Add/Update Hospice Information

Required Information (please complete):

Person Completing Form (Name, Email, & Phone):

Hospice Name & Current NHL Address (if applicable, so we can identify your specific hospice location):

CMS Hospice Provider ID Number (if applicable):

What Would You Like To Do (please select one)?

Add a new hospice to the Locator? (All fields below required; 1 hospice / form)
Update existing hospice information in the Locator? (Add only new information below; 1 hospice / form)

_____

Hospice Contact Information (please edit anything you would like changed):

Hospice Name

Hospice Web Site:

Hospice Email:

Hospice CEO / Administrator Name:

Hospice CEO / Administrator Email:

Hospice Street Address:

Hospice City, State, Zip:

Hospice Phone:

Primary location or satellite office?

Primary
Satellite

Please list all counties / states in your service area:

_____

Medicare certified:

Yes
No

Medicare Certified Date

Date of last CMS survey

Does the hospice have an inpatient hospice unit?

Yes
No

Does your hospice participate in a quality program benchmarking against other hospices (e.g., NHPCO's Quality Partners or Midwest Care Alliance's Care Data Pro, etc.)?

Yes
No

Circle of Life Award Winner or Citation of Honor (for innovative hospice practices):

Yes
No

Does your hospice have a pediatric program?

Yes
No

Does your hospice provide specialized services for Veterans (e.g., a hospice / veteran partnership program, etc.)?

Yes
No

Is your hospice a faith-based organization, or part of one?

Yes
No

Does your hospice provide community bereavement programs (i.e., services for community members otherwise unaffiliated with your hospice)?

Yes
No

Does your hospice provide 75%+ of care to patients in the home setting (vs. nursing facilities)?

Yes
No

Are 75%+ of your physicians certifed in hospice & palliative medicine?

Yes
No

Are 75%+ of your nurses certifed in hospice & palliative medicine?

Yes
No

Are 75%+ of your nurse aides certifed in hospice & palliative medicine?

Yes
No

Does your hospice primarily serve urban or rural populations?

Urban
Rural

Is your hospice based in a prison, or provide services in correctional facilities?

Yes
No

_____

Average daily census last calendar year (or if new, expected ADC this calendar year; NOTE: there is a sort option by ADC, so it is to your advantage to have this updated):

Accredited: Joint Commission (JC)?

Yes
No

Accredited: Community Health Accreditation Program (CHAP)?

Yes
No

Accredited: Accreditation Commission for Healthcare (ACHC)?

Yes
No

Accredited: Another (non-deemed status) organization (e.g., Oregon Hospice Association)?

Yes
No

Membership: State hospice organization?

Yes
No

Membership: National Hospice & Palliative Care Org. (NHPCO)?

Yes
No

Membership: National Home Care & Hospice Assn. (NAHC)?

Yes
No

Membership: Visiting Nurses Association of America (VNAA)?

Yes
No

Control / Ownership (only 2 choices):

Nonprofit, Gov, or Other
For-profit

Type of Facility

Freestanding
Hospital based
Home Health based
Nursing Facility based

_____

Additional Hospice Information (please complete / update):

Currently the NHL reports publically available information. Would you be willing to participate in additional data collection requested by hospices?

Yes
No

Additional Questions, Comments, or Feedback. Also, if you answered "yes" to the above question, what questions might you suggest be collected and reported on the NHL?:

HOSPICE ANALYTICS, INC.

Information to help you make the best decisions...

Add / Update Hospice Information Form