NQF

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Full Agenda

Measure Index

• All-Cause Readmission measure (Workgroup Recommendation: Support; Public comments received:10; MUC ID: X4210)
  
  
• Percent of Patients/Residents/Persons with an admission and discharge functional assessment and a care plan that addresses function (Workgroup Recommendation: Conditional Support; Public comments received:11; MUC ID: S2631)
  
  
• Percent of Residents/Patients/Persons Experiencing One or More Falls with Major Injury (Workgroup Recommendation: Conditional Support; Public comments received:9; MUC ID: E0674)
  
  
• Percent of Residents/Patients/Persons with Pressure Ulcers That Are New or Worsened (Workgroup Recommendation: Support; Public comments received:8; MUC ID: E0678)
  
  

Full Measure Information

Measure Specifications

• NQF Number (if applicable): Includes NQF#'s: 2502, 2510, 2512, 2380
  
  
• Description:
  
• IRF: This measure estimates the risk-standardized rate of unplanned, all-cause readmissions for patients discharged from an inpatient rehabilitation facility (IRF) who were readmitted to a short-stay - acute-care hospital or a long-term care hospital (LTCH), within 30 days of an IRF discharge. The measure will be based on data for 24 months of IRF discharges to lower levels of care or to the community.
  
• SNF: This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions.
  
• LTCH: This measure estimates the risk-standardized rate of unplanned, all-cause readmissions for patients discharged from a long-term care hospital (LTCH) who were readmitted to a short stay- acute-care hospital or a long-term care hospital (LTCH), within 30 days of an LTCH discharge. The measure will be based on data for 24 months of LTCH discharges to lower levels of care or to the community.
  
• HH: Percentage of home health stays in which patients who had an acute inpatient hospitalization in the 5 days before the start of their home health stay were admitted to an acute care hospital during the 30 days following the start of the home health stay.
  
  
• Numerator:
  
• IRF: The numerator is mathematically related to the number of patients in the target population who have the event of an unplanned readmission in the 30-day post-discharge window. The measure does not have a simple form for the numerator and denominator—that is, the risk adjustment method used does not make the observed number of readmissions the numerator and a predicted number the denominator. Instead, the numerator is the risk-adjusted estimate of the number of unplanned readmissions that occurred within 30 days from discharge. This estimate includes risk adjustment for patient characteristics and a statistical estimate of the facility effect beyond patient mix.
  
• SNF: This measure is designed to capture the outcome of unplanned all-cause hospital readmissions (IPPS or CAH) of SNF patients occurring within 30 days of discharge from the patient’s prior proximal acute hospitalization.The numerator is more specifically defined as the risk-adjusted estimate of the number of unplanned readmissions that occurred within 30 days from discharge from the prior proximal acute hospitalization. The numerator is mathematically related to the number of SNF stays where there was hospitalization readmission, but the measure does not have a simple form for the numerator and denominator—that is, the risk adjustment method used does not make the observed number of readmissions the numerator and a predicted number the denominator. The numerator, as defined, includes risk adjustment for patient characteristics and a statistical estimate of the facility effect beyond patient mix. Hospital readmissions that occur after discharge from the SNF stay but within 30 days of the proximal hospitalization are also included in the numerator. Readmissions identified using the Planned Readmission algorithms (see Section S.6) are excluded from the numerator. This measure does not include observation stays as a readmission (see Section S.6).
  
• LTCH: The numerator is mathematically related to the number of patients in the target population who have the event of an unplanned readmission in the 30-day post-discharge window. The measure does not have a simple form for the numerator and denominator—that is, the risk adjustment method used does not make the observed number of readmissions the numerator and a predicted number the denominator. Instead, the numerator is the risk-adjusted estimate of the number of unplanned readmissions that occurred within 30 days from discharge. This estimate includes risk adjustment for patient characteristics and a statistical estimate of the facility effect beyond patient mix.
  
• HH: Number of home health stays for patients in the measure denominator who have a Medicare claim for an admission to an acute care hospital in the 30 days following the start of the home health stay.
  
  
• Denominator:
  
• IRF: The denominator is computed with the same model used for the numerator. It is the model developed using all non-excluded IRF stays in the national data. For a particular facility the model is applied to the patient population, but the facility effect term is 0. In effect, it is the number of readmissions that would be expected for that patient population at the average IRF. The measure includes all the IRF stays in the measurement period that are observed in national Medicare FFS data and do not fall into an excluded category.
  
• SNF: The denominator is computed with the same model used for the numerator. It is the model developed using all non-excluded SNF stays in the national data. For a particular facility the model is applied to the patient population, but the facility effect term is 0. In effect, it is the number of SNF admissions within 1 day of a prior proximal hospital discharge during a target year, taking denominator exclusions into account. Prior proximal hospitalizations are defined as admissions to an IPPS acute-care hospital, CAH, or psychiatric hospital.
  
• LTCH: The denominator is computed with the same model used for the numerator. It is the model developed using all non-excluded LTCH stays in the national data. For a particular facility the model is applied to the patient population, but the facility effect term is 0. In effect, it is the number of readmissions that would be expected for that patient population at the average LTCH. The measure includes all the LTCH stays in the measurement period that are observed in national Medicare FFS data and do not fall into an excluded category.
  
• HH: Number of home health stays that begin during the relevant observation period for patients who had an acute (short-term) inpatient hospitalization in the five days prior to the start of the home health stay. A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days.
  
  
• Exclusions:
  
• IRF: 1. IRF patients who died during the IRF stay.Rationale: A post-discharge readmission measure is not relevant for patients who died during their IRF stay.2. IRF patients less than 18 years old.Rationale: IRF patients under 18 years old are not included in the target population for this measure. Pediatric patients are relatively few and may have different patterns of care from adults.3. IRF patients who were transferred at the end of a stay to another IRF or short-term acute care hospital.Rationale: Patients who were transferred to another IRF or short-term acute-care hospital are excluded from this measure because the transfer suggests that either their IRF treatment has not been completed or that their condition worsened, requiring a transfer back to the acute care setting. The intent of the measure is to follow patients deemed well enough to be discharged to a less intensive care setting (i.e., discharged to less intense levels of care or to the community).4. Patients who were not continuously enrolled in Part A FFS Medicare for the 12 months prior to the IRF stay admission date, and at least 30 days after IRF stay discharge date.Rationale: The adjustment for certain comorbid conditions in the measure requires information on acute inpatient bills for 1 year prior to the IRF admission, and readmissions must be observable in the observation window following discharge. Patients without Part A coverage or who are enrolled in Medicare Advantage plans will not have complete inpatient claims in the system.5. Patients who did not have a short-term acute-care stay within 30 days prior to an IRF stay admission date.Rationale: This measure requires information from the prior short-term acute-care stay in the elements used for risk adjustment.6. IRF patients discharged against medical advice (AMA). Rationale: Patients discharged AMA are excluded because these patients have not completed their full course of treatment in the opinion of the facility.7. IRF patients for whom the prior short-term acute-care stay was for nonsurgical treatment of cancer.Rationale: Consistent with the HWR Measure, patients for whom the prior short-term acute-care stay was for nonsurgical treatment of cancer are excluded because these patients were identified as following a very different trajectory after discharge, with a particularly high mortality rate.8. IRF stays with data that are problematic (e.g., anomalous records for hospital stays that overlap wholly or in part or are otherwise erroneous or contradictory).Rationale: This measure requires accurate information from the IRF stay and prior short-term acute-care stays in the elements used for risk adjustment. No-pay IRF stays involving exhaustion of Part A benefits are also excluded.
• SNF: 1. SNF stays where the patient had one or more intervening post-acute care (PAC) admissions (inpatient rehabilitation facility [IRF] or long-term care hospital [LTCH]) which occurred either between the prior proximal hospital discharge and SNF admission or after the SNF discharge, within the 30-day risk window. Also excluded are SNF admissions where the patient had multiple SNF admissions after the prior proximal hospitalization, within the 30-day risk window.Rationale: For patients who have IRF or LTCH admissions prior to their first SNF admission, these patients are starting their SNF admission later in the 30-day risk window and receiving other additional types of services as compared to patients admitted directly to the SNF from the prior proximal hospitalization. They are clinically different and their risk for readmission is different than the rest of SNF admissions. Additionally, when patients have multiple PAC admissions, evaluating quality of care coordination is confounded and even controversial in terms of attributing responsibility for a readmission among multiple PAC providers. Similarly, assigning responsibility for a readmission for patients who have multiple SNF admissions subsequent to their prior proximal hospitalization is also controversial.2. SNF stays with a gap of greater than 1 day between discharge from the prior proximal hospitalization and the SNFadmission.Rationale: These patients are starting their SNF admissions later in the 30-day risk window than patients admitted directly to the SNF from the prior proximal hospitalization. They are clinically different and their risk for readmission is different than the rest of SNF admissions.3. SNF stays where the patient did not have at least 12 months of FFS Medicare enrollment prior to the proximal hospital discharge (measured as enrollment during the month of proximal hospital discharge and the for 11 months prior to that discharge).Rationale: FFS Medicare claims are used to identify comorbidities during the 12-month period prior to the proximal hospital discharge for risk adjustment. Multiple studies have shown that using look back- scans of a year or more of claims data provide superior predictive power for outcomes including rehospitalization as compared to using data from a single hospitalization (e.g., Klabunde et al., 2000; Preen et al, 2006; Zhang et al., 1999).4. SNF stays in which the patient did not have FFS Medicare enrollment for the entire risk period (measured as enrollment during the month of proximal hospital discharge and the month following the month of discharge).Rationale: Readmissions occurring within the 30-day risk window when the patient does not have FFS Medicare coverage cannot be detected using claims.5. SNF stays in which the principal diagnosis for the prior proximal hospitalization was for the medical treatment of cancer. Patients with cancer whose principal diagnosis from the prior proximal hospitalization was for other diagnoses or for surgical treatment of their cancer remain in the measure.Rationale: These admissions have a very different mortality and readmission risk than the rest of the Medicare population, and outcomes for these admissions do not correlate well with outcomes for other admissions.6. SNF stays where the patient was discharged from the SNF against medical advice.Rationale: The SNF was not able to complete care as needed.7. SNF stays in which the principal primary diagnosis for the prior proximal hospitalization was for “rehabilitation care; fitting of prostheses and for the adjustment of devices”.Rationale: Hospital admissions for these conditions are not for acute care.
• LTCH: 1. LTCH patients who died during the LTCH stay.Rationale: A post-discharge readmission measure is not relevant for patients who died during their LTCH stay.2. LTCH patients less than 18 years old.Rationale: LTCH patients under 18 years old are not included in the target population for this measure. Pediatric patients are relatively few and may have different patterns of care from adults.3. LTCH patients who were transferred at the end of a stay to another LTCH or short-term acute-care hospital.Rationale: Patients who were transferred to another LTCH or short-term acute-care hospital are excluded from this measure because the transfer suggests that either their LTCH treatment has not been completed or that their condition worsened, requiring a transfer back to the acute care setting. The intent of the measure is to follow patients deemed well enough to be discharged to a less intensive care setting (i.e., discharged to less intense levels of care or to the community).4. Patients who were not continuously enrolled in Part A FFS Medicare for the 12 months prior to the LTCH stay admission date, and at least 30 days after LTCH stay discharge date.Rationale: The adjustment for certain comorbid conditions in the measure requires information on acute inpatient bills for 1 year prior to the LTCH admission, and readmissions must be observable in the observation window following discharge. Patients withoutPart A coverage or who are enrolled in Medicare Advantage plans will not have complete inpatient claims in the system. 5. Patients who did not have a short-term acute-care stay within 30 days prior to an LTCH stay admission date.Rationale: This measure requires information from the prior short-term acute-care stay in the elements used for risk adjustment.6. LTCH patients discharged against medical advice (AMA).Rationale: Patients discharged AMA are excluded because these patients have not completed their full course of treatment in the opinion of the facility.7. LTCH patients for whom the prior short-term acute-care stay was for nonsurgical treatment of cancer.Rationale: Consistent with the HWR Measure, patients for whom the prior short-term acute-care stay was for nonsurgical treatment of cancer are excluded because these patients were identified as following a very different trajectory after discharge, with a particularly high mortality rate.8. LTCH stays with data that are problematic (e.g., anomalous records for hospital stays that overlap wholly or in part or are otherwise erroneous or contradictory).Rationale: This measure requires accurate information from the LTCH stay and prior short-term acute-care stays in the elements used for risk adjustment. No-pay LTCH stays involving exhaustion of Part A benefits are also excluded.
• HH: First, the measure denominator for the Rehospitalization During the First 30 Days of Home Health measure excludes the following home health stays that are also excluded from the all-patient claims-based NQF 0171 Acute Care Hospitalization measure: (i) Stays for patients who are not continuously enrolled in fee-for-service Medicare during the measure numerator window; (ii) Stays that begin with a Low-Utilization Payment Adjustment (LUPA). Stays with four or fewer visits to the beneficiary qualify for LUPAs; (iii) Stays in which the patient is transferred to another home health agency within a home health payment episode (60 days); and (iv) Stays in which the patient is not continuously enrolled in Medicare fee-for-service during the previous six months.Second, to be consistent with the Hospital-Wide All-Cause Unplanned Readmission measure (as of January 2013), the measure denominator excludes stays in which the hospitalization occurring within 5 days of the start of home health care is not a qualifying inpatient stay. Hospitalizations that do not qualify as index hospitalizations include admissions for the medical treatment of cancer,primary psychiatric disease, or rehabilitation care, and admissions ending in patient discharge against medical advice.Third, the measure denominator excludes stays in which the patient receives treatment in another setting in the 5 days between hospital discharge and the start of home health.Finally, stays with missing payment-episode authorization strings (needed for risk-adjustment) are excluded.
  
  
• HHS NQS Priority: Promoting effective communication and coordination of care
  
  
• HHS Data Source: Claims
  
  
• Measure Type: Outcome
  
  
• Steward: CMS
  
  
• Endorsement Status: Endorsed
  
  

Summary of Workgroup Deliberations

• Workgroup Recommendation: Support
  
  
• Workgroup Rationale: The measure addresses an IMPACT domain and a MAP PAC/LTC core concept. NQF has recently endorsed these readmission measures for all four settings (IRF #2502; SNF #2510; LTCH #2512; HH #2380.) Skilled Nursing Facilities: In the 2015 pre-rulemaking cycle, MAP supported #2510 for the SNF Value-Based Purchasing Program. Measure #2510 was also recently finalized for use in MSSP in the 2015 PFS rule. The IRFQR, LTCHQR and HHQR programs currently include an all-cause unplanned readmission measure. The measures are all harmonized in the approach to capturing readmissions.
  
  
• Public comments received: 10

Rationale for measure provided by HHS

Measure Specifications

• NQF Number (if applicable): Identified as submitted measure NQF#2631
  
  
• Description: This quality measure reports the percentage of residents, patients, and persons with an admission and discharge functional assessment and a care plan that addresses function.
  
  
• Numerator: The numerator for this quality measure is the number of patients, residents, and persons with all three of the following:1. a valid numeric score indicating the patient’s, resident’s, or person’s status, or a valid code indicating the activity did not occur or could not be assessed for each of the functional assessment items on the admission assessment;AND2. a valid numeric score, which is a discharge goal indicating the patient’s, resident’s, or person’s expected level of independence for at least one self-care or mobility item on the admission assessment;AND3. a valid numeric score indicating the patient’s, resident’s, or person’s status, or a valid code indicating the activity did not occur or could not be assessed for each of the functional assessment items on the discharge assessment.
  
  
• Denominator: The denominator for this quality measure is the number of residents/patients/persons in the target population. Target PopulationInclusion CriteriaThe population included in this measure is all patient, resident, or persons including individuals of allages.
  
  
• Exclusions: The following three exclusion criteria apply to the collection of discharge functional status data:1. Patients/residents/persons with incomplete stays because of a medical emergency.2. Patients/residents/persons who leave the setting in which care is given against medical advice.3. No discharge functional status data are required if a patient, resident, or person dies while in the setting in which care is given.
  
  
• HHS NQS Priority: Making care safer, Promoting effective communication and coordination of care
  
  
• HHS Data Source: SNF: MDS; Home Health: OASIS; IRF: IRF PAI; LTCH: CARE
  
  
• Measure Type: Process
  
  
• Steward: CMS
  
  
• Endorsement Status: Not endorsed
  
  

Summary of Workgroup Deliberations

• Workgroup Recommendation: Conditional Support
  
  
• Workgroup Rationale: The measure addresses an IMPACT domain and a MAP PAC/LTC core concept. MAP conditionally supported this measure pending NQF-endorsement and resolution of concerns about the use of two different functional status scales for quality reporting and payment purposes. MAP reiterated its support for adding measures addressing function, noting the group's especial interest in this PAC/LTC core concept.
  
  
• Public comments received: 11

Rationale for measure provided by HHS

Measure Specifications

• NQF Number (if applicable): 0674
  
  
• Description: This measure reports the percent of patients, residents, and persons who have experienced one or more falls with major injury reported in the target period or look-back period. "Falls that result in a major injury" are defined as: falls that result in a major injury such as bone fractures, joint dislocations, closed head injuries, subdural hematoma, and altered consciousness, among other major injuries.
  
  
• Numerator: Patients/residents/persons with one or more look-back scan assessments that indicate one or more falls that resulted in major injury. "Falls with a major injury" are defined as: falls that result in a major injury such as bone fractures, joint dislocations, closed head injuries, subdural hematoma, and altered consciousness, among other major injuries.
  
  
• Denominator: All patients/residents/persons with one or more look-back scan assessments except those with exclusions.
  
  
• Exclusions: Resident/patient/person is excluded if one of the following is true for all of the look-back scan assessments:1. The occurrence of falls was not assessed, OR2. The assessment indicates that a fall occurred, and the number of falls with major injury was not assessed.
  
  
• HHS NQS Priority: Making care safer, Promoting effective communication and coordination of care
  
  
• HHS Data Source: SNF: MDS; Home Health: OASIS; IRF: IRF PAI; LTCH: CARE
  
  
• Measure Type: Outcome
  
  
• Steward: CMS
  
  
• Endorsement Status: Endorsed
  
  

Summary of Workgroup Deliberations

• Workgroup Recommendation: Conditional Support
  
  
• Workgroup Rationale: The measure addresses an IMPACT domain and a MAP PAC/LTC core concept. This measure is curretnly in use in the Nursing Home Quality Initiative and finalized for use in the LTCH QRP for the FY 2018 payment determination and subsequent years. and MAP conditionally supported this measure pending proper risk adjustments and attribution for the home health setting.
  
  
• Public comments received: 9

Rationale for measure provided by HHS

Measure Specifications

• NQF Number (if applicable): 0678
  
  
• Description: This measure captures the percentage of short-stay residents, patients, and persons with new or worsening Stage II-IV pressure ulcers.
  
  
• Numerator: Residents, patients, and persons for which a look-back scan indicates one or more new or worsening Stage II-IV pressure ulcers (e.g.., discharge and admission assessment).
  
  
• Denominator: All residents, patients, and persons with one or more assessments that are eligible for a look-back scan, except those with exclusions.
  
  
• Exclusions: Residents, patients, and persons are excluded if: 1. missing data on new or worsened pressure ulcers, and 2) expired during stay. Nursing homes, LTCHs and IRFs with denominator counts of less than 20 residents/patients/persons in the sample will be excluded from public reporting owing to small sample size.
  
  
• HHS NQS Priority: Making care safer
  
  
• HHS Data Source: SNF: MDS; Home Health: OASIS; IRF: IRF PAI; LTCH: CARE
  
  
• Measure Type: Outcome
  
  
• Steward: CMS
  
  
• Endorsement Status: Endorsed
  
  

Summary of Workgroup Deliberations

• Workgroup Recommendation: Support
  
  
• Workgroup Rationale: The measure addresses an IMPACT domain and a MAP PAC/LTC core concept. The measure is NQF-endorsed for the SNF, IRF and LTCH settings (NQF #0678). The measure is currently in use in the IRF and LTCH quality reporting programs and the Nursing Home Quality Initiative. In the 2015 MAP pre-rulemaking cycle, MAP conditionally supported X3704 Percent of Residents/Patients/Persons with Pressure Ulcers That Are New or Worsened for Home Health Quality Reporting. MAP recommended that the CMS continue to work to refine the adaption of this measure for the home health setting to ensure proper risk adjustment and exclusions.
  
  
• Public comments received: 8

Rationale for measure provided by HHS

Program Index

• IMPACT Act Programs 
  
  
• Long-Term Care Hospitals Quality Reporting Program 
  
  
• Inpatient Rehabilitation Facilities Quality Reporting Program 
  
  
• Skilled Nursing Facilities Value-Based Purchasing 
  
  
• Home Health Quality Reporting Program 
  
  

Full Program Summaries

Program Type: Through this off-cycle review, CMS has asked MAP to provide input on four measures under consideration to meet requirements of the IMPACT Act. While CMS will use the existing quality reporting programs to gather this data, MAP is asked to consider the requirements of the IMPACT Act as an overlay to the existing programs. MAP is asked to provide input on four measures that could be potentially used across settings to provide standardized quality data.

Incentive Structure: N/A

Program Goals: N/A

Critical Program Objectives: N/A

Program Update: The IMPACT Act is a bipartisan bill passed in September 2014. Under section 1899 (B) Title XVIII of the Social Security Act, post-acute care (PAC) providers are now required to report standardized patient assessment data as well as data on quality, resource use, and other measures. The IMPACT Act is an important step toward measurement alignment and shared accountability across the healthcare continuum, which MAP has emphasized over the past several years.

The IMPACT Act aims to enable CMS to compare quality across PAC settings, improve hospital and PAC discharge planning, and use standardized data to reform PAC payments, while ensuring beneficiaries have access to the most appropriate care. Recognizing that under the current system patients can receive post-acute care from four different settings, IMPACT requires standardized patient assessment data that will enable comparisons across skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health agencies (HHAs).

The standardized quality measures will address several domains including functional status and changes in function, skin integrity and changes in skin integrity, medication reconciliation, incidence of major falls, and the accurate communication of health information and care preferences when a patient is transferred. The IMPACT Act also requires the implementation of measures to address resource use and efficiency such as total Medicare spending per beneficiary, discharge to community, and risk-adjusted hospitalization rates of potentially preventable admissions and readmissions.

Program Type: Pay for Reporting, Public Reporting

Incentive Structure: For fiscal year 2014, and each year thereafter, Long-Term Care Hospital providers (LTCHs) must submit data on quality measures to the Centers for Medicare & Medicaid Services (CMS) to receive full annual payment updates; failure to report quality data will result in a 2 percent reduction in the annual payment update.  The data must be made publicly available, with LTCH providers having an opportunity to review the data prior to its release. No date has been specified to begin public reporting of quality data.  

Program Goals: Furnishing extended medical care to individuals with clinically complex problems (e.g., multiple acute or chronic conditions needing hospital-level care for relatively extended periods of greater than 25 days).

Critical Program Objectives: Statutory Requirements

• Measures should align with the National Quality Strategy (NQS), promote enhanced quality with regard to the priorities most relevant to LTCHs (such as patient safety, better coordination of care, and person- and family-centered care). 
• The Improving Medicare Post-Acute Care Transformation Act of 2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs : 
• Require post-acute care (PAC) providers to report standardized patient assessment data, data on quality measures, and data on resource use and other measures
• Require the data to be interoperable to allow for its exchange among PAC and other providers to give them access to longitudinal information so as to facilitate coordinated care and improve Medicare beneficiary outcomes
• Modify PAC assessment instruments applicable to PAC providers for the submission of standardized patient assessment data on such providers and enable assessment data comparison across all such providers
• Applicable PAC programs are defined as: 1)HHA Quality Reporting Program; 2) newly required SNF Quality Reporting Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality Reporting Program
• Specifies requirements for the creation and reporting of new quality measures which will be implemented in a staggered time frame by PAC providers.
• New quality measures will address, at a minimum, the following domains:
• functional status and changes in function;
• skin integrity and changes in skin integrity;
• medication reconciliation;
• incidence of major falls; and
• accurately communicating health information and care preferences when a patient is transferred
• Resource use measures will address the following:
• efficiency measures to include total Medicare spending per beneficiary;
• discharge to community; and
• risk adjusted hospitalization rates of potentially preventable admissions and readmissions.
• Directs the Secretary to: (1) provide confidential feedback reports to PAC providers on their performance with respect to required measures by October 1, 2017 for SNF, IRF, and LTCH and January 1, 2018 for HHA ; and (2) arrange for public reporting of PAC provider performance on quality, resource use, and other measures  by October 1, 2018 for SNF, IRF, and LTCH and January 1, 2019 for HHA.

• Functional status assessment should cover a broad range of mobility issues, such as position changes, locomotion, poor mobility, picking up objects, and chair-to-bed transfers. 
• Increased attention should be given to pain, agitation, and delirium among the ventilated population, as these factors are the biggest impediments to mobility.   
• Add measures to address cost, cognitive status assessment (e.g., dementia identification), medication management (e.g., use of antipsychotic medications), and advance directives.  

Program Update:

• Hospital Inpatient Prospective Payment System for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System FY 2015 Final Rule: 
• For the FY 2018 payment determination and subsequent years, in addition to retaining the previously finalized measures, CMS adopted three new quality measures:
• Percent of LTCH patients with an admission and discharge functional assessment and a care plan that addresses function (conditionally supported by MAP in the 2014 pre-rulemaking report )
• Functional Outcome Measure: change in mobility among patients requiring ventilator support (conditionally supported by MAP in the 2014 pre-rulemaking report)
• Ventilator-Associated Event (supported by MAP in the 2014 pre-rulemaking report)

Program Type: Pay for Reporting, Public Reporting

Incentive Structure: For fiscal year of 2014, and each year thereafter, Inpatient Rehabilitation Facility providers (IRFs) must submit data on quality measures to the Centers for Medicare & Medicaid Services (CMS) to receive annual payment updates. Failure to report quality data will result in a 2 percent reduction in the annual increase factor for discharges occurring during that fiscal year.  The data must be made publicly available, with IRF providers having an opportunity to review the data prior to its release. No date has been specified to begin public reporting of quality data.

Program Goals: Address the rehabilitation needs of the individual including improved functional status and achievement of successful return to the community post-discharge.  

Critical Program Objectives: Statutory Requirements

• Measures should align with the National Quality Strategy (NQS), be relevant to the priorities of IRFs (such as patient safety, reducing adverse events, better coordination of care, and person- and family-centered care.
  
  
• The Improving Medicare Post-Acute Care Transformation Act of 2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs : 
• Require post-acute care (PAC) providers to report standardized patient assessment data, data on quality measures, and data on resource use and other measures
• Require the data to be interoperable to allow for its exchange among PAC and other providers to give them access to longitudinal information so as to facilitate coordinated care and improve Medicare beneficiary outcomes
• Modify PAC assessment instruments applicable to PAC providers for the submission of standardized patient assessment data on such providers and enable assessment data comparison across all such providers
• Applicable PAC programs are defined as: 1)HHA Quality Reporting Program; 2) newly required SNF Quality Reporting Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality Reporting Program
• Specifies requirements for the creation and reporting of new quality measures which will be implemented in a staggered time frame by PAC providers.
• New quality measures will address, at a minimum, the following domains:
• functional status and changes in function;
• skin integrity and changes in skin integrity;
• medication reconciliation;
• incidence of major falls; and
• accurately communicating health information and care preferences when a patient is transferred
• Resource use measures will address the following:
• efficiency measures to include total Medicare spending per beneficiary;
• discharge to community; and
• risk adjusted hospitalization rates of potentially preventable admissions and readmissions.
• Directs the Secretary to: (1) provide confidential feedback reports to PAC providers on their performance with respect to required measures by October 1, 2017 for SNF, IRF, and LTCH and January 1, 2018 for HHA ; and (2) arrange for public reporting of PAC provider performance on quality, resource use, and other measures  by October 1, 2018 for SNF, IRF, and LTCH and January 1, 2019 for HHA.

• Program measure set is too limited and could be enhanced by addressing core measure concepts not currently addressed in the set such as care coordination, functional status, and medication reconciliation and the safety issues that have high incidence in IRFs, such as MRSA, falls, CAUTI, and C. difficile. 

Program Update:

• IRF Prospective Payment System for Federal Fiscal Year 2015 final rule: 
• For the FY 2017 adjustments to the IRF PPS annual increase factor, in addition to retaining the previously finalized measures, CMS adopted two new quality measures:
• Measure NQF#1717 NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (supported by MAP in the 2014 pre-rulemaking report)
• Measure NQF #1716 NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (conditionally supported by MAP in the 2014 pre-rulemaking report)

Program Type: Public Reporting

Incentive Structure: Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs. Part of this requirement includes completing the Minimum Data Set (MDS), a clinical assessment of all residents in Medicare- or Medicaid-certified nursing facilities. Quality measures are reported on the Nursing Home Compare website using a Five-Star Quality Rating System, which assigns each nursing home a rating of 1 to 5 stars, with 5 representing highest standard of quality, and 1 representing the lowest.

Program Goals: The overall goal of NHQI is to improve the quality of care in nursing homes using CMS’ informational tools. The objective of these informational tools is to share quality information with consumers, health care providers, intermediaries and other key stakeholders to help them make informed decisions about nursing home care (e.g., Nursing Home Compare, Nursing Home Checklist).

Critical Program Objectives: Statutory Requirements

• The Improving Medicare Post-Acute Care Transformation Act of 2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs : 
• Require post-acute care (PAC) providers to report standardized patient assessment data, data on quality measures, and data on resource use and other measures
• Require the data to be interoperable to allow for its exchange among PAC and other providers to give them access to longitudinal information so as to facilitate coordinated care and improve Medicare beneficiary outcomes
• Modify PAC assessment instruments applicable to PAC providers for the submission of standardized patient assessment data on such providers and enable assessment data comparison across all such providers
• Applicable PAC programs are defined as: 1)HHA Quality Reporting Program; 2) newly required SNF Quality Reporting Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality Reporting Program
• Establishes a new “SNF Quality Reporting Program” at the start of FY 2019 and directs the Secretary to reduce by 2% the update to the market basket percentage for skilled nursing facilities which do not report assessment and quality data under this program.
• Specifies requirements for the creation and reporting of new quality measures which will be implemented in a staggered time frame by PAC providers.
• New quality measures will address, at a minimum, the following domains:
• functional status and changes in function;
• skin integrity and changes in skin integrity;
• medication reconciliation;
• incidence of major falls; and
• accurately communicating health information and care preferences when a patient is transferred
• Resource use measures will address the following:
• efficiency measures to include total Medicare spending per beneficiary;
• discharge to community; and
• risk adjusted hospitalization rates of potentially preventable admissions and readmissions.
• Directs the Secretary to: (1) provide confidential feedback reports to PAC providers on their performance with respect to required measures by October 1, 2017 for SNF, IRF, and LTCH and January 1, 2018 for HHA; and (2) arrange for public reporting of PAC provider performance on quality, resource use, and other measures by October 1, 2018 for SNF, IRF, and LTCH and January 1, 2019 for HHA.
• The Protecting Access to Medicare Act of 2014 (PAMA) :
• Directs the Secretary to establish a skilled nursing facility value-based purchasing (SNF VBP) program under which value-based incentive payments are made in a fiscal year to skilled nursing facilities, beginning in fiscal year 2019.
• Readmission measure - Not later than October 1, 2015, the Secretary shall specify a skilled nursing facility all-cause all-condition hospital readmission measure (or any successor to such a measure).
• Resource use measure – Not later than October 1, 2016, the Secretary shall specify a measure to reflect an all-condition risk-adjusted potentially preventable hospital readmission rate for skilled nursing facilities.
• Directs the Secretary to: (1) provide confidential feedback reports to SNFs on their performance with respect to above measures, beginning October 1, 2016 and every quarter thereafter; and (2) establish procedures for making available to the public by posting on the Nursing Home Compare Medicare website (or a successor website) information on the performance of SNF with respect to the above measures beginning not later than October 1, 2017.

• Determine whether (1) there are opportunities to combine the long-stay and short-stay measures using risk adjustment and/or stratification to account for patient variations and (2) any of the measures could be applied to other PAC/LTC programs to align measures across settings.  
• Add measures that assess discharge to the community and the quality of transition planning. 
• Include Nursing Home-CAHPS measures in the program to address patient experience. 

Program Update: None

Program Type: Pay for Reporting, Public Reporting

Incentive Structure: Medicare-certified home health agencies (HHAs) are required to collect and submit the Outcome and Assessment Information Set (OASIS). The OASIS is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement. Home health agencies meet their quality data reporting requirements through the submission of OASIS assessments and Home Health CAHPS. HHAs that do not submit data will receive a 2 percentage point reduction in their annual HH market basket percentage increase. Subsets of the quality measures generated from OASIS are reported on the Home Health Compare website, which provides information about the quality of care provided by HHAs throughout the country.

Program Goals: As home health quality goals, CMS has adopted the mission of The Institute of Medicine (IOM) which has defined quality as having the following properties or domains: effectiveness, efficiency, equity, patient centeredness, safety, and timeliness.

Critical Program Objectives: Statutory Requirements

• Home health is a covered service under the Part A Medicare benefit. It consists of part-time, medically necessary skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) that is ordered by a physician.
• Two categories of quality measures used in HH QRP are outcome measures and process measures. There are three types of outcome measures used including: 
• Improvement measures (i.e., measures describing a patient’s ability to get around, perform activities of daily living, and general health);
• Measures of potentially avoidable events (i.e., markers for potential problems in care); and
• Utilization of care measures (i.e., measures describing how often patients access other health care resources either while home health care is in progress or after home health care is completed).
• The Improving Medicare Post-Acute Care Transformation Act of 2014, a.k.a “IMPACT ACT of 2014” provisions for PAC programs : 
• Require post-acute care (PAC) providers to report standardized patient assessment data, data on quality measures, and data on resource use and other measures
• Require the data to be interoperable to allow for its exchange among PAC and other providers to give them access to longitudinal information so as to facilitate coordinated care and improve Medicare beneficiary outcomes
• Modify PAC assessment instruments applicable to PAC providers for the submission of standardized patient assessment data on such providers and enable assessment data comparison across all such providers
• Applicable PAC programs are defined as: 1)HHA Quality Reporting Program; 2) newly required SNF Quality Reporting Program; 3) IRF Quality Reporting Program; and 4) LTCH Quality Reporting Program
• Specifies requirements for the creation and reporting of new quality measures which will be implemented in a staggered time frame by PAC providers.
• New quality measures will address, at a minimum, the following domains:
• functional status and changes in function;
• skin integrity and changes in skin integrity;
• medication reconciliation;
• incidence of major falls; and
• accurately communicating health information and care preferences when a patient is transferred
• Resource use measures will address the following:
• efficiency measures to include total Medicare spending per beneficiary;
• discharge to community; and
• risk adjusted hospitalization rates of potentially preventable admissions and readmissions.
• Directs the Secretary to: (1) provide confidential feedback reports to PAC providers on their performance with respect to required measures by October 1, 2017 for SNF, IRF, and LTCH and January 1, 2018 for HHA ; and (2) arrange for public reporting of PAC provider performance on quality, resource use, and other measures  by October 1, 2018 for SNF, IRF, and LTCH and January 1, 2019 for HHA.

• MAP noted that the large measure set reflects the heterogeneity of home health population; however, the measure set could be more parsimonious.   

• CMS will conduct a thorough analysis of the measure set to identify priority gap areas, measures that are topped out, and opportunities to improve the existing measures.

Program Update:

• Updates listed in the CY 2015 Home Health Final Rule:
• Specified the adoption of two claims based measures in the CY 2014 HH PPS final rule and the beginning date of CY 2014 for reporting. These claims based measures supported by MAP in the past pre-rulemaking cycle are: (1) Rehospitalization during the first 30 days of HH; and (2) Emergency Department Use without Hospital Readmission during the first 30 days of HH. These measures will be added to HH Compare for public reporting in CY 2015. 
• Set a date of October 2014 for removal of the 9 episode stratified process measures in the CASPER reports. In addition, five short stay measures which had previously been reported on HH Compare were recently removed from public reporting and replaced with non-stratified “all episodes of care” versions of these measures.
• Finalized a new pay-for-reporting performance requirement for OASIS reporting.  For episodes beginning on or after July 1st, 2015 and before June 30th, 2016, HHAs must score at least 70 percent on the Quality Assessments Only (QAO) metric of pay-for-reporting performance requirement or be subject to a 2 percentage point reduction to their market basket update for CY 2017.
• Will continue to require HHCAHPS

Index of Public Comments (by Measure and Program)

• Percent of Residents/Patients/Persons Experiencing One or More Falls with Major Injury (Program: IMPACT Act Programs; MUC ID: E0674)
  
  
• Percent of Residents/Patients/Persons with Pressure Ulcers That Are New or Worsened (Program: IMPACT Act Programs; MUC ID: E0678)
  
  
• Percent of Patients/Residents/Persons with an admission and discharge functional assessment and a care plan that addresses function (Program: IMPACT Act Programs; MUC ID: S2631)
  
  
• All-cause readmission measure (Program: IMPACT Act Programs; MUC ID: X4210)
  
  
• General (Program: IMPACT Act Programs; MUC ID: General)
  
  

Full Comments (Listed by Measure)

• APPLIES TO ALL MEASURES The American Hospital Association (AHA), on behalf of its nearly 5,000 member hospitals, health systems and other health care organizations – including more than 3,300 institutionally based or affiliated providers of acute long-term care, inpatient rehabilitation, hospitals with skilled nursing and extended care beds, hospital-based or affiliated home health agencies – appreciates the opportunity to comment on the Measure Applications Partnership’s (MAP) ad hoc review of four measures that the Centers for Medicare & Medicaid Services (CMS) intends to implement in order to meet the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The IMPACT Act requires the quality reporting programs for long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), home health (HH) agencies and skilled nursing facilities (SNFs) to include “standardized” and “interoperable” measures that address specific quality and resource use topics. The measures under consideration (MUC) list submitted to the MAP by CMS addresses four of the eight required measure topics – patient falls with injury, pressure ulcers, functional status assessment and readmissions. While the statute does not provide specific operational definitions of “standardized” and “interoperable,” we believe the intent is to promote the use of consistent -- though not necessarily identical --data definitions across post-acute care providers so that data can be better used to coordinate care across the continuum. The AHA applauds CMS for using the MAP process, even though the IMPACT Act does not obligate the agency to do so. While this ad hoc review provides a much more limited timeframe to review measures than the already abridged MAP pre-rulemaking process, the MAP can provide the agency with important guidance on potential implementation barriers as well as possible unintended consequences of measurement. The use of the MAP also can ensure the agency is using measures that address important priority areas for quality improvement. The AHA supports the MAP’s recommendation on the falls and pressure ulcer measures, but urges the MAP to reconsider its recommendations on the readmission and functional status measures. Moreover, we urge CMS to provide additional details on how it intends to implement these measures. We hope this information will be available as soon as possible, and certainly no later than when CMS formally proposes the measures. The MUC list provides us with the titles and basic descriptions of the measures. While this information is helpful for understanding the general direction of CMS’s efforts to implement the IMPACT Act, the field will ultimately need much more information on other crucial implementation details. Indeed, the IMPACT Act requires that quality measures be collected using various patient assessment instruments (e.g., the IRF-Patient Assessment Instrument, or IRF-PAI). We expect that CMS will need to adapt or modify these instruments so that data are collected in as consistent a fashion as possible across the post-acute care (PAC) providers. Changes to the assessment instruments will have a major operational impact for all post-acute providers. Providing detailed information as early as possible will allow providers to prepare for and advise CMS on the feasibility of the changes. We provide brief comments below on each measure on the MUC list. (Submitted by: American Hospital Association)
  
  
• CHA applauds CMS for engaging the Measures Application Partnership Post-Acute Care Workgroup and the Coordinating Committee in this process. CHA feels strongly that, while not mandated by the IMPACT Act, CMS use of stakeholder workgroups, including but not limited to the MAP, is critical to gathering input as well as giving providers an early indication of the agency’s current thinking and what they may expect going forward. We recognize that the timeline for implementation is short and that we are on a very accelerated schedule to meet the requirements for data collection and reporting. With that said, CMS articulation of a phased approach to implementation as discussed on the MAP workgroup call is one CHA strongly supports. In reviewing three of the four measures under consideration by the workgroup, CHA supports the MAP’s recommendations summarized in Table 1 below. In general, we agree the measures address the domains set forth in the IMPACT Act. With some revisions as specified by the workgroup — in particular the falls measure for home health — the measures are appropriate for inclusion into each of the respective quality reporting programs. We ask that CMS fully consider and evaluate each of the readmissions measures for appropriate adjustment for socioeconomic status. We believe strongly all of the readmissions measures should be reviewed by the special committee of the NQF to determine whether risk adjustment is needed. In addition, CHA is concerned that CMS has limited time to make revisions to these measures and release measure specifications in a timely way that would ensure accurate data collection by providers. Therefore, we urge CMS to move as quickly as possible in making information publicly available, so that providers can fully evaluate the measure specifications prior to data collection and begin to identify challenges that could be addressed prior to implementation. Further, a number of changes may also be needed in electronic medical records to ease data collection. (Submitted by: California Hospital Association )
  
  
• B. Comments on Proposed Falls Measure E0674, Percent of Residents Experiencing One or More Falls with Major Injury MAP also requested public comments on E0674, “Percent of Resident Experiencing One or More Falls with Major Injury.” As indicated on the ad hoc list measure specification table, this measure is the exact same as NQF measure #0674, “Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay),” which was highlighted by CMS in the FY 2015 IRF PPS rule for future addition to the IRF QRP. While this measure is already NQF endorsed, it does not and should not apply to IRFs without further adjustment because it is exclusively and narrowly focused on “long stay” care episodes in nursing homes.3 Under NQF #0674, a “long stay” is defined as “[a]n episode with cumulative days in facility (CDIF) greater than or equal to 101 days as of the end of the target period.” The average length of stay in an IRF is around 14 days, far short of the 101 day marker that is used in this measure. As such, we suggest that MAP carefully review the details of this measure to ensure they are appropriately tailored to the institutional and episodic characteristics of IRF care and IRF patients. (Submitted by: HealthSouth)
  
  
• Yes, under certain conditions: We agree with MAPs conditional support of this measure and echo the need for proper risk adjustment. Recognizing the difficulty in measuring all falls and the potential that any fall represents a risk to the patient and not only those that happened as a result of a major injury, additional focus on the measurement of all falls and risk of falls versus measurement of a major injury resulting from a major fall is offered for further measure-based consideration. (Submitted by: America's Health Insurance Plans)
  
  
• This measure has been endorsed only for use with the SNF population. It has not been endorsed for any other post-acute care site (HH, LTCH, and IRF), and its reliability and validity within each of these additional post-acute care sites have not been evaluated. Although CMS may be using this measure within the LTCH QRP, a prior MAP committee recommended that this measure undergo further development, stating, “[The] measure should be specified and tested for the LTCH setting.” As noted during the committee discussion, data collection for the home health population will differ from data collection in other settings because home health patients will not be under the care and supervision provided to patients at the other PAC sites. UDSMR appreciated the committee’s recommendation of conditional support, which noted the potential need for additional risk adjustment within the home health population. UDSMR believes that the NQF should recommend conditional support within each of the additional PAC sites. Fall rates should be risk adjusted by setting and analysis of patients by impairment should also be considered. In addition if the reliability and validity of the data within each of the PAC sites are not evaluated, we are concerned that this measure will increase the burden of data collection without positively affecting the quality of care. (Submitted by: Uniform Data Systemn for Medical Rehabiliation)
  
  
• AMGA: Recommend including all falls (not limiting to “falls resulting in major injury”). (Submitted by: AMGA)
  
  
• This measure is currently endorsed by NQF for use only in skilled nursing facilities. Currently in home health agencies there is an adverse event measure that is “emergent care for injury caused by a fall”. As an adverse event measure it is not endorsed by NQF and is not publicly reported. VNAA supports the direction of this measure across all post-acute providers. As with all measures there needs to be reliability and validity testing across all providers. Key to this would be a way to consistently report the data with clear definitions of what constitutes a fall with injury and a way to collect this data that would support consistent reporting in each setting. In home health care there needs to be adequate risk adjustment due to the nature of home care where a large majority of falls are not witnessed and agencies personnel are not present to prevent the fall. Risk adjustment would need to include issues such as support in the home. As all falls are not preventable, it would be important to distinguish between preventable as well as a clear definition of a major injury. (Submitted by: VNAA)
  
  
• 3. NQF 0674) Percent of Residents/Patients/ Persons Experiencing One or More Falls with Major Injury. This measure was designed for use in the SNF setting and relies on MDS data. While AHCA is pleased that a SNF measure is under consideration for use as a cross setting measure to comply with IMPACT act of 2014, does endorsement of this measure mean that the MDS items used to construct this measure will be incorporated into the other PAC assessment tools? Until CMS decides on the standardized assessment to be used across the four settings, proposing to use an existing measure that relies on specifications from one of the PAC assessment tools (i.e., MDS) does not make sense. Also, this measure is not risk adjusted. Falls and injurious falls in particular have been shown to be different based on patient’s characteristics. Also, CMS has shown that the patient acuity that can impact the risk of falls with injury across the PAC settings differs. These differences in acuity would suggest that such a measure must be risk adjusted. This is why the IMPACT Act calls for risk adjustment of outcome measures: “(B) RISK ADJUSTMENT.—Such quality measures shall be risk adjusted, as determined appropriate by the Secretary.” This measure is an outcome measure; however, it is not risk adjusted. (Submitted by: American Health Care Association)
  
  
• The Alliance supports the use of a measure that addresses falls, but has several concerns about the use of this measure. This measure is currently endorsed by NQF for use only in skilled nursing facilities. It is not endorsed by NQF for use in home health agencies, nor is it endorsed for inpatient rehabilitation facilities and long-term care hospitals. Although there is a measure related to falls that is reported to individual home health providers, it is a different measure and it is not endorsed by NQF. It is not publicly reported. Moreover, home health care is community-based, not facility-based care. If there is a fall, those falls are often not witnessed by a home health care professional. The question is whether it is possible for use of this measure to be comparable across post-acute care settings when in home health care there usually is nobody present to witness and document the fall. The Alliance is therefore concerned about the reliability of the data collection for this measure as it applies to home health care. Currently there is no uniform data collection method in home health care for falls. Some organizations use an incident reporting system, while others have nurses/therapists ask about falls on every visit. For this measure to be meaningful across settings we need standardization, or at the very least appropriate adjustment that takes into consideration the very different nature of home health in comparison to the facility-based settings. There also needs to be some recognition and distinction in assessment between/among falls. Our understanding is that MDS assessments distinguish between falls that result in major versus minor injuries. OASIS does not at present make distinctions. It is actually impossible to prevent falls completely. This measure does indicate that this is limited to falls with “major injury,” but any assessment instrument will need to be specific about asking questions that will enable distinctions between major and minor injuries. The definitions of major versus minor injury should be standard across post-acute care setting assessment instruments. Furthermore, there will also be issues with interpretation of the measure and what steps should be taken based on a provider’s performance against the measure. Given the importance of falls as a public health issue, consideration should be given to these questions of interpretation prior to putting any falls measure in place. The Alliance recommends use of this measure only in the context of traditional Medicare. (Submitted by: Alliance for Home Health Quality and Innovation)
  
  
  

• The AHA agrees with the MAP’s recommendation to support E0678. This measure assesses the percentage of patients with new or worsening pressure ulcers between state II and IV. The measure was originally designed for use in nursing homes. It is also used in both the IRF and LTCH quality reporting programs. Therefore, we appreciate that CMS intends to use a measure that is already known to and reported by most of the affected providers. However, we agree with the MAP’s recommendation to carefully assess the suitability of the existing measure specifications for home health agencies. We concur that the topic of pressure ulcers is likely to be important in assessing the quality of home health care, but we are concerned that the measures, as specified, may not be accurately and reliably collectable in the Home Health environment. (Submitted by: American Hospital Association)
  
  
• CHA applauds CMS for engaging the Measures Application Partnership Post-Acute Care Workgroup and the Coordinating Committee in this process. CHA feels strongly that, while not mandated by the IMPACT Act, CMS use of stakeholder workgroups, including but not limited to the MAP, is critical to gathering input as well as giving providers an early indication of the agency’s current thinking and what they may expect going forward. We recognize that the timeline for implementation is short and that we are on a very accelerated schedule to meet the requirements for data collection and reporting. With that said, CMS articulation of a phased approach to implementation as discussed on the MAP workgroup call is one CHA strongly supports. In reviewing three of the four measures under consideration by the workgroup, CHA supports the MAP’s recommendations summarized in Table 1 below. In general, we agree the measures address the domains set forth in the IMPACT Act. With some revisions as specified by the workgroup — in particular the falls measure for home health — the measures are appropriate for inclusion into each of the respective quality reporting programs. We ask that CMS fully consider and evaluate each of the readmissions measures for appropriate adjustment for socioeconomic status. We believe strongly all of the readmissions measures should be reviewed by the special committee of the NQF to determine whether risk adjustment is needed. In addition, CHA is concerned that CMS has limited time to make revisions to these measures and release measure specifications in a timely way that would ensure accurate data collection by providers. Therefore, we urge CMS to move as quickly as possible in making information publicly available, so that providers can fully evaluate the measure specifications prior to data collection and begin to identify challenges that could be addressed prior to implementation. Further, a number of changes may also be needed in electronic medical records to ease data collection. (Submitted by: California Hospital Association )
  
  
• Yes, under certain conditions: We support this measure while suggesting the consideration of additional risk adjustment and exclusions for conditions such as pressure ulcers with slough or eschar and or otherwise unavoidable pressure ulcers as defined by the National Pressure Ulcer Advisory Panel. (Submitted by: America's Health Insurance Plans)
  
  
• Although UDSMR appreciates that data is already being collected for this measure within the SNF, IRF, and LTCH QRPs, the data collection efforts for this measure required the additional collection of roughly thirty new fields that were added to the various PAC assessment tools. This has increased the burden of data collection within PAC sites, creating additional costs for administrative requirements instead of improving patient care and quality. Furthermore, using IRF-PAI discharge data from the UDSMR database from October 2014 to the present, only 1% of IRF Medicare patients would be identified as having a pressure ulcer that was new or had worsened during their IRF stay. The maximum facility-level value did not exceed 5%. We question whether the added burden of collecting this data is necessary when assessing the ability to affect the quality of care on such a small population of patients. (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• The IMPACT Act requires CMS for FY 2017 (October 1, 2016) to collect specific quality information in each of three settings. Those settings are Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs) and Long Term Acute Care Hospitals (LTCHs). Home Health providers do not need to begin reporting data for IMPACT purposes until Oct. 1, 2017 (FY 2018). For purposes of IMPACT for FY 2017, LTCHs and SNFs must report on skin integrity; and LTCHs, IRFS and SNFs must all report on functional status, major falls with injuries, resource use and transfer of health information and preferences. Because working out the details of how data will be collected in comparable ways across all four settings is complicated, the FAH recommends that MAP consider recommending only one measure in each category until it is clear how the measures will work and how data will be collected and compared across settings. (Submitted by: Federation of American Hospitals)
  
  
• While CMS is currently using this measure to collect data from home health agencies, it is not currently publicly reported. A critical issue is whether the data is reliable and accurate. There are significant issues regarding the accurate documentation of the etiology &/staging of ulcers. As mentioned in prior comments, VNAA has concerns about this measure for several reasons: In home health, caring for patients with pressures ulcers is different than institutional settings. First patients are not seen 24 hours a day as they are in other post-acute institutional settings but usually several times a week depending on the level of care needed. Important factors in preventing the decline in or presence of a wound would be the availability of a willing and able caregiver. Partnerships with caregivers is a critical aspect to care of the patient in the home but this is most important with patients who are bedbound or patients with limited mobility who have pressure ulcers. These partnerships are a key factor in the ability to care for these patients in a home care setting. Preventing decline is most successful when patients receive optimum nutrition. This factor cannot be as easily controlled in home care settings as it is in SNF, ITCH and IRB settings. Additionally, referring physicians do not always identify the underlying etiology of the wound resulting in treatment that is not appropriate. Also staging of the wound may not be correct at admission so patients may have wounds that are at a higher stage at discharge, not because they worsen but because they were not correctly identified as the appropriate stage at admission. Referring physicians are not always knowledgeable about the correct diagnosis and staging of chronic wounds. Adequate risk-adjustment for wound care is important and should include factors that take into account the availability and willingness of a caregiver, patient current mobility and socio-economic status are critical. Patient comorbidities especially the presence of Diabetes are critical factors in whether patient’s wound deteriorates and need to part of a risk adjustment formula as well. These factors affect the ability for home health to prevent decline or presence of a new wound. There are certain patients who may be deconditioned or pre-hospice who may be at risk for developing wounds or having a wound that deteriorated. We also want to assure that patients who are transferred to a Hospice are included in the exclusion criteria. (Submitted by: VNAA)
  
  
• 1. (NQF 0768) Percent of Residents/Patients/ Persons with Pressure Ulcers That Are New or Worsened. This measure is a SNF specific measure that relies on MDS items. While AHCA is pleased that a SNF measure is under consideration for use as a cross setting measure to comply with IMPACT Act of 2014, does the inclusion of this measure as a cross setting measure indicate that the MDS pressure ulcer assessment will be incorporated into the OASIS and IRF PIA? Without knowing the assessment tool to be used, it is nearly impossible to comment on the adequacy of this proposed measure as a cross setting measure to comply with the IMPACT Act of 2014. Until CMS decides on the standardized assessment to be used across the four PAC settings, proposing to use an existing measure that relies on specifications from one of the PAC assessment tools (i.e., MDS) but not the others does not make sense. It is also not clear why CMS is abandoning the CARE tool that contains a pressure ulcer assessment component that took years to develop and was shown to be a reliable and valid cross setting assessment tool. This proposed measure also does not include any risk adjustment other than to exclude individuals who die. A pressure ulcer measure must be risk adjusted, particularly if used across settings that have been shown by CMS to take care of different acuity patients. This is why the IMPACT Act calls for risk adjustment of outcome measures: “(B) RISK ADJUSTMENT.—Such quality measures shall be risk adjusted, as determined appropriate by the Secretary.” This measure is an outcome measure yet is not risk adjusted. (Submitted by: American Health Care Association )
  
  
• While CMS is currently using this measure to collect data from home health agencies, it is not currently publicly reported. A critical issue is whether the data is reliable and accurate. There may be significant issues regarding the accurate documentation/staging of ulcers.  While the Wound, Ostomy and Continence Nursing Society (WOCN) criteria are useful for documentation and staging in home health care, it is unclear whether the same criteria are used by the other post-acute care settings. It is important to note also that there is variability in application of the WOCN criteria. The way the WOCN criteria are applied is very dependent on the training of the home health professional. In addition, as the Alliance commented to the NQF when the measure originally went through the endorsement process, there are certain patients with conditions that simply make improvement with wounds impossible. For example, patients with immune system deficiencies and patients who may be pre-hospice are very unlikely to see improvements related to pressure ulcers. It is therefore impossible for this number to be zero. The Alliance recommends recognition of this issue in the context of this measure. In addition, it is important to note that this measure does not reflect steps that might be taken to improve how wounds are addressed in transitions of care. We recognize that this measure is not meant to address this issue, but developing measures to support would care in the context of care transitions may also be worthwhile. The Alliance recommends use of this measure only in the context of traditional Medicare. (Submitted by: Alliance for Home Health Quality and Innovation)
  
  

• The proposed measure assesses the percentage of patients who have functional status assessments completed at both admission and discharge and who have a care plan that addresses function. In general, functional status measures assess the extent to which patients regain the ability to perform activities (or “functions”) essential to daily living. The measure would be collected using a modified version of the Continuity Assessment Record and Evaluation (CARE) data set. At the times of admission and discharge, trained clinicians would be required to numerically score the level of independence that patients demonstrate on several assessment items, including self-care, mobility, cognition, communication and bladder continence. Additionally, clinicians would be required to record a numerical functional goal score at admission for at least one of the assessment items. The measure was initially developed as part of the Post-Acute Care Payment Reform Demonstration (PAC-PRD) project, and CMS continued to fund the development of the measure after the conclusion of the project. While we agree that functional status is an important measurement topic for post-acute care providers, the AHA does not agree with the MAP’s recommendation to conditionally support S2601. There are many questions about whether this measure is feasible to implement and suitable for public reporting programs. Most importantly, as discussed by the committee, we are very concerned that this measure is not aligned with CMS-mandated functional status assessments used for payment purposes. Specifically, CMS requires that IRFs complete the functional status assessment in the IRF-PAI instrument to receive payment under the IRF prospective payment system (IRF PPS). Asking providers to collect functional status information in two different ways will introduce not only confusion among IRFs reporting measure data, but also an unintended misalignment between IRF quality improvement efforts and reimbursement. As currently designed, the CARE tool and IRF-PAI use different “rating scales” to assess patient function. That is, the CARE tool rates patient function using six levels, while the IRF-PAI uses seven levels. The IRF staff collecting assessment information may inadvertently conflate the two scales, leading to the reporting of inaccurate data into both assessment instruments. Moreover, available evidence suggests there is ample room to improve the reliability of this measure. The AHA raised these concerns to CMS when commenting on its 2014 proposal to add this measure to the FY 2018 LTCH quality reporting program, and we are disappointed that the agency appears to be committed to a measure with such known and substantial reliability issues. Evidence from the August 2012 final report on the development of the CARE tool indicates there is significant room to improve the reliability of the measures when used in LTCHs. One gauge of reliability is “inter-rater reliability,” which assesses whether two people collecting the same measure obtain the same measure results. This test of reliability is especially appropriate for the functional status measures because it relies on data collection by multiple clinicians. The level of agreement between the raters can be quantified using a Kappa statistic that a result between 0 and 1; the higher the Kappa statistic, the better the agreement between raters. The 2012 CARE tool final report indicates that “LTCHs appear to have slightly lower rates of items than other settings.” Additionally, several specific self-care and mobility items have Kappa statistics that categorize inter-rater reliability as only fair (Kappas of between 0.21 and 0.40) or moderate (0.41 to 0.60). These items include eating (0.446), oral hygiene (0.331), toilet hygiene (0.339), lower body dressing (0.447), sit to stand (0.551), and chair/bed to chair transfers (0.556). We also note that these testing results are based on an ineffective sample size of only 46 LTCH patient records. These levels of reliability are insufficient for a national quality reporting program. Fair or moderate reliability may be acceptable for exploratory studies or internal improvement efforts. However, CMS would implement these measures on a national scale across most post-acute care providers. In addition, the collection and reporting of these measures would require substantial resources. In order for such an investment of resources to return value to providers seeking to benchmark their quality improvement efforts, and to consumers seeking to understand the quality of care in LTCHs, it is essential that the measure yield accurate results. The available evidence suggests these measures, as currently constructed, fall well short of that standard. Instead of conditionally supporting the implementation of a functional status measure with known flaws, the MAP could instead recommend that CMS use a more gradual approach to measuring functional status. The statute does not require that CMS assess all of the functional status areas assessed by this measure. Thus, the agency could focus on attempting to standardize the collection of data on one or two functional areas before expanding to a more comprehensive set of topics. This would allow CMS time to ensure reliable data collection, and would result in less burden and disruption to providers. REFERENCES 1.See RTI International, The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report. August 2012. All three volumes of the report are available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE.html. 2.See RTI International, The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on Reliability Testing, Volume 2 of 3. August 2012. Referenced numbers are on the table on pp. 45-46. (Submitted by: American Hospital Association)
  
  
• CHA does not support the MAP’s recommendation for conditional support for percent of patients/residents/persons with an admission and discharge functional assessment and a care plan that addresses function. We believe this measure needs further development and testing prior to receiving the MAP conditional support recommendation. Moreover, CHA urges CMS to first develop and share with stakeholders the common patient assessment tool elements being considered and required under the IMPACT Act before proceeding with this measure. We wish to support many of the MAP workgroup member comments concerned with completing data collection for this measure at a time when the common patient assessment elements have not yet been finalized, which we anticipate would require an alternative data collection method to meet the measure’s requirements. CHA shares the workgroup’s concerns that having two sets of data collection on function — one for quality and one for payment purposes — will likely call into question the validity and reliability of both data sets. CHA urges CMS to perform additional testing of providers in collecting both sets of data elements to understand the potential challenges in ensuring reliable and meaningful data collection. Taking a phased approach, first testing data collection in the patient assessment tool and then moving to using that data for the measure under consideration, is an approach CHA would support. We ask CMS to fully consider and evaluate the administrative burden this measure would cause and to delay it until a later date. Our comments are informed by the experience of several of our member facilities that served as pilot sites for the PAC-PRD. The need to complete and manage dual, but different data presents significant operational challenges and ultimately undermines the accuracy of data collection. Clinicians will need to be familiar with and apply different rules, definitions and metrics, when completing patient assessment, depending on whether they are compleitng existing data sets for planning and payment purposes, or the newly implemented quality measures. Providers will be required to spend significant time and resources in providing training and oversight to ensure that each data set is completed accurately. Record keeping and reporting will also be complicated as electronic medical records will be challenged to accomodate dual processes for recording similar clinical information. Implementation of parallel and differing quality measures with existing patient assessment tools will result in greater cost to providers, and a decrease in the quality and accuarcy of the data collected. We believe this weill lead into inaccurate data leading to misleading information regarding the quality of care provided. (Submitted by: California Hospital Association )
  
  
• A. Comments on Proposed Measure S2637, Percent of Patients/Residents with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function 1. FIM® Scores Should Satisfy the S2637Meausure for IRFs We generally agree that comparing post-acute providers on their ability to generate improvement in patient functionality between admission and discharge is a useful method of measuring the comparative effectiveness of different types of post-acute care. Data from the “FIM”® tool, which is already used by all IRFs, satisfies the technical requirements of proposed measure S2637 and thus should meet the requirements of the measure. FIM® is a data collection instrument developed by the Uniform Data System for Medical Rehabilitation (“UDSMR”) and has been in use by all IRFs for over two decades. A FIM® score measures a patient’s functional status upon admission, and again at discharge, thereby allowing an objective calculation of the functional improvement made by the patient during his/her IRF stay. Since the proposed ad hoc measure S2637 seeks to measure this same information, FIM® data would meet the technical specifications of the proposed ad hoc measure. Additionally, FIM® data are already reported to CMS and are utilized for payment purposes in categorizing patients into specific case mix groups (“CMGs”) under the IRF PPS. With FIM® already in place as a widely accepted and validated mechanism to collect data on patients’ functional capabilities at admission and discharge, there is no need for a different or additional data collection mechanism(s). The FIM® tool is also available to CMS free of charge and has been offered to NQF for perpetual use, royalty free. Many IRFs have built the FIM® tool directly into their record and payment systems and maintain a significant amount of historical data which directly affect rehabilitation programs and patient care. UDSMR describes the legitimacy of the FIM® Instrument further: “[t]he construct validity of the FIM® Instrument has been tested with Rasch models, which have shown that the FIM® Instrument measures two unidimensional domains of motor and cognitive function. Perhaps the most important test of the validity of a measure is the extent to which it predicts outcomes in medical rehabilitation. This form of validity is often referred to as predictive validity, and it represents how well a scale predicts criterion scores. A wide variety of studies have shown the FIM® Instrument to be predictive of a patient’s need for assistance.”2 Because FIM® already meets all the technical specifications of S2637 and because it is already reported, we respectfully urge that: 1) MAP adopts FIM® as the IRF standard for proposed ad hoc measure S2637; 2) MAP not recommend that IRFs implement a different patient functional assessment instrument in lieu of FIM®; and, 3) MAP not recommend that IRFs implement an additional functional assessment alongside FIM®, such as the CARE Tool. Requiring clinicians to report additional functional measures alongside FIM® would create two seemingly similar yet fundamentally different rating scales for measuring patients’ function. This would cause confusion among IRF caregivers and clinicians and would require significant clinician education and training that could easily require years to fully complete. For example, the CARE Tool item set has only six levels of function, one level less than the existing FIM® functional measure. This one-level difference makes the proposed CARE functional measure less differentiated and therefore less capable of measuring and expressing a patient’s precise functional status. Having two patient measures of function for each patient would be overly confusing and burdensome, and could easily send conflicting information and signals to patients who are trying to understand how to meet specific functional goals. Experts in both FIM® and CARE would acknowledge that there is no formula for converting one score to an equivalent score on the other scale, so keeping dual measurements would be tremendously burdensome. In addition, trying to manage dual systems would be fraught with human error as caregivers would either try to master two detailed and rigorous scoring systems or resort to inherently inaccurate work-around techniques in an effort to fulfill competing requirements. Accordingly, we recommend utilizing the FIM® data that IRFs already report to CMS in order to fulfill the requirements of measure S2637. (Submitted by: HealthSouth)
  
  
• NASL is an organization representing providers and suppliers of ancillary services in the long term and post-acute care setting including rehabilitation therapy providers and information technology developers. NASL recommends use of the CARE item set for Functional Mobility and for Self Care since these items were standardized across settings which specifically meets the requirements of the IMPACT Act. We wish to point out that there are varying items and timeframes for each assessment tool used in the post-acute settings referred to in the IMPACT Act. The MDS data, in addition to using the ‘rule of 3’s, is gathered across 7 calendar days, the IRF-PAI is gathered across 3 calendar days, and the OASIS is used on the very first visit, taking approximately 2 hours. All of these are established processes for use in post-acute care. NASL requests any quality measure application utilize established tools and in these tools the same standardized item set be embedded. NASL believes that the following conditions must be met in order for this process measure to be fully feasible and supportable throughout the 4 settings of post-acute care: 1. It is essential to assure clinically appropriate care to all Medicare beneficiaries throughout post-acute care. Professional best practice requires the most appropriate assessment to meet the patient needs. To determine the functional needs and the clinical justification for care, a standard item set should be used in all post-acute care venues. The item set would then allow for the assessment to be clinically appropriate to that patient. 2. NASL also believes that provider burden should not be increased by the use of a standardized set of assessment items. By integrating the same item set in each of the established post-acute care assessments, timely and complete assessment information would be feasible. 3. Currently, providers must report functional limitation for their Part B patients using the G Code submission process. This statutorily mandated reporting utilizes assessments that do not consist of a standardized item set. Any use of this data for quality monitoring, payment model changes or other is extremely challenged when the data cannot be used due to varying scales and inconsistent assessment items. For example, G codes are reported for Mobility (defined as G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals). Therapists collect this information. However, a therapist can use any assessment tool and then convert this tool to the ‘modifier’ scale to report a score for this item. Because a multitude of assessment tools can be utilized, we are unable to use the data to compare from one post-acute care setting to another. Therefore, we do not support the current G-code process for use in meeting this quality measure under consideration. 4. We question how the numerator is calculated in the formula for risk adjustment. It is not clear whether the 3 factors in the numerator are given equal weight. Also, if one or more of the three factors is not reported or cannot be reported beyond the control of the provider, it is unknown how will the measure be adjusted or risk adjusted. NQF is currently reviewing two risk adjusted functional status measures: change in self-care (NQF #2613) and change in mobility (NQF #2612) that are based on CMS’s CARE item set. NASL and the American Health Care Association (AHCA) jointly sponsored the development of these measures and each has actively supported the IMPACT Act. Our two organizations have actively participated in the development of the CARE item set and support its use and adoption by our respective members as a means for standardized assessment of our patients. As a result of these efforts, NASL member software companies that support therapy services in SNFs are incorporating these measures into their software. We believe these two risk adjusted outcome measures under consideration by NQF would be the preferred measures for the MAP to consider rather than the proposed process measure. We believe that these two measures must be considered as they were developed to meet the intent and purpose of the IMPACT Act of 2014. However, neither of these measures is included in this list for discussion and review. (Submitted by: National Association for the Support of Long Term Care)
  
  
• The proposed measure is currently being reviewed by the Person- and Family-Centered Care Standing Committee for LTCHs and has not been endorsed at this time. Considerations for this measure have been subject to numerous procedural changes within NQF, allowing for reconsideration and revoting. UDSMR shares the committee’s concerns about including “plan of care” data elements when only a discharge goal for one data element is mentioned, not an actual care plan. They, too, are concerned about the availability of evidence that a plan of care is related to outcomes. What is being measured—the quality of the physician’s documentation skills or selection of a goal, or the quality of the care provided? The proposed measure would require HH providers, IRFs, and SNFs to collect an additional twenty-two data elements and would place an extreme burden on care providers. Furthermore, the proposed quality data elements of self-care and mobility are measured on a rating scale of 1 to 6, whereas the similar (but not interchangeable) items currently collected by IRFs for the IRF-PAI for payment use a scale of 1 to 7. The resulting confusion will likely compromise the integrity of both quality and payment data sets. UDSMR appreciates that conditional support has been recommended for this measure pending “resolution of concerns about the use of two different functional status scales for quality reporting and payment purposes.” As if the variation in rating scales were not enough, this measure (2631) is being considered for use in the Medicare quality program even though its inclusion criteria covers all LTCH patients, including patients of all ages and all payer sources. Furthermore, the Person and Family Centered Care Committee is currently reviewing for the IRF population self-care and mobility items (measures 2633, 2634, 2635, and 2636) that feature a great deal of overlap yet are not collected in a consistent fashion. The inclusion criteria for these elements cover only Medicare patients who are twenty-one years old or older. UDSMR recommends that CMS revise this measure to allow each PAC site to utilize the functional status tools that are already in place without increasing the data collection burden, thereby eliminating any potential effects on payment or quality. CMS can then meet the requirements of this proposed process measure—assessing the patient’s functional status at admission and discharge and providing a completed “care plan” that addresses function—while at the same time being parsimonious in its implementation. (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• UDSMR is concerned that the notice to the MAP Post-Acute Care/Long-Term Care Workgroup and materials for this meeting were provided only two business days prior to the scheduled PAC/LTAC Workgroup discussion. We question whether each of the voting workgroup members had sufficient time to review all the materials and the details for each measure that was considered. Without adequate review of these materials, we are concerned that the consideration and voting process for each of these measures is not meeting the standards required by NQF for endorsed quality measures. In addition, several of the proposed measures are being considered for multiple sites of care, and it was noted that certain measures were supported by the MAP committees at varying levels of support within each site. On slide 20 and 25, measures that were listed as “support direction,” indicating that they received support for their intent but required additional development in order to receive full support and/or NQF endorsement. We recommend that measures be fully endorsed before being implemented into the PAC QRP. (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• AMGA - Also recommends one scale. We also recommend that functional assessments be performed when patient’s transfer to another setting (i.e., from LTACH to SNF). This is especially true for when a patient converts from skilled to long term care. Often if the patient stays in the same facility, this is not performed as technically it is not a discharge (Submitted by: AMGA)
  
  
• ARN supports these indicators with the caveat that they are risk-adjusted and diagnosis/impairment group specific with definitive inclusion/exclusion criteria. (Submitted by: Association of Rehabilitation Nurses)
  
  
• AMRPA agrees with the conditional support of this measure. While we acknowledge improving the function of the patients we treat is central to the mission of inpatient rehabilitation hospitals and units (IRH/Us), this measure is not ready for implementation at this time. This measure has been under consideration for use in CMS quality reporting programs by both the Measure Applications Partnership and the Person and Family-Centered Care workgroups convened by NQF. Participants in these workgroups have raised numerous concerns about the measure including that it would require the use of two different assessment tools on the part of providers. Specifically, IRH/Us use the Inpatient Rehabilitation Facility Patient Assessment Instrument for payment purposes which includes items that assess function. This measure, which would be used for quality reporting purposes, is part of the CARE Tool. To require providers to complete two functional assessment items is burdensome and could lead to confusion within the provider community. The measures are quite similar and depending on the measures selected may measure duplicate tasks, this could lead to decreased reliability of both functional tools. If the CARE Tool, in whole or in part, were to be implemented at a later date it would require extensive training for providers. In addition, it is not clear how one would determine if the functional score is associated with a care plan. Would chart audits take place? The measure needs to include a mechanism to ensure the functional score is in fact tied to the care plan. As a result, we have serious concerns about moving forward with this measure without these issues being resolved. (Submitted by: American Medical Rehabilitation Providers Association)
  
  
• The Alliance supports a cross-setting measure on functional status. This measure, however, has not yet gone through the endorsement process. Further, CMS is only seeking endorsement for use of this measure in long-term care hospitals (LTCH). Endorsement is not being pursued for home health care, skilled nursing facilities or inpatient rehabilitation facilities. We are concerned that this measure has never been considered as a measure for other care settings. Given that one of the goals of the IMPACT Act is to achieve harmonization across settings particularly for functional status, true testing and validation for a measure along these lines in each of the formal post-acute care settings is key. Moreover, as proposed, this measure entails collecting data on functional assessment and links to a care plan goal, but there is no data available to date on if, how or whether this is feasible and how reliable the data would be. Although common sense suggests that functional assessment is related to outcomes, there is no data on whether this particular measure is actually related to the quality of care (because there is no data that links this measure to outcomes). There is therefore no data on whether this particular measure can meaningfully identify differences among LTCH providers, nor is there data to suggest differences among different types of post-acute care providers. We understand that members of the NQF Person and Family Centered Care Committee raised very serious and significant issues and concerns about this measure. The Alliance strongly recommends that these issues be addressed and that further testing and validation be performed for all of the post-acute care settings before CMS pursues use of this measure further. Moreover, for any measure created related to function, a standardized functional assessment with the same elements needs to be used in all of the post-acute care settings. CMS should look to advancements in measurement of function that can demonstrate change in functional status and preferably avoid self-reporting. It is also not clear in this measure what steps would be considered acceptable to ensure that the care plan addresses functional needs. This measure has not yet been tested in any setting (neither LTCH, nor any other post-acute care setting) and it is premature for use as a cross-cutting measure for purposes of IMPACT Act implementation. The Alliance recommends that CMS pilot using the measure among all four settings and bring forward data on usability/feasibility, reliability, and impact on outcomes. This testing should be done and data should be presented before completing the NQF endorsement process. The Alliance would recommend use of this measure only in the context of traditional Medicare. (Submitted by: Alliance for Home Health Quality and Innovation)
  
  
• 2. (Under NQF review) Percent of Patients/Residents/ Persons with an admission and discharge functional assessment and a care plan that addresses function. AHCA disagrees with the inclusion of this measure. It is a process measure. The IMPACT Act of 2014 emphasizes outcomes and specifically states “functional status” as the measure for this domain. This measure does not assess functional status. We are also not aware of any evidence other than expert opinion that shows this process measure linked with improved outcomes. NQF is currently reviewing two risk adjusted outcome measures that would be better measures for the MAP to consider than the proposed process measure. Both are based on the CARE tool: change in mobility (NQF #2612) and change in self-care (NQF #2613) The measure (NQF #2612) calculates a skilled nursing facility’s (SNFs) average change in mobility between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the mobility subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment. The measure is calculated on a rolling 12 month, average updated quarterly. The measure (NQF #2613) calculates a skilled nursing facility’s (SNFs) average change in self-care score between admission and discharge for all residents admitted to a SNF from a hospital or another post-acute care setting for therapy (i.e., PT or OT) regardless of payor status. This is a risk adjusted outcome measure, based on the self-care subscale of the Continuity Assessment and Record Evaluation (CARE) Tool and information from the admission MDS 3.0 assessment. The measure is calculated on a rolling 12 month, average updated quarterly. American Health Care Association (AHCA) and National Association of the Support of Long Term Care (NASL) who jointly sponsored the development of these measures have actively supported the IMPACT Act. They also participated in the development of the CARE Tool and support its use and adoption by their respective members as a means for standardized assessment of our patients. As a result of these efforts, software companies that support therapy services in SNFs have already incorporated the CARE Tool into their software and are working to incorporate this quality measure into their software. This has resulted in 48 organizations representing 1,016 SNFs adopting the use of the CARE tool. To date, they have completed CARE Tool assessments on over 48,971 of patients. Also, the IMPACT Act “shall require PAC providers to submit to the Secretary, under the applicable reporting provisions and through the use of PAC assessment instruments, the standardized patient assessment data.” The ACT goes onto say “the Secretary shall require such reporting by a PAC provider of quality measures under paragraph (1) through the use of a PAC assessment instrument and shall modify such PAC assessment instrument as necessary to enable the use of such instrument with respect to such quality measures.” Does this mean that the data in this proposed measure will be added to all of the current PAC provider assessment instruments (MDS, IRF-PIA or OASIS)? Does approval of this measure equate to the new assessment instrument for use in PAC settings? Is this information necessary and helpful to patient care and improved outcomes? It is not clear why CMS is abandoning the CARE tool that took years to develop and was shown to be a reliable and valid cross setting assessment tool. AHCA recommends that the MAP consider outcome measures that rely on the CARE tool components for self-care and mobility not process measures that lack validity. (Submitted by: American Health Care Association )
  
  

• CHA applauds CMS for engaging the Measures Application Partnership Post-Acute Care Workgroup and the Coordinating Committee in this process. CHA feels strongly that, while not mandated by the IMPACT Act, CMS use of stakeholder workgroups, including but not limited to the MAP, is critical to gathering input as well as giving providers an early indication of the agency’s current thinking and what they may expect going forward. We recognize that the timeline for implementation is short and that we are on a very accelerated schedule to meet the requirements for data collection and reporting. With that said, CMS articulation of a phased approach to implementation as discussed on the MAP workgroup call is one CHA strongly supports. In reviewing three of the four measures under consideration by the workgroup, CHA supports the MAP’s recommendations summarized in Table 1 below. In general, we agree the measures address the domains set forth in the IMPACT Act. With some revisions as specified by the workgroup — in particular the falls measure for home health — the measures are appropriate for inclusion into each of the respective quality reporting programs. We ask that CMS fully consider and evaluate each of the readmissions measures for appropriate adjustment for socioeconomic status. We believe strongly all of the readmissions measures should be reviewed by the special committee of the NQF to determine whether risk adjustment is needed. In addition, CHA is concerned that CMS has limited time to make revisions to these measures and release measure specifications in a timely way that would ensure accurate data collection by providers. Therefore, we urge CMS to move as quickly as possible in making information publicly available, so that providers can fully evaluate the measure specifications prior to data collection and begin to identify challenges that could be addressed prior to implementation. Further, a number of changes may also be needed in electronic medical records to ease data collection. (Submitted by: California Hospital Association )
  
  
• Yes, under certain conditions: We support this measure and suggest consideration of alignment with hospital readmission measures. (Submitted by: America's Health Insurance Plans)
  
  
• We support this measure and suggest consideration of alignment with hospital readmission measures. (Submitted by: America's Health Insurance Plans)
  
  
• Various readmission measures have received various levels of support and/or endorsement from NQF, but UDSMR is concerned that each of these measures has its own set of criteria and does not represent a standardized measure between the various PAC sites. Each PAC site has a different time frame for data collection, and the risk-adjustment methodologies were created in a site-specific manner. We do not believe that this criteria meets the requirements of the IMPACT Act, where collection and reporting of measures is “standardized.” We also support AHA’s comments, made during the public comment portion of the meeting, which noted the need to consider risk-adjustment methodologies for various sociodemographic factors that are beyond the control of the providers and their ability to improve quality. There continues to be significant concerns within the PAC industry related to readmissions and how they are measured, and we are concerned that implementing these measures without considering sociodemographic factors could lead to issues with access to care. (Submitted by: Uniform Data System for Medical Rehabilitation)
  
  
• APTA supports the concept of this measure. APTA would encourage CMS to examine the potential to better align these measures across the post-acute care settings. Additionally, APTA is concerned that the risk adjustment methodologies for these measures do not account for variables, such as sociodemographic factors or function, that may impact the patient’s ability to remain independent following discharge from the post-acute care settings. APTA supports the continued work towards harmonized comprehensive readmissions measures that include appropriate risk adjustment methodologies. (Submitted by: American Physical Therapy Association (APTA))
  
  
• VNAA supports the use of this measure in home health care, but recommends adequate risk adjustment for socio-economic and demographic status. Socio-economic status is an important factor in rehospitalization that should be adjusted for to protect patients with low socio-economic status and to encourage appropriate care by the providers who serve them. For this measure it would be important that each of the post-acute providers have the same time frames for their 30-day readmission. For example home health care readmission data collection will capture patients who were admitted to home care within 5 days from hospital discharge. (Submitted by: VNAA)
  
  
• NAHC supports use of this measure, but continues to believe that risk adjustment for socio-economic status is needed for this and other measures of rehospitalization. There are numerous factors associated with rehospitalization. Socio-economic status is an important factor in rehospitalization that should be adjusted for to protect patients with low socio-economic status and to encourage appropriate care by the providers who serve them. NAHC requests that the measures be restricted to Medicare Fee for Service patients to align the data collection requirements with the other PAC providers. (Submitted by: National Association for Home Care & Hospice )
  
  
• National Quality Forum, Post-Acute Care MAP List of Ad Hoc Measures under Consideration for the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 The American Occupational Therapy Association (AOTA) is the national professional association representing the interests of more than 185,000 occupational therapists, students of occupational therapy, and occupational therapy assistants. The practice of occupational therapy is science-driven, evidence-based, and enables people of all ages to live life to its fullest by promoting health and minimizing the functional effects of illness, injury, and disability. Many occupational therapy practitioners work in all of the post-acute and acute care settings in which Medicare services are provided including home health, skilled nursing facilities (SNF), long term acute care hospitals, inpatient rehabilitation facilities (IRF) and acute hospitals, all of which will be affected by the IMPACT law. AOTA appreciates the opportunity to comment on the MAP measures listed in The “List of Ad Hoc Measures under Consideration for the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014”. As a preliminary matter, AOTA is concerned to read that each of these four measures are intended to apply across all four post-acute care settings because each of the measures were developed with only one setting in mind, with considerations for the severity and patient characteristics in that setting. It is not clear in the “List of Ad Hoc Measures” that CMS will be required to risk-adjust each of these four measures for each of the setting in which the measure will be applied. For example, the pressure ulcer measure, NQF#0768, was designed for use in the SNF setting based on MDS data, not to use across settings. AOTA is concerned with the CMS proposal to also apply this measure in home health, inpatient rehabilitation settings, and long term care hospital settings. AOTA urges NQF to require risk adjustment for all measures prior to using these measures in post-acute care settings. (Submitted by: American Occupational Therapy Association)
  
  
• The Alliance supports use of this measure, but continues to believe that risk adjustment for socio-economic status is needed for this and other measures of rehospitalization. There are numerous factors associated with rehospitalization. Socio-economic status is an important factor in rehospitalization that should be adjusted for to protect patients with low socio-economic status and to encourage appropriate care by the providers who serve them. In addition, Alliance members are finding that there is a correlation between rehospitalization rates and mental and behavioral health conditions. To the extent possible, risk adjustment for these conditions should be considered. The Alliance recommends use of this measure only in the context of traditional Medicare. (Submitted by: Alliance for Home Health Quality and Innovation)
  
  
• AHCA has concerns with the use of this measure for several reasons. First, one of the primary purposes of the IMPACT Act is to provide information to consumers for choice. This measure (NQF 2510) only captures readmission rates for Medicare fee for service (FFS) beneficiaries. For over three-quarters (approximately 9,800 of the 15,000+) skilled nursing facilities in the country, Medicare FFS admissions comprise less than or equal to 70 percent of their total admissions (see Table 1 below). Nearly 50% of SNFs have less than or equal to 50 percent of their admissions as Medicare FFS (see Table 1). In general, when data is not available on 30 to 50% or more of a population; the measures may not be representative. So a FFS Medicare only measure (which NQF #2510 is) will have missing data for all non-Medicare FFS admissions. Thus, measure #2510 can provide misleading information to the public when evaluating the readmission rate for a SNF. Second, this measure captures readmissions that occur both during and after SNF discharge. The IMPACT Act is designed to address readmissions during the PAC stay not combine readmissions occurring across different settings. Again, the purpose of the IMPACT Act is to provide cross setting measures to compare across settings and to provide information to the public for choice. A measure that captures readmission measures after discharge from a PAC setting, may be a good population based measure but aggregates outcomes across settings and attributes them to one PAC setting. This measure is not consistent with the intent of IMPACT Act. Third, this measure does not capture hospital admissions classified as observation status since it utilizes only Medicare Part A claims and observation status are billed under Part B. Observation status admissions contribute both to the morbidity of patients and consumer costs and should be included in all PAC readmission measures. Fourth, this measure uses a predicted actual for the numerator which adjusts the actual readmission rate based on bed size. This has the effect of muting differences in rates for smaller SNFs. It also makes interpreting this measure much more difficult by providers, public and payors. We recommend using the actual readmission rate in the risk adjusted formula, not a predicated actual figure. Fifth, this measure can only risk adjust for diagnoses and demographic characteristics available on claims. However, diagnoses alone do not capture illness severity. Additional clinical characteristics such as functional status and clinical symptoms are strong predictors of hospital readmissions and should be included in readmission measures. This information can be found on PAC assessment tools but not on claims. We recommend that MAP look at NQF endorsed measure #2375 (PointRight ® Pro 30™) before taking a position on measure #2510. NQF measure #2375 is a MDS based measure that captures all patients regardless of payor type and also observation admissions. Additionally, it risk adjusts for functional and clinical symptoms as well as demographics and diagnoses. Measure #2357 can be reconciled with claims as an indicated requirement in the IMPACT Act. An article published by researchers at Brown University compared MDS data with Medicare Part A claims data showing that MDS information is reliable and valid compared to claims (see JAMDA Rahman et al Sensitivity and Specificity of the Minimum Data Set 3.0 Discharge Data Relative to Medicare Claims. JAMDA 2014 Volume 15 (11) 775-852). Table 1. The number of SNFs by the % of admissions that are Medicare FFS % of Admissions # of Facilities % of Facilities that are Medicare Exactly 0% 24 0% =10% 152 1% =20% 636 5% =30% 1,717 15% =40% 3,548 30% =50% 5,831 50% =60% 8,058 69% =70% 9,843 84% =80% 10,991 94% =90% 11,536 98% =100% 11,726 100% (Submitted by: American Health Care Association )
  
  

• C. Risk Adjustment and Case Mix Adjustment Should Account for Regulatory Differences between Post-Acute Providers The IMPACT Act requires that each of its quality and resource use measures be risk adjusted “as determined appropriate by the Secretary [of the Department of Health and Human Services].”4 The statutory text illustrates the Act’s authors’ awareness of how important risk adjustment is when comparing provider types on a cross-spectrum basis. Specifically, adjusting for both the patient mix and case mix profiles of different post-acute provider types helps to account for the significant variance in the types of patients and conditions in the post-acute spectrum. For example, every IRF patient is required by regulation to have a need for and be expected to benefit from at least 3 hours of intensive rehabilitation therapy per day.5 IRFs must also derive at least 60% of their case mix from a list of specific conditions and diagnoses derived from a list of 13 medical categories (known as the “60% Rule).6 These IRF-specific requirements do not apply to other post-acute providers, but restrict the numbers and types of patients IRFs can treat, thereby establishing unique patient and case mix profiles for IRF providers. These regulatory effects should be accounted for when developing IMPACT Act measures that are to be applied equally across all post-acute providers. This cross-spectrum dynamic demonstrates the need for MAP and CMS to establish resource use and quality measures that are well-calibrated to the particular patient mix and case mix profiles of each type of post-acute provider, and that account not only for traditional risk-adjustment parameters, such as geographical location or case mix, but also for the existing regulatory environments that govern each type of post-acute provider. Without such consideration, measures could unfairly favor one type of post-acute provider over another. We therefore respectfully recommend that MAP and CMS consider how differing regulatory requirements create different patient mix and case mix profiles for different types of post-acute providers. D. Conclusion We appreciate the opportunity to highlight these important dynamics surrounding the proposed IMPACT Act measures regarding functional assessment and major falls. Given the unique regulations governing IRFs, we believe our recommendations and suggestions as contained in the comments above reflect well-reasoned observations on how the proposed ad hoc measures should be tailored in order to achieve the IMPACT Act’s goal of producing true apples-to-apples comparative data across the spectrum of post-acute providers. Thank you for your time and attention to our comments on these measures. Should you wish to discuss the issues or suggestions raised herein in further detail, please feel free to contact me via phone or email (Submitted by: HealthSouth)
  
  
• It is unclear how these measures can be evaluated and recommended to be cross setting when we don’t know the single cross setting data source to construct each measure. The IMPACT Act requires the use of standardized assessment tools as the data source for measures. These standardized assessment tools need to be incorporated into existing setting specific assessment tools (OASIS, IRF-PIA and MDS). Yet, the listed measures are based on assessment tools from only one PAC setting. For example, the pressure ulcer measure NQF#0768 was designed for use in the SNF setting and is based on MDS data. Does the recommendation of this measure on the MAP list mean the MDS items related to pressure ulcers will be used in OASIS and IRF-PIA? Second, this list appears to have selectively picked NQF endorsed or submitted measures to NQF for these PAC settings but does not consider other NQF endorsed or submitted measures that are applicable to the PAC setting and IMPACT act or the topics covered by this proposed list. For example, NQF endorsed a SNF rehospitalization measure (NQF # 2375) that is based on MDS data, which is consistent with intent of IMPACT act to use information from standardized assessment instruments at admission and discharge. However, the list only includes a claims based SNF rehospitalization measure (NQF #2510). Similarly, NQF is currently reviewing two risk adjusted functional status measures: change in self-care (NQF #2613) and change in mobility (NQF #2612) that are based on the CMS’s CARE tool. However, none of these measures are included in this this list for discussion and review. We believe that these measures must be consider as they were developed to meet the intent and purpose of the IMPACT Act of 2014. (Submitted by: American Health Care Association )