problem
Enter Code

Is pain an active problem for the patient?
0. No — Skip to J2030, Screening for Shortness of Breath
1. Yes

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J0910. Comprehensive Pain Assessment
Enter Code

A. Was a comprehensive pain assessment done?
B.

0. No — Skip to J2030, Screening for Shortness of Breath
1. Yes
Date of Comprehensive pain assessment:

C.

Month    Day      Year
Comprehensive pain assessment included:

↓ Check all that apply
1. Location
2. Severity
3. Character
4. Duration
5. Frequency
6. What relieves/worsens pain
7. Effect on function or quality of life
9. None of the above
J0915. Neuropathic Pain
Enter Code

Does the patient have neuropathic pain (e.g., pain with burning, tingling, pins and needles, hypersensitivity to
touch)?
0. No
1. Yes

J2030. Screening for Shortness of Breath
Enter Code

A. Was the patient screened for shortness of breath?
0.
1.

No — Skip to J2050, Symptom Impact Screening
Yes

B. Date of first screening for shortness of breath:

Enter Code

Month    Day      Year
C. Did the screening indicate the patient had shortness of breath?
0.
1.

No — Skip to J2050, Symptom Impact Screening
Yes

J2040. Treatment for Shortness of Breath
Enter Code

A. Was treatment for shortness of breath initiated?
0.
1.
2.
B.

No — Skip to J2050, Symptom Impact Screening
No, patient declined treatment — Skip to J2050, Symptom Impact Screening
Yes

Date treatment for shortness of breath initiated:

Month    Day      Year

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J2050. Symptom Impact Screening
Enter Code

A. Was a symptom impact screening completed?
0. No — Skip to M1190, Skin Conditions
1. Yes
B.

Date of symptom impact screening:

Month     Day      Year

J2051. Symptom Impact
Over the past 2 days, how has the patient been affected by each of the following symptoms? Base this on your clinical
assessment (including input from patient and/or caregiver). Symptoms may impact multiple patient activities including, but not
limited to, sleep, concentration, day to day activities, or ability to interact with others.
Coding:
0. Not at all – symptom does not affect the patient, including symptoms well-controlled with current treatment
1. Slight
2. Moderate
3. Severe
9. Not applicable (the patient is not experiencing the symptom)
Enter Code
↓
A. Pain
B. Shortness of breath
C. Anxiety
D. Nausea
E. Vomiting
F. Diarrhea
G. Constipation
H. Agitation

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J2052. Symptom Follow-up Visit (SFV) (complete only if any response to J2051 Symptom Impact = 2. Moderate or 3. Severe)

Enter Code

An in-person Symptom Follow-up Visit (SFV) should occur within 2 calendar days as a follow-up for any moderate
or severe pain or non-pain symptom identified during Symptom Impact assessment at Admission or HOPE Update
Visit (HUV).
A.

B.

Was an in-person SFV completed?
0. No — Skip to J2052C. Reason SFV Not Completed.
1. Yes
Date of in-person SFV:

Enter Code

Month    Day       Year
C.

Reason SFV Not Completed.
1.
2.
3.
9.

Patient and/or caregiver declined an in-person visit.
Patient unavailable (e.g., in ED, hospital, travel outside of service area, expired).
Attempts to contact patient and/or caregiver were unsuccessful.
None of the above

J2053. SFV Symptom Impact
Since the last Symptom Impact assessment was completed, how has the patient been affected by each of the following
symptoms? Base this on your clinical assessment (including input from patient and/or caregiver). Symptoms may impact multiple
patient activities including, but not limited to, sleep, concentration, day to day activities, or ability to interact with others.
Coding:
0. Not at all – symptom does not affect the patient, including symptoms well-controlled with current treatment
1. Slight
2. Moderate
3. Severe
9. Not applicable (the patient is not experiencing the symptom)
Enter Code
↓
A. Pain
B. Shortness of breath
C. Anxiety
D. Nausea
E. Vomiting
F. Diarrhea
G. Constipation
H. Agitation

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Section M

Skin Conditions

M1190. Skin Conditions
Enter Code

Does the patient have one or more skin conditions?
0. No - Skip to N0500, Scheduled Opioid
1. Yes

M1195. Types of Skin Conditions
Indicate which following skin conditions were identified at the time of this assessment.
↓ Check all that apply
A. Diabetic foot ulcer(s)
B. Open lesion(s) other than ulcers, rash, or skin tear (cancer lesions)
C. Pressure Ulcer(s)/Injuries
D. Rash(es)
E. Skin tear(s)
F. Surgical wound(s)
G. Ulcers other than diabetic or pressure ulcers (e.g., venous stasis ulcer, Kennedy ulcer)
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration,
drainage)
Z. None of the above were present
M1200. Skin and Ulcer/Injury Treatments
Indicate the interventions or treatments in place at the time of this assessment.
↓ Check all that apply
A. Pressure reducing device for chair
B. Pressure reducing device for bed
C. Turning/repositioning program
D. Nutrition or hydration intervention to manage skin problems
E. Pressure ulcer/injury care
F.  Surgical wound care
G. Application of nonsurgical dressings (with or without topical medications) other than to feet
H. Application of ointments/medications other than to feet
I. Application of dressings to feet (with or without topical medications)
J. Incontinence Management
Z. None of the above were provided

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Section N

Medications

N0500. Scheduled Opioid
Enter Code

A.

Was a scheduled opioid initiated or continued?
0.
1.

B.

No — Skip to N0510, PRN Opioid
Yes

Date scheduled opioid initiated or continued:

Month    Day       Year

N0510. PRN Opioid
Enter Code

A. Was PRN opioid initiated or continued?
0.
1.
B.

No — Skip to N0520, Bowel Regimen
Yes

Date PRN opioid initiated or continued:

Month    Day       Year

N0520. Bowel Regimen (Complete only if N0500A or N0510A=1)
Enter Code

A.

Was a bowel regimen initiated or continued? - Select the most accurate response
0.
1.
2.

B.

No — Skip to Z0400. Signature(s) of Person(s) Completing the Record
No, but there is documentation of why a bowel regimen was not initiated or continued — Skip to
Z0400. Signature(s) of Person(s) Completing the Record
Yes

Date bowel regimen initiated or continued:

Month    Day       Year

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Section Z

Assessment Administration

Z0350. Date Assessment was Completed

Month    Day      Year

Z0400. Signature(s) of Person(s) Completing the Record
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected
or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected
in accordance with applicable Medicare and Medicaid requirements. I understand that reporting this information is used as a basis
for payment from federal funds. I further understand that failure to report such information may lead to a payment reduction in
the Fiscal Year payment determination. I also certify that I am authorized to submit this information by this provider on its behalf.
Signatures

Title

Sections

Date Section Completed

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Record Completion

A.

___________________________________________________
B.

Signature

Date

Month    Day      Year

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