| 3:30 pm | Welcome, Introductions, and Review of Meeting Objectives |
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| 3:40 pm | MAP Off-Cycle Review Approach |
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| 3:45 pm | IMPACT ACT Reporting Requirements |
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| 3:55 pm | CMS Approach to Standardizing Measures Under the IMPACT Act |
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| 4:05 pm | Input on Measures under Consideration |
| Provide recommendations on measures under consideration | |
| Programs under consideration: IMPACT
Act Programs | |
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| 5:15 pm | Opportunity for Public Comment |
| 5:25 pm | Next Steps |
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| 5:30 pm | Adjourn |
| All-cause readmission measure for program(s): IMPACT (MUC ID: X4210) |
NQF Number (if applicable): Includes NQF#'s: 2502, 2510, 2512, 2380
Programs under consideration: IMPACT Act Programs
Preliminary analysis result: Support
Preliminary analysis summary: 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.
Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses the IMPACT Act domain all-condition risk-adjusted potenitally preventable hospital readmission rates. This measure aligns with MAP PAC/LTC core concept of "avoidable admissions."
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. Home Health: The developer provided split-half reliability testing, which assesses the consistency with which measuredentities are assigned performance scores. The testing results showed that 80 percent of the agencies were grouped into the same performance category, demonstrating a “high level of internal consistency.” SNF: The Committee noted that the reliability testing results (interclass correlation coefficient – 0.56) was low,but within a generally acceptable range. LTCH: The developers provided split sample reliability testing resulting in an ICC of 0.57, indicating a modest level of consistency in the standardized risk ratios assigned to facilities. IRF: The developers provided Split Sample reliability testing, which involved calculating the level of agreement between facilities scored. Agreement was evaluated using intraclass correlations (ICC) and the developers calculated an ICC of 0.39, indicating a modest level of agreement between facilities’ Standardized RiskRatios.
Is the measure currently in use? Yes. The IRF, LTCH and Home Health quality reporting programs currently include an all-cause unplanned readmission measure.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. IMPACT Act 0f 2014
Is the measure NQF endorsed for the program's setting and level of
analysis? Endorsed. NQF has recently endorsed these readmission measures for
all four settings (IRF #2502; SNF #2510; LTCH #2512; HH #2380.)
SNF (#2510): NQF Admissions/Readmissions
Standing Committee noted that this measure would encourage care coordination and
could be easily implemented. The Standing Committee noted a significant
performance gap with performance ranging from 11.9 to 41.9%.
Home Health
#2380: Rehospitalization During the First 30 Days of Home Health is harmonized
with other post-acute rehospitalization measures in the types of initial
hospitalizations included and in the definition of unplanned hospitalizations.
They differ from other post-acute hospital readmission measures, however, in the
definition of eligible post-acute stays, in the risk adjustment approach, and by
measuring ED use as an outcome. The differences arise due to the unique nature
of home health care as a post-acute setting.
| Percent of Patients/Residents/Persons with an admission and discharge functional assessment and a care plan that addresses function for program(s): IMPACT (MUC ID: S2631) |
NQF Number (if applicable): Identified as submitted measure NQF#2631
Programs under consideration: IMPACT Act Programs
Preliminary analysis result: Conditional support
Preliminary analysis summary: The measure addresses an IMPACT domain and a MAP PAC/LTC core concept. MAP reviewed this measure in its 2014 pre-rulemaking for LTCHQR program, and provided a recommendation of conditional support, pending NQF endorsement. This measure for LTCHs (2631) is currently under review by NQF by the Person and Family Centered Care Standing Committee. The Standing Committee has not reached consensus on recommending this measure due to concerns about the inclusion of the "plan of care" data elements for this measure. The Committee notes that the specifications indicate a discharge goal related to at least one of the assessment items rather than a plan. Concerns have also been raised about the evidence for a plan of care being related to outcomes. The Committee evaluation and recommendations will be posted for public comment very soon and NQF will make a final recommendation on endorsement in the Spring.
Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses the IMPACT Act domain functional status, cognitive function, and changing in function and cognitive function. This measure aligns with MAP PAC/LTC core concept of "functional and cognitive status assessment."
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The data elements were tested in a variety of settings including Acute Care Hospitals, Skilled Nursing Facilities, Inpatient Rehabilitation Facilities and Home Health Agencies in addition to Long-term Care Hospitals. For the traditional interrater reliability analyses, kappa statistics indicated substantial agreement among raters. The video interrater reliability analyses indicated substantial agreement with the mode and clinical team among all items, typically upward of 70%. The notable exception to this trend exists among the clinicians in the “Other” category (mostly licensed practical nurses).
Is the measure currently in use? No. Not in use - new measure
Does the measure promote alignment and parsimony? Yes. IMPACT Act 0f 2014
Is the measure NQF endorsed for the program's setting and level of
analysis? Not endorsed. The measure for LTCH is under review by NQF.
| Percent of Residents/Patients/Persons Experiencing One or More Falls with Major Injury for program(s): IMPACT (MUC ID: E0674) |
NQF Number (if applicable): 0674
Programs under consideration: IMPACT Act Programs
Preliminary analysis result: Support
Preliminary analysis summary: The measure addresses an IMPACT domain and a MAP PAC/LTC core concept. MAP provided a recommendation of conditional support for this measure for IRFs during the 2014 pre-rulemaking cycle. MAP recommended "support direction" for this measure for the LTCHQR program during the 2013 pre-rulemaking cycle. This measure is in use in the LTCHQR program.
Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses the IMPACT Act domain incidence of major falls. This measure aligns with MAP PAC/LTC core concept of "safety - falls."
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The MDS data elements for this measure were tested. Among nurses who participated in the MDS 3.0 national study, 88% reported that the fall-related injury definitions were clear, and 94% felt that facility falls documentation would provide the necessary information to complete these items. Saliba and Buchanan further demonstrated that the revised MDS 3.0 fall items had excellent reliability both for gold-standard to gold-standard comparisons (alpha = 0.967) as well as gold-standard to facility-nurse comparisons (alpha = 0.945).
Is the measure currently in use? Yes. This measure is publicly reported on Nursing Home Compare. The national average is 3.2%.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. IMPACT Act 0f 2014
Is the measure NQF endorsed for the program's setting and level of
analysis? Endorsed . NQF #0674 applies only to long-stay nursing home
patients. September 2012.
| Percent of Residents/Patients/Persons with Pressure Ulcers That Are New or Worsened for program(s): IMPACT (MUC ID: E0678) |
NQF Number (if applicable): 0678
Programs under consideration: IMPACT Act Programs
Preliminary analysis result: Support
Preliminary analysis summary: 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. 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.
Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses the IMPACT Act domain of skin integrity and changes in skin integrity. This measure aligns with MAP PAC/LTC core concept of "safety - pressure ulcers."
Measure development status: Fully developed
Is the measure fully tested for the program's setting and level of analysis? Yes. The national pilot test of the data elements items underlying the short stay pressure ulcer measure showed good reliability:the average kappa for gold-standard nurse to facility nurse agreement was 0.937. Several studies have demonstrated the validity and reliability of the MDS items used for this measure in nursing home settings. The data elements are the same for IRF and LTCH settings.
Is the measure currently in use? Yes. The measure is publicly reported on Nursing Home Compare for short stay patients - the national average is 1%. The measure is currently in use in the IRF and LTCH quality reporting programs.
Does a review of its performance history raise any concerns? No.
Does the measure promote alignment and parsimony? Yes. IMPACT Act 0f 2014
Is the measure NQF endorsed for the program's setting and level of
analysis? Endorsed. NQF #0678 is a fully harmonized/standardized measure
that applies to SNFs, LTCHs, and IRFs. Endorsed November 2012
| MUC ID: X4210 All-cause readmission measure |
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 statement: 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 statement: 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
| MUC ID: S2631 Percent of Patients/Residents/Persons with an admission and discharge functional assessment and a care plan that addresses function |
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 statement: 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 statement: 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
| MUC ID: E0674 Percent of Residents/Patients/Persons Experiencing One or More Falls with Major Injury |
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 statement: 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 statement: 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
| MUC ID: E0678 Percent of Residents/Patients/Persons with Pressure Ulcers That Are New or Worsened |
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 statement: 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 statement: 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
| IMPACT Act Programs |
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.
| Long-Term Care Hospitals Quality Reporting Program |
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
Program Update:
| Inpatient Rehabilitation Facilities Quality Reporting Program |
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
Program Update:
| Skilled Nursing Facilities Value-Based Purchasing |
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
Program Update: None
| Home Health Quality Reporting Program |
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
Program Update: