HOPE Assessment Tool Blog Series: Health Conditions Explained

Written by Jennifer Kennedy

Welcome back to CHAP’s HOPE assessment tool blog series. We are counting down the time to the October 1, 2025, implementation date with monthly education about each section of the HOPE assessment tool. Breaking education into bite-size pieces for individuals is less overwhelming and accommodates the fast-paced schedules of hospice providers and their staff. Ideally, providers have been training their staff about the HOPE tool with information from the updated HOPE Manual V.1.01 and other available material posted by the Centers for Medicare and Medicaid Services (CMS) on the Hospice Quality Reporting Program webpage.

This blog discusses Section J: Health Conditions information in the updated HOPE manual and provides assessment and documentation guidance related to the physical symptom assessment and impact of pain or non-pain for patients. It includes assessments of imminent death, pain screening, thorough pain evaluation if needed, dyspnea screening, and symptom impact determination. CMS states that screening for pain and non-pain symptoms and their impact on the patient is an essential step for effective symptom management and treatment and supports the hospice team and patient/family with care planning. Information in this section is collected from interviews with the patient and family/caregiver, as well as the nurse’s clinical assessment when the patient cannot participate. Let’s look at the items and associated considerations in Health Conditions.

Item J0050: Death is Imminent

Recognizing the clinical signs and symptoms of imminent death in terminally ill patients helps the hospice team anticipate care needs, individualize care, and support bereavement adjustment for families. Nurses assess the imminence of death through clinical assessment and their judgment to determine if the patient is expected to live three (3) days or less at the time of admission and subsequent on HOPE Update Visits (HUVs) depending on the patient’s length of stay. The nurse is indicating the probability of imminent death based on observed symptoms vs documenting a medical prognosis which is out of the scope of practice for a nurse.

Resource: A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals with Advanced Illness (2023)

Item J0900: Pain Screening

Studies show that as many as half of patients at end-of-life experience moderate to severe pain in their final months. This emphasizes the importance of frequent pain assessment, pain management, and adjustment of pain medications to ensure comfort and quality of life for the patient.

This item and pain as an active problem and the comprehensive pain assessment should be familiar to providers from the Hospice Item Set (HIS) and is completed at Admission to Hospice Care. Item J0900 directs the nurse to screen for patient pain based on the patient’s pain status and assessment at the time of the screening clinical encounter. Although the patient may report a history of pain, item J0900 is completed based on the clinician’s assessment that the patient did not experience any pain at the time of the visit.

Nurses should screen for pain based on clinical assessment, outcomes of a standardized pain screening tool, patient/family interview, and information in the clinical record. CMS instruct nurses not to use external sources of data when screening for pain. Pain Severity Ratings and Standardized Tools for Pain Assessment are clinical resources in the HOPE manual V.1.01 to assist the nurse in completing this item. Organization designation of a standardized pain assessment rating tool is essential to ensure consistency of data. It is also important to ensure the competency of all nurses who administer the organization’s designated standardized pain assessment rating tool. As a reminder, registered nurses must complete the pain screening and comprehensive assessment.

Item J0905: Pain Active Problem

This item has an incorporated skip pattern and directs the nurse to item J2030: Screening of Shortness of Breath if pain is not indicated as an active problem. Pain screening is a current item in the HIS, and providers typically score well for its completion. The CMS May 2025 refresh of hospice quality of care measure data for pain screening indicated a national score of 98.3%.

Item J0910: Comprehensive Pain Assessment

Per the federal Conditions of Participation, a patient has the right to receive effective pain management and symptom control for conditions related to the terminal illness. The federal State Operations Manual, Appendix M or the hospice interpretive guidelines outline a comprehensive assessment of the patient’s pain based on accepted clinical standards of practice. Clinical outcomes of a pain assessment should include the patient/family’s goals for pain management subsequent assessment of their satisfaction with the current level of pain control. This HOPE assessment item dovetails with the federal regulation to standardize and capture the documentation related to pain assessment.

If pain is an active problem, the nurse will complete item J0910: Comprehensive Pain Assessment which addresses multiple aspects of pain beyond a determination of the pain presence and severity. There are seven characteristics addressed in the item collection including location, severity, character, duration, frequency, pain relief, and effect on quality of life. There is also guidance in the HOPE manual for assessment of nonverbal pain indicators and pain character with multiple clinical coding examples and rationale in this item that nurses can use a reference. Hospice nurses documenting pain assessment as part of the current HIS collection. The CMS May 2025 refresh of hospice quality of care measure data for pain assessment showed a national score of 95.5% which denotes overall hospice organization competence and compliance with this item.

Resources: End-of-Life Evaluation and Management of Pain (2023), The Importance of Cultural Competence in Pain and Palliative Care (2023)

Item J0915. Neuropathic Pain

CMS uses the definition of neuropathic pain as, “Pain caused by a lesion or disease of the somatosensory nervous system” from the International Association for the Study of Pain. The nurse assesses the patient for signs and symptoms of neuropathic pain and uses several data sources and resources separately or collectively to respond to this item. Acceptable data collection methods for this item include patient and/or caregiver interview (including family and facility staff), observation, clinical assessment, and clinical judgment.

Patients should take an active role in their pain management treatment plan, regardless of the type of pain they are experiencing. Effectively managing a patient’s pain doesn’t necessarily mean eliminating it entirely. Collaborating with the patient and their family in pain management helps to determine a pain intensity that allows the patient to function at their best. By asking the patient baseline questions about their pain, healthcare providers can set pain-intensity goals that assist the patient in coping with their discomfort.

The nursing process provides a structured approach to pain management, leading to better pain relief for many patients. Through this process, nurses can identify the unique ways patients perceive and respond to pain. It’s important to include nonpharmacologic complementary methods for pain relief in the patient’s care plan. The ultimate aim of pain assessment and management is to create a personalized care plan that maintains the patient’s pain at a tolerable level.

Item J2030: Screening of Shortness of Breath

The HOPE process for screening dyspnea or shortness of breath is similar to screening for pain. Nurses should screen for dyspnea based on clinical assessment, outcomes of a standardized symptom screening tool, patient/family interview, and information in the clinical record. Again, CMS instructs nurses not to use external sources of data when screening for pain.

Resource: Dyspnea (2023)

Item J2040: Treatment for Shortness of Breath

This item is asking if treatment for dyspnea was initiated. Nurses should include non-pharmacologic and pharmacologic treatments, scheduled, and PRN treatments for dyspnea. Nurses should only include treatments if the clinical record indicates that the intended purpose of the treatment is to address the patient’s dyspnea.

Note that comfort kits or pre-printed admission orders, are considered proactive and education on medications in a comfort kit in anticipation of symptoms is not considered initiation. Nurses should carefully review the coding guidance in the HOPE manual for this item as it is extensive.

Resource: Management of dyspnea at the end of life (2020)

Item J2050. Symptom Impact Screening

In this item, the nurse is required to take the outcomes of the pain and dyspnea (non-pain) assessment to determine the impact of the symptoms on the patient. CMS defines symptom impact in the HOPE manual as “the effect of symptom(s) on the patient. Symptoms may impact a patient in multiple ways, (e.g., sleep, concentration, day-to-day activities)”. This visit is not to assess the severity, intensity, frequency, or other characteristics of the symptoms, but the impact these symptoms have on the patient.

Symptom impact is determined based on the nurse’s evaluation after reviewing information from the patient, family/caregiver, and/or facility staff as well as their own assessment. Symptoms may affect various patient activities such as sleep, concentration, daily activities, or interactions with others.

Here are some reminders about the Symptom Follow up Visit (SFV):

Symptom impact is assessed during the admission and HOPE Update Visit(s)
An SFV must be completed within 2 calendar days if the patient’s pain or non-pain symptoms are rated as moderate or severe
The SFV is an in-person visit that can be completed by a registered or licensed/vocational nurse
- A process change may be necessary for your nurses to complete these visits in- person
An SFV cannot be conducted during the same visit as the initial assessment to conduct a HOPE Admission or HUV, but it can occur later in the same day, as a separate visit

Impact of the SFV on future quality Measures

CMS has developed two measures related to the HOPE assessment tool. Both measures capture the percent of hospice patient assessments that have a symptom follow-up visit within two (2) days when the symptom impact was initially assessed as moderate or severe, as follows:

Timely Follow-up for Pain Impact measure captures the percent of hospice patient assessments that have a symptom follow-up visit within two (2) days after pain impact was initially assessed as moderate or severe
Timely Follow-up for Non-Pain Symptom Impact measure captures the percent of assessments that have a symptom follow-up visit within two (2) days after non-pain symptom impact was initially assessed as moderate or severe.

Measure exclusions

The exclusions for both measures include the patient was discharged from hospice for any reason before an SFV could be completed and the hospice was unable to complete the SFV.

Public Reporting Threshold

Hospices must have at least 20 qualifying cases (HOPE ADM or HUV assessments rated as moderate or severe) during the reporting period for scores to be reported on Care Compare. If a hospice does not meet this threshold, its measure scores will be suppressed. If only one measure meets the threshold, it will be reported, while the other will be suppressed.

The future impact

It is very important for hospice providers to understand the SFV purpose, its timing, and consistency of completion for patients who meet the criteria for the visit. The SFV is not counted as a record in calculating compliance with HOPE data submission, but the outcomes of these visits will be utilized by CMS to calculate your measure score down the line.

HOPE Material Update

CMS announced the availability of a Hospice Vendor Update slide deck and an Errata (V1.00.2) for HOPE Data Specs (FINAL) Effective October 1, 2025. This information is available in the Downloads section of the HOPE Technical Information webpage and will help hospice vendors to prepare for HOPE Implementation. Hospice Vendor Update and Errata (V1.00.2) for HOPE Data Specs (FINAL) Effective October 1, 2025

A Hospice Vendor Update slide deck and Errata V1.00.2 is now available in the Downloads section for the final Hospice Outcomes and Patient Evaluation (HOPE) data submission specifications (V1.00.1). The slide deck provides important updates about HOPE, the transition to iQIES, the anticipated availability of the VUT, and how to access iQIES training tutorials to prepare you for the implementation of HOPE.

The errata document contains three issues (two edit changes, and the addition of caret as an allowed value for item J0915), which address item J0915 not being previously included in two skip pattern edits. These revisions will go into effect along with the rest of the previously posted final specs on October 1, 2025.

Stay tuned for the next installment in the HOPE Assessment Tool blog series and keep your actions and momentum moving forward for the October 1, 2025 implementation.