NQF

Meeting Objectives

• Review and provide input on measures under consideration for federal programs applicable to post-acute care/long-term care settings
• Identify high-priority measure gaps for each program measure set
• Finalize input to the MAP Coordinating Committee on measures for use in federal programs

Agenda

Preliminary Analysis Index

• Acute Care Hospitalization (Claims-Based) for program(s): MSSP (MUC ID: E0171)
  
  
• Antipsychotic Use in Persons with Dementia for program(s): MSSP (MUC ID: E2111)
  
  
• Compliance with Ventilator Process Elements during LTCH stay for program(s): LTCH QRP (MUC ID: X3705)
  
  
• Cultural Competency Implementation Measure for program(s): ESRD QIP (MUC ID: E1919)
  
  
• Cultural Competency Reporting Measure for program(s): ESRD QIP (MUC ID: X3716)
  
  
• Delivered Dose in Peritoneal Dialysis Above Minimum for program(s): ESRD QIP (MUC ID: X3718)
  
  
• Delivered Dose of Dialysis Above Minimum - Composite Score for program(s): ESRD QIP (MUC ID: X2051)
  
  
• Delivered Dose of Hemodialysis Above Minimum for program(s): ESRD QIP (MUC ID: X3717)
  
  
• Documentation of Current Medications in the Medical Record for program(s): ESRD QIP (MUC ID: E0419)
  
  
• Documentation of Current Medications in the Medical Record for program(s): MSSP (MUC ID: E0419)
  
  
• IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients for program(s): IRF QRP (MUC ID: S2634)
  
  
• IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients for program(s): IRF QRP (MUC ID: S2633)
  
  
• IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients for program(s): IRF QRP (MUC ID: S2636)
  
  
• IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients for program(s): IRF QRP (MUC ID: S2635)
  
  
• Medications Documentation Reporting for program(s): ESRD QIP (MUC ID: X3721)
  
  
• Percent of Patients with Pressure Ulcers That Are New or Worsened for program(s): HH QRP (MUC ID: X3704)
  
  
• Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure for program(s): MSSP (MUC ID: S2510)
  
  
• Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure for program(s): SNF VBP (MUC ID: S2510)
  
  
• Venous Thromboembolism Prophylaxis for program(s): IRF QRP (MUC ID: E0371)
  
  
• Venous Thromboembolism Prophylaxis for program(s): LTCH QRP (MUC ID: E0371)
  
  
• Ventilator Weaning (Liberation) Rate for program(s): LTCH QRP (MUC ID: X3706)
  
  

Full Preliminary Analysis

Full Measure Specifications

NQF Number (if applicable): 0171

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: The measure meets a critical program objective by encouraging coordination and shared accountability and promoting alignment across quality measurement reporting programs and addresses a gap of post-acute outcome measures and supports alignment with Home Health Quality Reporting program. It also addresses a PAC/LTC core concept of avoidable admissions and included in the MAP families of affordability, care coordination, and hospice.

Does the measure address a critical program objective as defined by MAP? Yes. The measure meets a critical program objective by encouraging coordination and shared accountability and promoting alignment across quality measurement reporting programs.

PAC/LTC core competency addressed by the measure: Avoidable admissions

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. The measure tested for Home Health

Is the measure currently in use? Yes. The measure is used in Home Health Quality Reporting Program.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes. The measure addresses a gap of post-acute outcome measures and supports alignment with Home Health Quality Reporting program. It addresses a PAC/LTC core concept of avoidable admissions and included in the MAP families of affordability, care coordination, and hospice.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Addresses a gap of post-acute outcome measures and supports alignment with Home Health quality reporting.

Full Measure Specifications

NQF Number (if applicable): 2111

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: Addresses a critical program objective of including high-value measures in the set such as appropriate use measures. It also addresses a PAC/LTC core concept of inappropriate medication use. The measure promotes alignment as it is included in the MAP duals eligible beneficiary Family of Measures.

Does the measure address a critical program objective as defined by MAP? Yes. Addresses a critical program objective of including high-value measures in the set such as appropriate use measures. It also addresses a PAC/LTC core concept of inappropriate medication use.

PAC/LTC core competency addressed by the measure: Inappropriate medication use

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. It is tested for post-acute care facilities and the health plan level of analysis.

Is the measure currently in use? No. None.

Does the measure promote alignment and parsimony? Yes. The measure is included in the MAP duals eligible beneficiary Family of Measures.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Recommended by MAP for dual eligible beneficiaries.

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Long-Term Care Hospitals Quality Reporting Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: The measure addresses an important patient safety priority for LTCHs. It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia. There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs. Further development is encouraged.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses an important patient safety priority for LTCHs. It is estimated that 25% of ventilated patients in LTCHs acquire ventilator-associated pneumonia.  There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care. VAP and VAE are associated with substantial morbidity, mortality, and excess healthcare costs.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. Measure development contract awarded but development has not started.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? . None

Is the measure currently in use? No. Not currently being used in a program.

Does the measure promote alignment and parsimony? Yes. VAP is associated with approximately 10K in extra costs per patient who develops it.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: There is evidence for interventions developed to decrease incidence of ventilator-associated pneumonia and improve ventilator care 2. VAP and VAE is associated with substantial morbidity, mortality, and excess healthcare costs. 3. Patients who develop VAP incur an extra $10K (2005) in hospital costs (Sadfar 2005). 4. Based on an analysis of CY 2004 MedPAR data for Medicare beneficiaries, 25% of ventilated patients in LTCHs acquired VAP (Buczko 2009).

Full Measure Specifications

NQF Number (if applicable): 1919

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Support

Preliminary analysis summary: The measure addresses a critical program objective of expanding the measure set to include nonclinical aspects of care such as patient engagement. Culturally competent care improves patient engagement. It addresses the NQS priority of person and family engagement and is NQF endorsed. While this measure is not publicly reported, it could be used as a means of assessing whether standards for providing culturally competent care are being met and specifically, the degree to which healthcare organizations are adhering to the NQF-endorsed preferred practices for providing culturally competent care.

Does the measure address a critical program objective as defined by MAP? Yes. This measure meets a critical program objective to expand the measure set beyond dialysis procedures to include nonclinical aspects of care such as patient engagement. Culturally competent care is a crucial aspect of patient engagement. Additionally there is evidence that providing culturally competent care can help to reduce healthcare disparities and improve outcomes and satisfaction for racial and ethnic minorities.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested in ?Dialysis Facilities

Is the measure currently in use? Yes. This survey measure is used for internal and external quality improvement purposes.  It is not currently in use for public reporting.

Does a review of its performance history raise any concerns? No. No data found.

Does the measure promote alignment and parsimony? Yes. This measure addresses the cross-cutting gap areas of Care Coordination, Disparities, Patient and Family Engagement.  However, measure is not yet publicly reported.

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Endorsed in 2012; due for Annual Update 2014.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Numerous studies have documented the existence of significant disparities in access to health care, outcomes, and health status among racial and ethnic minorities. Studies conducted across a variety of healthcare settings have found that racial/ethnic minority patients as well as those with low socioeconomic status or LEP report worse experiences of care, compared with whites, those with higher socioeconomic status, and English speakers. Growing evidence points to the fact that minority populations tend to receive lower quality of care even when factors such as access, health insurance, and income are taken into account. In short, racial and ethnic minorities face disproportionately higher rates of disease, disability, and mortality. For example, compared to whites, African Americans have higher death rates from heart disease, diabetes, AIDS, and cancer, and American Indians and Alaskan Natives have lower life expectancies and higher rates of infant mortality. Despite the fact that health care systems in the U.S. have improved over time, that racial and ethnic disparities have been widely documented, and that numerous attempts have been made to reduce or eliminate these disparities, they continue to be widespread and pervasive. No doubt the causes of these health disparities are the result of multiple factors including bias (conscious or unconscious) on the part of the providers, differences in patients’ expectations, miscommunication caused by cultural differences, and organizational factors that impact the quality of patient–provider interactions. However, there is also growing evidence that a major contributor to healthcare disparities is a lack of culturally competent care. Cultural competence can be defined as the ongoing capacity of healthcare systems, organizations, and professionals to provide diverse populations high quality care that is safe, patient and family centered, evidence-based, and equitable. To be culturally competent, health care providers have to employ various interpersonal and organizational strategies to overcome or at the very least reduce the barriers to access, communication, and understanding that stem from racial, ethnic, cultural, and linguistic differences. Providing culturally appropriate care has the potential to reduce disparities and improve outcomes while at the same time improving patient satisfaction. In recent years, more and more organizations have begun exploring ways to improve cultural competency—that is, to ensure that diverse patient populations receive high-quality care that is safe, patient and family centered, evidence-based, and equitable. The National Quality Forum (NQF), an organization dedicated to improving healthcare quality, aims to promote culturally competent care, to reduce disparities, and to make care more patient-centered by endorsing a comprehensive framework for measuring and reporting cultural competency. It also endorsed a set of 45 preferred practices to provide culturally competent care. The framework and practices were published in an NQF report titled, "A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency", and cover issues such as communication, community engagement and workforce training, and providing healthcare systems with practices they can implement to help reduce persistent disparities in healthcare and create higher-quality, more patient-centered care.

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: This measure meets a critical program objective previously identified by MAP that the measure set should expand beyond dialysis procedures to include nonclinical aspects of care such as patient engagement; culturally competent care improves patient engagement.This measure would serve as an important first step in implementing the cultural competency survey. However, MAP would encourage the rapid implementation of NQF #1919.

Does the measure address a critical program objective as defined by MAP? Yes. This measure meets a critical program objective to expand the measure set beyond dialysis procedures to include nonclinical aspects of care such as patient engagement.Culturally competent care is a crucial aspect of patient engagement. Additionally there is evidence that providing culturally competent care can help to reduce healthcare disparities and improve outcomes and satisfaction for racial and ethnic minorities.This measure is distinct from NQF #1919 Cultural Competency Implementation Measure.  This reporting measure is designed to collect data needed to score NQF #1919.

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Tested in Dialysis Facilities

Is the measure currently in use? No. Not currently used in another CMS program. This is distinct from NQF # 1919 Cultural Competency Implementation Measure in that it would be used to assess the reporting of data contained in the survey, but not to assess facility performance in the survey.

Does the measure promote alignment and parsimony? Yes. Addresses a critical program objective of expanding the measure set to include nonclinical aspects of care such as patient engagement; addresses the NQS priority of person and family engagement. The measure is not yet in use in public programs.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Numerous studies have documented the existence of significant disparities in access to health care, outcomes, and health status among racial and ethnic minorities. Studies conducted across a variety of healthcare settings have found that racial/ethnic minority patients as well as those with low socioeconomic status or LEP report worse experiences of care, compared with whites, those with higher socioeconomic status, and English speakers. Growing evidence points to the fact that minority populations tend to receive lower quality of care even when factors such as access, health insurance, and income are taken into account. In short, racial and ethnic minorities face disproportionately higher rates of disease, disability, and mortality. For example, compared to whites, African Americans have higher death rates from heart disease, diabetes, AIDS, and cancer, and American Indians and Alaskan Natives have lower life expectancies and higher rates of infant mortality. Despite the fact that health care systems in the U.S. have improved over time, that racial and ethnic disparities have been widely documented, and that numerous attempts have been made to reduce or eliminate these disparities, they continue to be widespread and pervasive. No doubt the causes of these health disparities are the result of multiple factors including bias (conscious or unconscious) on the part of the providers, differences in patients’ expectations, miscommunication caused by cultural differences, and organizational factors that impact the quality of patient–provider interactions. However, there is also growing evidence that a major contributor to healthcare disparities is a lack of culturally competent care. Cultural competence can be defined as the ongoing capacity of healthcare systems, organizations, and professionals to provide diverse populations high quality care that is safe, patient and family centered, evidence-based, and equitable. To be culturally competent, health care providers have to employ various interpersonal and organizational strategies to overcome or at the very least reduce the barriers to access, communication, and understanding that stem from racial, ethnic, cultural, and linguistic differences. Providing culturally appropriate care has the potential to reduce disparities and improve outcomes while at the same time improving patient satisfaction. In recent years, more and more organizations have begun exploring ways to improve cultural competency—that is, to ensure that diverse patient populations receive high-quality care that is safe, patient and family centered, evidence-based, and equitable. The National Quality Forum (NQF), an organization dedicated to improving healthcare quality, aims to promote culturally competent care, to reduce disparities, and to make care more patient-centered by endorsing a comprehensive framework for measuring and reporting cultural competency. It also endorsed a set of 45 preferred practices to provide culturally competent care. The framework and practices were published in an NQF report titled, "A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency", and cover issues such as communication, community engagement and workforce training, and providing healthcare systems with practices they can implement to help reduce persistent disparities in healthcare and create higher-quality, more patient-centered care.

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Meets critical program objectives previously identified by MAP to include more outcome measures and measures applicable to pediatric population in the set.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses critical program objectives to include outcome measures and to assess performance in pediatric populations. Assessing the Kt/V is a way to measure the dose of dialysis to ensure enough waste products are removed from the patient's blood. This is a revision to NQF #0318,Peritoneal Dialysis Adequacy Clinical Performance Measure III-Delivered Dose of Peritoneal Dialysis Above Minimum.The measure has been revised to address both adult and pediatric populations.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. Testing in Dialysis Facilities

Is the measure currently in use? No. Not yet in use.

Does the measure promote alignment and parsimony? Yes. Addresses the NQS priority of prevention; will be a high value measure as an intermediate outcome measure.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.  

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This is a revision of the existing NQF measure 0318. The measure has been revised to include both adult and pediatric patients

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Meets a critical program objective previously identified by the MAP to explore whether clinically focused measures could be combined into composites for assessing optimal care. Assessing the Kt/V is a way to measure the dose of dialysis to ensure enough waste products are removed from the patient's blood.This measure is a composite of two existing Kt/V dialysis adequacy measures (#0318 and #0249) and allows for assessment of all dialysis patients, avoiding the exclusion of pediatric and peritoneal dialysis patients from assessment in the program.

Does the measure address a critical program objective as defined by MAP? Yes. This measure meets a program objective to explore whether clinically focused measures could be combined into composites for assessing optimal care. Assessing the Kt/V is a way to measure the dose of dialysis to ensure enough waste products are removed from the patient's blood.This measure is a composite of two existing Kt/V dialysis adequacy measures (#0318 and #0249) and allows for assessment of all dialysis patients, avoiding the exclusion of pediatric and peritoneal dialysis patients from assessment in the program.Additionally, MAP has expressed its preference for outcomemeasures; this is an intermediate outcome measure.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. Testing in Dialysis Facilities

Is the measure currently in use? No. Not yet in use.

Does the measure promote alignment and parsimony? Yes. Addresses the NQS priority of prevention; will be a high value measure as an intermediate outcome measure, and is a composite measure.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This measure is a composite of two existing Kt/V dialysis adequacy measures. It permits assessment for all dialysis patients included in those two measures with a single composite score, avoiding the systematic exclusion of pediatric and peritoneal dialysis patients from assessment in the QIP.

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: Meets critical program objectives previously identified by MAP to include more outcome measures and measures applicable to pediatric population in the set.  

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses critical program objectives to include outcome measures and to assess performance in pediatric populations. Assessing the Kt/V is a way to measure the dose of dialysis to ensure enough waste products are removed from the patient's blood. This is a revision to NQF #0249,Hemodialysis Adequacy Clinical Performance Measure III: Hemodialysis Adequacy--HD Adequacy-- Minimum Delivered Hemodialysis Dose.  The measure has been revised to address both adult and pediatric populations. 

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? Yes. Testing in Dialysis Facilities

Is the measure currently in use? No. Not yet in use.

Does the measure promote alignment and parsimony? Yes. Addresses the NQS priority of prevention; this will be a high value measure as an intermediate outcome measure.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: This is a revision of the existing NQF measure 0249. The measure has been revised to include both adult and pediatric patients

Full Measure Specifications

NQF Number (if applicable): 0419

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Support is conditional on the measure being tested at the levels appropriate for ESRD facilities.It addresses a critical program objective that the measure set should expand beyond dialysis procedures to include non clinical aspects of care, including medication reconciliation. It also addresses the NQS priority of safety and is included in the MAP duals family. It promotes alignment across federal programs as it is used in clinician programs (e.g. PQRS, MU) and was recently finalized for use in MSSP.  

Does the measure address a critical program objective as defined by MAP? Yes. Meets a critical program objective previously identified by MAP to expand the measure set beyond dialysis procedures to include non clinical aspects of care, including medication reconciliation.It is estimated that the rate of adverse drug events in ambulatory settings is 27 per 100 patients. Approximately 700,000 people are treated in emergency departments annually for ADEs and approximately 115,000 are hospitalized for ADEs.

PAC/LTC core competency addressed by the measure: Inappropriate medication use

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? No. This measure is tested at the clinician.  

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes. Yes, as the measure is specified for these settings: Ambulatory Care: Clinician Office/Clinic, Behavioral Health/Psychiatric: Outpatient, Dialysis Facility, Home Health, Other, Post Acute/Long Term Care Facility: Inpatient Rehabilitation Facility, Post Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility

Is the measure currently in use? Yes. Meaningful Use Stage 2 (EHR Incentive Program) - Eligible Professionals; Physician Feedback; Physician Quality Reporting System (PQRS)

Does a review of its performance history raise any concerns? No. Average 2011 Performance: 85.7% The measure is in current operational use. Data collection for reliability testing (medical record audits) is dependent on the provider. Specific elements of the medical record must be requested to insure the audit process is standardized across providers. Oftentimes, reminder letters are required to attain a 50% or greater response rate. PQRS selection rate is 6.2%: Number of Eligible Professionals: 710,120; Number and % of EPs Reporting: 44,027 (6.2%)

Does the measure promote alignment and parsimony? Yes. This measure is in use in several federal programs, and fills a gap in the area of inappropriate medication use. The measure is included in the Duals Family of measures and was recently finalized in the 2015 PFS final rule.  

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Scheduled for NQF review in 2015.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Meets gap in medication reconciliation measures and aligns with PQRS and MU. In 2005, the rate of medication errors during hospitalization was estimated to be 52 per 100 admissions, or 70 per 1,000 patient days. Emerging research suggests the scope of medication-related errors in ambulatory settings is as or more extensive than during hospitalization. Ambulatory visits result in a prescription for medication 50 to 70% of the time. One study estimated the rate of adverse drug events (ADE) in the ambulatory setting to be 27 per 100 patients. It is estimated that between 2004 and 2005, in the United States 701,547 patients were treated for ADEs in emergency departments and 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65 years and older are more likely than any other population group to require treatment in the emergency department for ADEs (American Medical Association (AMA), 2010). In the United States, it is estimated that in any given week, most adults aged 18 years and older take at least one prescription medication, OTC drug, vitamin, mineral, herbal product or supplement, while 10 percent take five or more. Overall, 26 percent of the population takes herbal products and supplements, and 30 percent of prescription drug users take an herbal product or supplement. In all settings of care, drug-drug interactions are significant, but undetected causes of ADEs. Drug-drug interactions—including interactions between drugs a patient is known to be taking—are frequently not recognized. Controversy, confusion and uncertainty about the significance of many drug-drug interactions further increase risk and opportunity for ADEs (AMA, 2010).

Full Measure Specifications

NQF Number (if applicable): 0419

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: This measure addresses a critical program objective:Encourage coordination and shared accountability across settings. It addresses the NQS priority of safety and included in the MAP duals family. It promotes alignment across federal programs, and recently finalized for use in MSSP.   

Does the measure address a critical program objective as defined by MAP? Yes. Encourage coordination and shared accountability across settings.

PAC/LTC core competency addressed by the measure: Inappropriate medication use

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes. Testing appears to be only at the Clinician Level

Is the measure currently in use? Yes. Meaningful Use Stage 2 (EHR Incentive Program) - Eligible Professionals; Physician Feedback; Physician Quality Reporting System (PQRS) 

Does a review of its performance history raise any concerns? No. Average 2011 Performance: 85.7% The measure is in current operational use. Data collection for reliability testing (medical record audits) is dependent on the provider. Specific elements of the medical record must be requested to insure the audit process is standardized across providers. Oftentimes, reminder letters are required to attain a 50% or greater response rate. PQRS selection rate is 6.2%: Number of Eligible Professionals: 710,120; Number and % of EPs Reporting: 44,027 (6.2%) 

Does the measure promote alignment and parsimony? Yes. This measure is in use in several federal programs, and fills a gap in the area of inappropriate medication use. The measure is included in the Duals Family of measures and was recently finalized for use in MSSP. 

Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed. Scheduled for NQF review in 2015

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Meets gap in medication reconciliation measures and aligns with PQRS and MU. In 2005, the rate of medication errors during hospitalization was estimated to be 52 per 100 admissions, or 70 per 1,000 patient days. Emerging research suggests the scope of medication-related errors in ambulatory settings is as or more extensive than during hospitalization. Ambulatory visits result in a prescription for medication 50 to 70% of the time. One study estimated the rate of adverse drug events (ADE) in the ambulatory setting to be 27 per 100 patients. It is estimated that between 2004 and 2005, in the United States 701,547 patients were treated for ADEs in emergency departments and 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65 years and older are more likely than any other population group to require treatment in the emergency department for ADEs (American Medical Association (AMA), 2010). In the United States, it is estimated that in any given week, most adults aged 18 years and older take at least one prescription medication, OTC drug, vitamin, mineral, herbal product or supplement, while 10 percent take five or more. Overall, 26 percent of the population takes herbal products and supplements, and 30 percent of prescription drug users take an herbal product or supplement. In all settings of care, drug-drug interactions are significant, but undetected causes of ADEs. Drug-drug interactions—including interactions between drugs a patient is known to be taking—are frequently not recognized. Controversy, confusion and uncertainty about the significance of many drug-drug interactions further increase risk and opportunity for ADEs (AMA, 2010).

Full Measure Specifications

NQF Number (if applicable): 2634

Programs under consideration: Inpatient Rehabilitation Facilities Quality Reporting Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: The measure is conditionally supported pending NQF endorsement. Improvement in functional status is the primary goal of rehabilitation and also a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domian under the IMPACT Act. Functional status is also a priority area for measurement of the Duals population. This measure is fully specified and tested for use in IRFs and has been submitted for NQF endorsement under the person and family centered care project phase 2.  

Does the measure address a critical program objective as defined by MAP? Yes. This measure estimates the mean change in mobility score between admission and discharge for IRF patients.Improvement in functional status is the primary goal of rehabilitation and a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act.

PAC/LTC core competency addressed by the measure: 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.

Is the measure currently in use? No. This is a new measure. No prior use data is available.

Does the measure promote alignment and parsimony? Yes. It addresses a priority measurement area identified by the MAP Duals Workgroup.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has been submitted for endorsement under the PFCC phase 2 project.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Given that the primary goal of rehabilitation is improvement in function, IRF clinicians have traditionally assessed and documented patients’ functional status at admission and discharge to evaluate the effectiveness of the rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, and race/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, which supports the need to monitor IRF patients’ functional outcomes.

Full Measure Specifications

NQF Number (if applicable): 2633

Programs under consideration: Inpatient Rehabilitation Facilities Quality Reporting Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: The measure is conditionally supported pending NQF endorsement. Improvement in functional status is the primary goal of rehabilitation and also a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act. Functional status is also a priority area for measurement for the Duals population. This measure is fully specified and tested for use in IRFs and has been submitted for NQF endorsement under the person and family centered care project phase 2.

Does the measure address a critical program objective as defined by MAP? Yes. This measure estimates the change in self-care score among IRF patients. Improvement in functional status is the primary goal of rehabilitation and is a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act. 

PAC/LTC core competency addressed by the measure: 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.

Is the measure currently in use? No. This is a new measure. No prior use data is available.

Does the measure promote alignment and parsimony? No. It addresses a priority measurement area identified by the MAP Duals Workgroup.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has been submitted for endorsement under the PFCC phase 2 project.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Given that the primary goal of rehabilitation is improvement in functional status, IRF clinicians have traditionally assessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness of the rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, and race/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, which supports the need to monitor IRF patients’ functional outcomes.

Full Measure Specifications

NQF Number (if applicable): 2636

Programs under consideration: Inpatient Rehabilitation Facilities Quality Reporting Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: The measure is conditionally supported pending NQF endorsement. Improvement in functional status is the primary goal of rehabilitation and also a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act. Functional status is also a priority area for measurement for the Duals population. This measure is fully specified and tested for use in IRFs and has been submitted for NQF endorsement under the person and family centered care project phase 2.

Does the measure address a critical program objective as defined by MAP? Yes. This measure estimates the percentage of IRF patients who meet or exceed an expected discharge mobility score. ?Improvement in functional status is the primary goal of rehabilitation and a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act.

PAC/LTC core competency addressed by the measure: 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.

Is the measure currently in use? No. This is a new measure. No prior use data is available.

Does the measure promote alignment and parsimony? No. It addresses a priority measurement area identified by the MAP Duals Workgroup.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has been submitted for endorsement under the PFCC phase 2 project.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Given that the primary goal of rehabilitation is improvement in function, IRF clinicians have traditionally assessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness of the rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, and race/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, which supports the need to monitor IRF patients’ functional outcomes.

Full Measure Specifications

NQF Number (if applicable): 2635

Programs under consideration: Inpatient Rehabilitation Facilities Quality Reporting Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: The measure is conditionally supported pending NQF endorsement. Improvement in functional status is the primary goal of rehabilitation and also a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act.Functional status is also a priority area for measurement for the Duals population. This measure is fully specified and tested for use in IRFs and has been submitted for NQF endorsement under the person and family centered care project phase 2.

Does the measure address a critical program objective as defined by MAP? Yes. This measure estimates the percentage of IRF patients who meet or exceed an expected discharge self-care score.Improvement in functional status is the primary goal of rehabilitation and a PAC/LTC core concept not currently addressed in the program. It is also a required measurement domain under the IMPACT Act.

PAC/LTC core competency addressed by the measure: 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.

Is the measure currently in use? No. This is a new measure. No prior use data is available.

Does the measure promote alignment and parsimony? No. It addresses a priority measurement area identified by the MAP Duals Workgroup.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure has been submitted for endorsement under the PFCC phase 2 project.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? Yes.

Rationale for measure provided by HHS: Given that the primary goal of rehabilitation is improvement in functional status, IRF clinicians have traditionally assessed and documented patients’ functional status at admission and at discharge to evaluate the effectiveness of the rehabilitation care provided to individual patients, as well as the effectiveness of the rehabilitation unit or hospital overall. Studies have shown differences in IRF patients’ functional outcomes by geographic region, insurance type, and race/ethnicity after adjusting for key patient demographic characteristics and admission clinical status, which supports the need to monitor IRF patients’ functional outcomes.

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: End-Stage Renal Disease Quality Incentive Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Measure addresses a critical program objective to expand the measure set beyond dialysis procedures to include non clinical aspects of care, including medication reconciliation. Addresses the gap area and NQS priority of safety(inappropriate medication use) and effective communication and coordination ofcare.This reporting measure is designed to collect data needed to score NQF #0419 in the ESRD QIP.

Does the measure address a critical program objective as defined by MAP? Yes. Meets a critical program objective previously identified by MAP to expand the measure set beyond dialysis procedures to include non clinical aspects of care, including medication reconciliation.It is estimated that the rate of adverse drug events in ambulatory settings in 27 per 100 patients. Approximately 700,000 people are treated in emergency departments annually for ADEs and approximately 115,000 are hospitalized for ADEs. Medication documentation in outpatient settings has been shown to have a need and opportunity for improvement. This reporting measure is designed to collect the data needed to score NQF#0419 in the ESRD QIP. 

PAC/LTC core competency addressed by the measure: Inappropriate medication use

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No. No record found. This reporting measure is designed to collect data needed to score NQF #0419 in the ESRD QIP.

Does the measure promote alignment and parsimony? Yes. Addresses a critical program objective previously identified by MAP that this measure set should expand beyond dialysis procedures to include non clinical aspects of care, including medication reconciliation. Addresses the gap area and NQS priority of safety (inappropriate medication use) and effective communication and coordination of care.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: In 2005, the rate of medication errors during hospitalization was estimated to be 52 per 100 admissions, or 70 per 1,000 patient days. Emerging research suggests the scope of medication-related errors in ambulatory settings is as or more extensive than during hospitalization. Ambulatory visits result in a prescription for medication 50 to 70% of the time. One study estimated the rate of adverse drug events (ADE) in the ambulatory setting to be 27 per 100 patients. It is estimated that between 2004 and 2005, in the United States 701,547 patients were treated for ADEs in emergency departments and 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65 years and older are more likely than any other population group to require treatment in the emergency department for ADEs (American Medical Association (AMA), 2010). In the United States, it is estimated that in any given week, most adults aged 18 years and older take at least one prescription medication, OTC drug, vitamin, mineral, herbal product or supplement, while 10 percent take five or more. Overall, 26 percent of the population takes herbal products and supplements, and 30 percent of prescription drug users take an herbal product or supplement. In all settings of care, drug-drug interactions are significant, but undetected causes of ADEs. Drug-drug interactions—including interactions between drugs a patient is known to be taking—are frequently not recognized. Controversy, confusion and uncertainty about the significance of many drug-drug interactions further increase risk and opportunity for ADEs (AMA, 2010).

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Home Health Quality Reporting Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: Conditional support pending further development and NQF endorsement. This measure addresses a PAC/LTC core concept and will be a required measurement domain under the IMPACT Act. This measure promotes alignment as is ?harmonized with NQF# 0678 - "Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay)" which is used in the SNF, LTCH and IRF settings.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a PAC/LTC core concept and will be a required measurement domain under the IMPACT Act. Pressure ulcers may be a relatively rare event in the home health setting but they have substantial adverse impact on quality of life and are associated with increased morbidity and mortality. Pressure ulcers have been found to be largely preventable with proper interventions.  

PAC/LTC core competency addressed by the measure: Pressure ulcers

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. No level of analysis testing.Testing will be conducted and risk adjustment will be developed once sufficient OASIS-C1 data are collected, under a contract that has yet to be awarded by CMS.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes.

Is the measure currently in use? No. This measure is ?harmonized with NQF# 0678 - "Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay)" which is used in the SNF, LTCH and IRF settings.

Does the measure promote alignment and parsimony? Yes. Similar measure is being used in SNF, IRFs, and LTCHs.Specifications for this measure have been developed, and are harmonized with NQF# 0678 - "Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay)" used in the SNF, LTCH and IRF settings. The measure differs from 0678 in that it includes pressure ulcers that are unstageable due to slough or eschar. The OASIS-C1 instrument (effective 1/1/2015) will support the reporting of the "New or Worsened Pressure Ulcers" measure.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure will be submitted for NQF endorsement in late 2015/early 2016.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: Studies have demonstrated that while pressure ulcers may be relatively rare in the home health setting, they have a substantial adverse impact on patient quality of life, and incidence is associated with an increased morbidity and mortality. They are a national focus because they are widely seen as preventable with sufficient risk assessment and quality care provision. This measure is envisioned to encourage agencies to implement actions that can reduce the development of new pressure ulcers and facilitate healing to prevent the worsening of existing pressure ulcers. Additionally, the measure will provide home health agencies and consumers with information that will enable them to monitor the quality of care received by all patients at risk of developing pressure ulcers.

Full Measure Specifications

NQF Number (if applicable): 2510

Programs under consideration: Medicare Shared Savings Program

Preliminary analysis result: Support

Preliminary analysis summary: This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA). It promotes alignment and shared responsibility across settings. MAP had reviewed and supported the direction of the measure concept in the 2013 pre-rulemaking. This measure is currently under review for endorsement and was recently finalized for use in MSSP. 

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA).It encourages coordination and shared accountability across programs. 

PAC/LTC core competency addressed by the measure: Avoidable admissions

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.

Is the measure currently in use? No.

Does the measure promote alignment and parsimony? Yes. In the 2013 pre-rulemaking, MAP had supported the direction of the measure concept. MAP had noted that a consolidated, evidence-based readmission measure should be developed to promote alignment and shared responsibility across the care continuum and PAC/LTC settings and the measure should be appropriately risk adjusted to accommodate variations in population. Based on the 2015 PFS Final rule, this measure was recently finalized for use in MSSP. 

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure is in final stages of review for endorsement. 

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure is a SNF VBP measure.

Full Measure Specifications

NQF Number (if applicable): 2510

Programs under consideration: Skilled Nursing Facilities Value-Based Purchasing

Preliminary analysis result: Support

Preliminary analysis summary: This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA). MAP had reviewed and supported the direction of the measure concept in the 2013 pre-rulemaking. This measure is currently under review for endorsement and was recently finalized for use in MSSP in the 2015 PFS rule.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses a PAC/LTC Core Concept and is a required measure for the SNF value-based purchasing program under the Protecting Access to Medicare Act of 2014 (PAMA).The 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 percent.This measure was recommended for NQF-endorsement.

PAC/LTC core competency addressed by the measure: Avoidable admissions

Measure development status: Fully developed

Is the measure fully tested for the program's setting and level of analysis? Yes.  

Is the measure currently in use? No. This is a new measure.  

Does the measure promote alignment and parsimony? Yes. In the 2013 pre-rulemaking, MAP had supported the direction of the measure concept. MAP had noted that a consolidated, evidence-based readmission measure should be developed to promote alignment and shared responsibility across the care continuum and PAC/LTC settings and the measure should beappropriately risk adjusted to accommodate variations in population.The NQF Admissions/Readmissions Standing Committee noted that this measures approach to capturing readmissions is consistent with other CMS readmission measures.This measure was recentlyfinalized for use in MSSP in the 2015 PFS rule.

Is the measure NQF endorsed for the program's setting and level of analysis? Not Endorsed. This measure is in final stages of review for endorsement.

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure is a SNF VBP measure.

Full Measure Specifications

NQF Number (if applicable): 0371

Programs under consideration: Inpatient Rehabilitation Facilities Quality Reporting Program

Preliminary analysis result: Conditional support

Preliminary analysis summary: It addresses the NQS priority of safer care and is relevant to the priorities of IRFs. It promotes alignment across programs because it is either used or will be used in other acute or post/acute settings. The measure is not ready for implementation as it needs further development or testing for this setting before being used in the program.

Does the measure address a critical program objective as defined by MAP? Yes. It addresses the NQS priority of safer care and is relevant to the priorities of IRFs.  Venous thromboembolism (VTE) has an annually incidence of approximately 900,000 cases, of which 300,000 are fatal. AHRQ has noted that the appropriate use of preventative measures has major potential for reducing the incidence of VTE and improving patient safety.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? Yes.  

Is the measure currently in use? Yes. It is currently finalized for use in Hospital Inpatient Quality Reporting Program and Meaningful Use for Hospitals and CAHs, and under consideration for Long-Term Care Hospital Quality Reporting Program.

Does a review of its performance history raise any concerns? No.

Does the measure promote alignment and parsimony? Yes. It is either used or will be used in other acute or post/acute care settings.

Is the measure NQF endorsed for the program's setting and level of analysis? .

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 cases. Of these, approximately one third of the cases (300,000) are fatal PE, and the remaining two-thirds are non-fatal episodes of DVT or PE. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE. Of the estimated 600,000 cases of non-fatal venous thromboembolism each year, about 60% are cases of DVT, and 40% are episodes PE. Among patients who present with symptomatic DVT as the chief presenting complaint, 50% or more have evidence of pulmonary embolism (mostly asymptomatic) by diagnostic imaging procedures such as radionuclide lung scanning or CT imaging .The incidence of venous thromboembolism increases markedly in patients of age 60 years or more. Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that “the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism.” Although the majority of cases of DVT and PE are associated with recent hospitalization, many of the patients present clinically after hospital discharge, because the length of stay for most surgeries and medical conditions has been markedly reduced in recent years. The aging of the United States population, the more extensive use of surgical procedures in older patients, and multiple hospital admissions of patients for the care of chronic conditions such as heart failure or diabetes, are strong factors fostering the potential for an increase in the incidence of DVT and PE in future years. Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery.

Full Measure Specifications

NQF Number (if applicable): 0371

Programs under consideration: Long-Term Care Hospitals Quality Reporting Program

Preliminary analysis result: Conditional Support

Preliminary analysis summary: This measure addresses the NQS priority of safer care and is relevant to the priorities of IRFs. Venous thromboembolism (VTE) has an annually incidence of approximately 900,000 cases, of which 300,000 are fatal. AHRQ has noted that the appropriate use of preventative measures has major potential for reducing the incidence of VTE and improving patient safety.  It promotes alignment across programs because it is either used or will be used in other acute or post/acute settings. The measure is not ready for implementation as it needs further development or testing for this setting before being used in the program.

Does the measure address a critical program objective as defined by MAP? Yes. This measure addresses the NQS priority of safer care and is relevant to the priorities of LTCHs.Venous thromboembolism (VTE) has an annually incidence of approximately 900,000 cases, of which 300,000 are fatal. AHRQ has noted that the appropriate use of preventative measures has major potential for reducing the incidence of VTE and improving patient safety.

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No.  

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? N/A. Facility

Is the measure currently in use? Yes. ?It is currently finalized for use in Hospital Inpatient Quality Reporting Program and Meaningful Use for Hospitals and CAHs, and under consideration for Inpatient Rehabilitation Facility Quality Reporting Program.

Does a review of its performance history raise any concerns? No. N/A

Does the measure promote alignment and parsimony? Yes. It is either used or will be used in other acute or post/acute care settings.

Is the measure NQF endorsed for the program's setting and level of analysis? .

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 cases. Of these, approximately one third of the cases (300,000) are fatal PE, and the remaining two-thirds are non-fatal episodes of DVT or PE. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE. Of the estimated 600,000 cases of non-fatal venous thromboembolism each year, about 60% are cases of DVT, and 40% are episodes PE. Among patients who present with symptomatic DVT as the chief presenting complaint, 50% or more have evidence of pulmonary embolism (mostly asymptomatic) by diagnostic imaging procedures such as radionuclide lung scanning or CT imaging .The incidence of venous thromboembolism increases markedly in patients of age 60 years or more. Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that “the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism.” Although the majority of cases of DVT and PE are associated with recent hospitalization, many of the patients present clinically after hospital discharge, because the length of stay for most surgeries and medical conditions has been markedly reduced in recent years. The aging of the United States population, the more extensive use of surgical procedures in older patients, and multiple hospital admissions of patients for the care of chronic conditions such as heart failure or diabetes, are strong factors fostering the potential for an increase in the incidence of DVT and PE in future years. Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40% have three or more risk factors. Without thromboprophylaxis, the incidence of objectively confirmed, hospital-acquired DVT is approximately 10% to 40% among medical or general surgical patients and 40% to 60% following major orthopedic surgery.

Full Measure Specifications

NQF Number (if applicable): N/A

Programs under consideration: Long-Term Care Hospitals Quality Reporting Program

Preliminary analysis result: Encourage continued development

Preliminary analysis summary: This measure addresses an important safety priority for LTCHs. MedPAC estimates that 16% of LTCH patients use ventilator services. Weaning is the process of decreasing the amount of support a patient receives from the ventilator.  Successful weaning is associated with decreased morbidity, mortality, and resource use. Further development is encouraged.

Does the measure address a critical program objective as defined by MAP? Yes. The measure addresses an important safety priority for LTCHs. MedPAC estimates that 16% of LTCH patients use ventilator services. Weaning is the process of decreasing the amount of support a patient receives from the ventilator.  Successful weaning is associated with decreased morbidity, mortality, and resource use.  

Measure development status: Early development

Is the measure fully tested for the program's setting and level of analysis? No. None

Since no, could the measure be revised to use in the setting or at level of analysis under consideration? No. None

Is the measure currently in use? No. Not currently used in a program

Does the measure promote alignment and parsimony? No. According to MedPAC analysis, 16 percent of LTCH patients used at least one ventilator-related service in 2012. Nearly 18,000 LTCH discharges are associated with two diagnosis-related groups involving ventilator use: respiratory diagnosis with ventilator support and tracheostomy with ventilator support. Delaying ventilator weaning can lead to complications such as excess stay, iatrogenic lung injury, unnecessary sedation, and higher mortality.    

Is the measure NQF endorsed for the program's setting and level of analysis? .

Does the measure address a high-priority quality issue in the dual eligible beneficiary population? No.

Rationale for measure provided by HHS: MedPAC analysis of the Medicare Provider Analysis and Review data found that 16 percent of LTCH patients used at least one ventilator-related service in 2012. 2. In 2012, Respiratory diagnosis with ventilator support for 96 or more hours (MS-LTC-DRG-207) represented the most frequently occurring diagnosis among LTCH patients (11.3% of all discharges). 3. Tracheostomy with ventilator support for 96 or more hours or primary diagnosis except face, mouth, and neck without major OR procedure (MS-LTC-DRG-4) represented an additional 1.3% of all LTCH discharges. 4. These two diagnosis-related groups account for a total of nearly 18,000 LTCH discharges. http://www.medpac.gov/chapters/Mar14_Ch11.pdf 5. Weaning comprises 40 percent of the duration of mechanical ventilation. (Cite) 6. Undue delay leads to excess stay, iatrogenic lung injury, unnecessary sedation, and even higher mortality. (McIntyre 2012) 7. Complications of mechanical ventilation include respiratory muscle weakness, ventilator-associated pneumonia, upper airway pathology (Burns 2014) 8. Prolonged mechanical ventilation is associated with even higher rates of mortality and LOS (Zilberberg 2009).

Measure Index

• Acute Care Hospitalization (Claims-Based) (E0171)
  
  
• Antipsychotic Use in Persons with Dementia (E2111)
  
  
• Compliance with Ventilator Process Elements during LTCH stay (X3705)
  
  
• Cultural Competency Implementation Measure (E1919)
  
  
• Cultural Competency Reporting Measure (X3716)
  
  
• Delivered Dose in Peritoneal Dialysis Above Minimum (X3718)
  
  
• Delivered Dose of Dialysis Above Minimum - Composite Score (X2051)
  
  
• Delivered Dose of Hemodialysis Above Minimum (X3717)
  
  
• Documentation of Current Medications in the Medical Record (E0419)
  
  
• IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (S2634)
  
  
• IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (S2633)
  
  
• IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (S2636)
  
  
• IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (S2635)
  
  
• Medications Documentation Reporting (X3721)
  
  
• Percent of Patients with Pressure Ulcers That Are New or Worsened (X3704)
  
  
• Skilled Nursing Facility All-Cause 30 Day Post Discharge Readmission Measure (S2510)
  
  
• Venous Thromboembolism Prophylaxis (E0371)
  
  
• Ventilator Weaning (Liberation) Rate (X3706)
  
  

Full Measure Specifications

NQF Number (if applicable): 0171

Description: Percentage of home health stays in which patients were admitted to an acute care hospital during the 60 days following the start of the home health stay.

Numerator statement: Number of home health stays for patients who have a Medicare claim for an admission to an acute care hospital in the 60 days following the start of the home health stay.[For reference, numerator for endorsed measure from QPS: Number of home health stays for patients who have a Medicare claim for an unplanned admission to an acute care hospital in the 60 days following the start of the home health stay.]

Denominator statement: Number of home health stays that begin during the 12-month observation period. 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: Home health stays that begin with a Low Utilization Payment Adjustment (LUPA) claim. Home health stays in which the patient receives service from multiple agencies during the first 60 days. Home health stays for patients who are not continuously enrolled in fee-for-service Medicare for the 6 months prior to and the 60 days following the start of the home health stay or until death.[For reference, exclusions for endorsed measure from QPS: The following are excluded: home health stays for patients who are not continuously enrolled in fee-for-service Medicare during the numerator window (60 days following the start of the home health stay) or until death; home health stays that begin with a Low Utilization Payment Adjustment (LUPA) claim; home health stays in which the patient receives service from multiple agencies during the first 60 days; and home health stays for patients who are not continuously enrolled in fee-for-service Medicare for the 6 months prior to the start of the home health stay.]

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Administrative Claims

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Endorsed

NQF Number (if applicable): 2111

Description: The percentage of individuals 65 years of age and older with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition.

Numerator statement: The number of patients in the denominator who had at least one prescription and > 30 days supply for any antipsychotic medication during the measurement period and do not have a diagnosis of schizophrenia, bipolar disorder, Huntington’s disease or Tourette’s Syndrome.

Denominator statement: All patients 65 years of age and older continuously enrolled during the measurement period with a diagnosis of dementia and/or two or more prescription claims and >60 days supply for a cholinesterase inhibitor or an NMDA receptor antagonist.

Exclusions: None

HHS NQS Priority: Making Care Safer

HHS Data Source: Administrative Claims

Measure type: Process

Steward: Pharmacy Quality Alliance

Endorsement Status: Endorsed

NQF Number (if applicable): N/A

Description: This measure "Compliance with Ventilator Process Elements during LTCH stay" is a paired quality measure (QM#1 and QM#2); it assesses facility-level compliance with Ventilator Process Elements for eligible patients in the LTCH setting. Quality Measure #1: Compliance with Tracheostomy Collar Trial (TCT) or Spontaneous Breathing Trial (SBT) by the end of the first calendar day following admission to the LTCH. Quality Measure #2: Compliance with TCT or SBT during LTCH stay - day 2 through discharge date/ date when patient is fully weaned. Definitions: i. Invasive mechanical ventilation: The use of a device to assist or control pulmonary ventilation, either intermittently or continuously through a tracheostomy or by endotracheal intubation. ii. Tracheostomy Collar Trial: Trial of unassisted breathing via a tracheostomy collar (mask) with aerosol (mist), administered to patients with tracheostomy tubes. iii. Spontaneous Breathing Trial: Trial of unassisted breathing for at least X time period and full ventilator support at night, administered to patients with endotracheal tubes.

Numerator statement: QM#1: The percentage of patients who are admitted to a LTCH on invasive mechanical ventilation and for whom tracheostomy collar trial (TCT) or Spontaneous Breathing Trial (SBT) was assessed, ordered, and performed by the end of the first calendar day following admission to the LTCH. (a) Percentage of patients on invasive mechanical ventilation prior to admission for whom TCT or SBT was assessed, ordered and performed within 24 hours of admission. (b) Percentage of patients for whom TCT or SBT was not assessed, ordered and performed within 24 hours of admission. (c) Percentage of patients for whom TCT or SBT within 24 hours of admission was deemed medically inappropriate. QM#2: The total number of patient ventilator-days for patients discharged (unplanned discharge, planned discharge, death) during the reporting period who were admitted to the LTCH requiring invasive mechanical ventilation. (a) Percentage of ventilator days that TCT or SBT was assessed, ordered and performed during each day of invasive mechanical ventilation during the LTCH stay. (b) Percentage of ventilator days that TCT or SBT was not assessed, ordered and performed during each day of invasive mechanical ventilation during the LTCH stay. (c) Percentage of ventilator days that TCT or SBT was deemed medically inappropriate during each day of invasive mechanical ventilation LTCH stay.

Denominator statement: All patients admitted to the LTCH requiring invasive mechanical ventilation support of any duration at the time of admission to the LTCH during the reporting period. If a patient has more than one LTCH stay during the reporting period, then, each admission will be included in the measure calculation and reporting for QM#1. For QM#2, the patient population includes all discharged patients who are admitted to a LTCH on invasive mechanical ventilation. If a patient has more than one LTCH stay during the reporting period, then, each discharge will be included in the measure calculation and reporting for QM#2. Denominator for QM#2 is the total number of patient ventilator-days for patients discharged (unplanned discharge, planned discharge, death) during the reporting period who were admitted to the LTCH requiring invasive mechanical ventilation support of any duration at the time of admission to the LTCH.

Exclusions: Patients identified as unweanable at the time of admission to an LTCH are excluded. These include (a) patients who are chronically ventilated (i.e., who have been on invasive mechanical ventilator support for more than 180 days prior to admission to the short-stay acute care hospital (if it this stay preceded the current LTCH stay) or prior to admission to the LTCH, whichever is earlier) [this would include patients on a ventilator due to cerebral palsy since childhood); or (b) patients with an acute or chronic condition (for e.g., irreversible neurological injury or disease or dysfunction such as ALS, or high (C2) spinal cord injury that has rendered the patient unweanable. This measure also excludes patients admitted to LTCH and requiring on non-invasive mechanical ventilation. LTCHs with denominator counts of less than 20 in the sample during the reporting period will be excluded from public reporting, owing to small sample size.

HHS NQS Priority: Making Care Safer

HHS Data Source: LTCH CARE Data Set

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 1919

Description: The Cultural Competence Implementation Measure is an organizational survey designed to assist healthcare organizations in identifying the degree to which they are providing culturally competent care and addressing the needs of diverse populations, as well as their adherence to 12 of the 45 NQF-endorsed® cultural competency practices prioritized for the survey. The target audience for this survey includes healthcare organizations across a range of health care settings, including hospitals, health plans, community clinics, and dialysis organizations. Information from the survey can be used for quality improvement, provide information that can help health care organizations establish benchmarks and assess how they compare in relation to peer organizations, and for public reporting.

Numerator statement: The target audience for this survey includes health care organizations across a range of health care settings, including hospitals, health plans, community clinics, and dialysis organizations. The focus of the measure is the degree to which health care organizations have adopted or implemented 12 of the 45 NQF-endorsed cultural competency preferred practices.

Denominator statement: As mentioned above, the survey can be used to measure adherence to 12 of the 45-NQF endorsed cultural competence preferred practices. The survey could be used to focus on a particular type of health care organization, or more broadly to collect information across various organization types.

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Survey

Measure type: Process

Steward: RAND Corporation

Endorsement Status: Endorsed

NQF Number (if applicable): N/A

Description: This reporting measure is designed to collect data needed to score NQF #1919 in the ESRD QIP.

Numerator statement: Facility reports Cultural Competency survey data to CMS.

Denominator statement: N/A

Exclusions: None

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Survey

Measure type: Process

Steward: RAND Corporation

Endorsement Status: Not Endorsed

NQF Number (if applicable): N/A

Description: Percentage of all patient months whose delivered peritoneal dialysis dose was a weekly Kt/V urea of at least 1.7 within past four months (Adult >= 18) or 1.8 within past 6 months (pediatric <18).

Numerator statement: Number of patient months in the denominator whose delivered peritoneal dialysis was a weekly Kt/Vurea of at least 1.7 within past four months (Adult >=18) or 1.8 within past 6 months (pediatric <18).

Denominator statement: To be included in the denominator for a particular month, the patient must have been on dialysis for at least 90 days.

Exclusions: None

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Administrative Claims

Measure type: Intermediate Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): N/A

Description: Percentage of all patient months whose delivered dose of dialysis (either hemo or peritoneal) met the specified threshold. This measure is a composite of NQF #0318 and NQF #0249.

Numerator statement: Number of patients months in the denominator whose delivered dose of dialysis met the specified thresholds. The thresholds are as follows: • Hemodialysis (all ages): Kt/V >= 1.2 • Peritoneal dialysis (pediatric): Kt/V >= 1.8 (within past 6 months) • Peritoneal dialysis (adult): Kt/V >= 1.7 (within past 4 months)

Denominator statement: To be included in the denominator for a particular month, patients need to meet the following requirements that month: Peritoneal dialysis patients: All peritoneal dialysis patients who have been on dialysis for at least 90 days. Hemodialysis patients: Pediatric (<18 years old) in-center HD patients who have been on dialysis for 90 days or more and dialyzing thrice weekly, adult >= 18 years old) patients who have been on dialysis for 90 days or more and dialyzing thrice weekly.

Exclusions: Frequent hemodialysis patients >= 4 times per week).

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Administrative Claims

Measure type: Intermediate Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): N/A

Description: Percentage of all patient months whose average delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2.

Numerator statement: Number of patient months in denominator whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2.

Denominator statement: To be included in the denominator for a particular month, the patients must have been on dialysis for at least 90 days and must be dialyzing thrice weekly during the month.

Exclusions: Pediatric home hemodialysis patients and frequent hemodialysis patients >=4 times per week).

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: Administrative Claims

Measure type: Intermediate Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 0419

Description: Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

Numerator statement: Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration[For reference, the numerator for endorsed measure on QPS: Eligible professional attests to documenting, updating or reviewing a patient´s current medications using all immediate resources available on the date of the encounter. This list must include ALL prescriptions, over-the counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and routeNUMERATOR NOTE: The eligible professional must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible professionals reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible professional documented that the patient is not currently taking any medications.]

Denominator statement: All visits occurring during the 12 month reporting period for patients aged 18 years and older on the date of the encounter where one or more CPT or HCPCS codes are reported on the claims submission for that encounter. All discussed coding is listed in "2a1.7. Denominator Details" section below.[For reference, denominator for endorsed measure from QPS: All visits for patients aged 18 years and older]

Exclusions: A patient is not eligible or excluded (B) from the performance denominator (PD) if one or more of the following reason exists: • Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: EHR

Measure type: Process

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Endorsed

NQF Number (if applicable): 2634

Description: This quality measure estimates the average risk-adjusted mean change in mobility function between admission and discharge for patients discharged from an IRF.

Numerator statement: The mean change in mobility function.

Denominator statement: Patients discharged from the IRF.

Exclusions: Three exclusion criteria apply to the change in mobility function score quality measure: 1) Patients with incomplete stays: It can be challenging to gather accurate discharge functional status data for patients who experience incomplete stays. Patients with incomplete stays include patients who are unexpectedly discharged to an acute care setting (IPPS, CAH, IPF, or LTCH) due to a medical emergency; patients who die or leave an IRF against medical advice; and patients with a length of stay less than 3 days. 2) Patients who are independent with CARE mobility activities at the time of admission: Patients who are independent with the CARE mobility items at the time of admission are assigned the highest score on all the mobility items, and thus, would not be able to show functional improvement on this same set of items at discharge. 3) Patients younger than age 21.

HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination

HHS Data Source: Other

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 2633

Description: This measure estimates the average risk-adjusted mean change in self-care function between admission and discharge for patients discharged from IRFs.

Numerator statement: The mean change in self-care function.

Denominator statement: Patients discharged from the IRF.

Exclusions: Four exclusion criteria apply to the change in self-care function score measure: 1) Patients with incomplete stays: It can be challenging to gather accurate discharge functional status data for patients who experience incomplete stays. Patients with incomplete stays include patients who are unexpectedly discharged to an acute-care setting (Inpatient Prospective Payment System, Critical Access Hospital, Inpatient Psychiatric Hospital, or LTCH) due to a medical emergency; patients who die; patients who leave an IRF against medical advice; and patients with a length of stay less than 3 days. 2) Patients who are independent with CARE self-care activities at the time of admission: Patients who are independent with the CARE self-care items at the time of admission are assigned the highest score on all the self-care items, and thus, would not be able to show functional improvement on this same set of items at discharge. 3) Patients in coma, persistent vegetative state, complete teraplegia, and locked-in syndrome are excluded, because they may have limited or less predictable self-care improvement. 4) Patients younger than age 21.

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Other

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 2636

Description: This measure calculates the percent of patients who meet or exceed an expected discharge mobility score.

Numerator statement: The number of patients who meet or exceed an expected discharge mobility score.

Denominator statement: Patients discharged during the selected time period.

Exclusions: Two exclusion criteria apply to the discharge mobility function score measure: 1) Patients with incomplete stays: It can be challenging to gather accurate discharge functional status data for patients who experience incomplete stays. Patients with incomplete stays include patients who are unexpectedly discharged to an acute-care setting (IPPS, CAH, or LTCH) due to a medical emergency; patients who die or leave an IRF against medical advice; and patients with a length of stay less than 3 days. 2) Patients younger than age 21.

HHS NQS Priority: Patient and Family Engagement

HHS Data Source: Other

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 2635

Description: This quality measure calculates the percent of patients who meet or exceed an expected discharge self-care score in IRFs.

Numerator statement: The number of patients who meet or exceed an expected discharge self-care score.

Denominator statement: Patients discharged during the selected time period.

Exclusions: Two exclusion criteria apply to the discharge in self-care function quality measure: 1) Patients with incomplete stays: It can be challenging to gather accurate discharge functional status data for patients who experience incomplete stays. Patients with incomplete stays include patients who are unexpectedly discharged to an acute-care setting (IPPS, CAH, IPF, or LTCH) due to a medical emergency; patients who die or leave an IRF against medical advice; and patients with a length of stay less than 3 days. 2) Patients younger than age 21.

HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination

HHS Data Source: Other

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): N/A

Description: This reporting measure is designed to collect data needed to score NQF #0419 in the ESRD QIP.

Numerator statement: For each eligible patient-visit, facility reports whether or not the patient's list of current medications is documented.

Denominator statement: All eligible patient visits.

Exclusions: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: CROWNWeb

Measure type: Structure

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): N/A

Description: Percentage of home health episodes of care in which the patient is discharged from home health with one or more pressure ulcer(s) that are Stage 2 - 4 or unstageable due to slough or eschar and are new or worsened since the start or resumption of care. The measure is based on data obtained from the Outcome Assessment and Information Set (OASIS-C1) Data Item Set.

Numerator statement: Number of home health episodes of care in which the patient is discharged from home health with one or more pressure ulcer(s) that are Stage 2 - 4 or unstageable due to slough or eschar and are new or have worsened since the start or resumption of care.

Denominator statement: Number of home health episodes of care ending with a discharge during the reporting period, other than those covered by generic or measure-specific exclusions.

Exclusions: Episodes of care ending with a transfer to an inpatient setting or death are excluded from the denominator. HHA's with denominator counts of less than 20 in the sample will be excluded from public reporting owing to small sample size.

HHS NQS Priority: Effective Prevention and Treatment

HHS Data Source: OASIS-C1

Measure type: Intermediate Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 2510

Description: 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. A risk-adjusted readmission rate for each facility is calculated as follows: Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk-standardized ratio is the indicator of a facility’s effects on readmission rates. Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility-level standardized readmission rate. For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 - 5 for a list of planned procedures. The measure specifications are designed to harmonize with CMS’s hospital-wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital-level, risk-standardize rate of unplanned, all-cause readmissions within 30 days of a hospital discharge and uses the same 30-day risk window as the SNFRM.

Numerator statement: The numerator is 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.

Denominator statement: The denominator includes all patients who have been admitted to a SNF within one day of discharge from a prior proximal hospitalization, taking denominator exclusions into account.

Exclusions: Numerator exclusions: We exclude for planned readmissions as per the HWR measure. Denominator exclusions: The following are excluded from the denominator: 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. 2. SNF stays with a gap of greater than 1 day between discharge from the prior proximal hospitalization and the SNF admission. 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 for the 11 months prior to that discharge). 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). 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. 6. SNF stays where the patient was discharged from the SNF against medical advice. 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”.

HHS NQS Priority: Communication and Care Coordination

HHS Data Source: Administrative Claims

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status: Not Endorsed

NQF Number (if applicable): 0371

Description: This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. This measure is part of a set of six nationally implemented prevention and treatment measures that address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Hospital Acquired Potentially-Preventable VTE) that are used in The Joint Commission’s accreditation process.

Numerator statement: Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given: • the day of or the day after hospital admission • the day of or the day after surgery end date for surgeries that start the day of or the day after hospital admission

Denominator statement: All discharged hospital inpatients

Exclusions: Patients less than 18 years of age • Patients who have a length of stay (LOS) less than two days and greater than 120 days • Patients with Comfort Measures Only documented on day of or day after hospital arrival • Patients enrolled in clinical trials related to VTE • Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU LOS greater than or equal to one day • Patients with ICD-9-CM Principal Diagnosis Code of Mental Disorders or Stroke as defined in Appendix A, Table 7.01, 8.1 or 8.2 • Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics or VTE as defined in Appendix A, Table 7.02, 7.03 or 7.04 • Patients with ICD-9-CM Principal Procedure Code of Surgical Care Improvement Project (SCIP) VTE selected surgeries as defined in Appendix A, Tables 5.17, 5.19, 5.20, 5.21, 5.22, 5.23, 5.24

HHS NQS Priority: Making Care Safer

HHS Data Source: EHR, Paper Medical Record

Measure type: Process

Steward: The Joint Commission

Endorsement Status:

NQF Number (if applicable): N/A

Description: This measure assesses facility-level patient weaning (liberation) rate for patients in the LTCH setting. This measure reports the percentage of patients who are discharged from a Long-Term Care Hospital (LTCH) and reported as successfully (fully) weaned at discharge. The measure will analyze and report the fully weaned and not weaned separately for patients discharged alive. The measure will also analyze and report on weaning status of patients who die. Definitions: i. Invasive mechanical ventilation: The use of a device to assist or control pulmonary ventilation, either intermittently or continuously through a tracheostomy or by endotracheal intubation. ii. Weaning covers the entire process of liberating the patient from invasive mechanical ventilation support. iii. Fully weaned: Patients who are discharged alive from a LTCH and require no invasive mechanical ventilation support for 72 consecutive hours or more during 3 consecutive days immediately prior to discharge. iv. Not weaned (invasive mechanical ventilation dependent): Patients who require continuous invasive mechanical ventilation support for more than 12 consecutive hours per day during each of the 3 consecutive calendar days immediately prior to discharge.

Numerator statement: The ventilator weaning rate will be calculated and reported for the following four numerator components separately. Each of the numerator components will be calculated and reported as a percentage of all patients requiring invasive mechanical ventilation immediately prior to admission to an LTCH: (a) Fully weaned: Patients who are discharged alive and fully weaned prior to discharge from an LTCH. (b) Not weaned (invasive mechanical ventilation dependent): Patients who are discharged alive and require invasive mechanical ventilation support for more than 12 consecutive hours per day during each of the three consecutive calendar days immediately prior to discharge. (c) Patients who died.

Denominator statement: All patients requiring continuous invasive mechanical ventilation support of any duration immediately prior to admission to an LTCH. Patients discharged (unplanned discharge, planned discharge, death) from the LTCH during the reporting period. If patient has had more than one LTCH stay during the reporting period, then, each LTCH stay will be included in the measure calculation and reporting. If patient is admitted to LTCH, weaned, has to return to the short-stay acute care hospital for a procedure, surgery, or some other reason, returns to the LTCH within 3 calendar days, and then, is the discharged from the LTCH, this is considered one “patient stay”. However, if patient returns to the LTCH after 3 calendar days, a new admission assessment is conducted and this will be the start of a “second patient stay” for this same patient. Each of these two stays will be included in the measure calculation and reporting.

Exclusions: Patients identified as unweanable at the time of admission to an LTCH are excluded. These include (a) patients who are chronically ventilated (i.e., who have been on invasive mechanical ventilator support for more than 180 days prior to admission to the short-stay acute care hospital (if it this stay preceded the current LTCH stay) or prior to admission to the LTCH, whichever is earlier) [this would include patients on a ventilator due to cerebral palsy since childhood); or (b) patients with an acute or chronic condition (for e.g., irreversible neurological injury or disease or dysfunction such as ALS, or high (C2) spinal cord injury that has rendered the patient unweanable. This measure also excludes patients admitted to LTCH and requiring on non-invasive mechanical ventilation. LTCHs with denominator counts of less than 20 in the sample during the reporting period will be excluded from public reporting, owing to small sample size.

HHS NQS Priority: Making Care Safer

HHS Data Source: LTCH CARE Data Set

Measure type: Outcome

Steward: Centers for Medicare & Medicaid Services

Endorsement Status:

Program Index

• Medicare Shared Savings Program 
  
  
• Long-Term Care Hospitals Quality Reporting Program 
  
  
• Hospice Quality Reporting Program 
  
  
• Inpatient Rehabilitation Facilities Quality Reporting Program 
  
  
• Skilled Nursing Facilities Value-Based Purchasing 
  
  
• Home Health Quality Reporting Program 
  
  
• End-Stage Renal Disease Quality Incentive Program  
  
  

Full Program Summaries

Program Type: MSSP is a combination pay for reporting and pay for performance program.

Incentive Structure: Option for one-sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year) or a two-sided risk model (sharing of savings and losses for all three years).

Program Goals: “Facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs.”

Critical Program Objectives:

• Improve the overall health for a population of Medicare Fee-For-Service (FFS) beneficiaries and ensuring that care improvements and health outcomes are widely shared across subpopulations;
• Improve quality and health outcomes while lowering the rate of growth of healthcare spending;
• Encourage coordination and shared accountability by including measures relevant to individuals with multiple chronic condition, measures in all settings that patients receive care (including ambulatory, acute, and post-acute settings), measures that span different parts of the life span and different types of patients (such as including end of life or patients receiving palliative care), and measures that span across settings;
• Promote alignment across other quality measurement reporting programs;
• Include more high-value measures such as:
• Patient-reported outcome measures in the areas of depression remission, functional status, and smoking;
• Patient-reported outcome measures  for medically complex patients (e.g., chronically ill or those with multiple chronic conditions);
• Measure of health risks with follow-up interventions;
• Cost and resource use measures; and
• Appropriate use measures.

Program Update: For 2014, the MSSP program has 33 measures that may be submitted through a CMS web interface, currently the group practice reporting (GPRO) web interface, calculated by CMS from internal and claims data, and collected through a patient and caregiver experience of care  survey.  
The 2015 Physician Fee Schedule final rule includes the following changes:

• Modifying the measure set (added 8 measures, retired/replaced 8)  to be more outcome-oriented and reduce the reporting burden on ACOs;
• Modifying benchmarking approach for topped-out measures;
• Interest in aligning with physician programs (like Value-Based Payment Modifier and EHR incentive program);
• Finalized that CMS will award ACOs for quality improvement and that ACOs entering their second or subsequent agreement period will be assessed on the quality performance standard that would otherwise apply to an ACO if It were in the third performance year of the first agreement; and
• Sought input on (proposed rule):
• Measures that might be used to assess the ACO’s performance with respect to care coordination in post-acute care and other settings;
• Specific caregiver experience of care measures that might be considered in future rulemaking;
• Suggestions of new measures of the quality of care furnished to the frail elderly population; and
• Measures/tools to assess changes in physical and mental health over time.

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: Failure to submit required quality data, beginning in FY 2014 and for each year thereafter, shall result in a 2 percentage point reduction to the market basket percentage increase for that fiscal year.   The data must be made publicly available, with Hospice Programs having an opportunity to review the data prior to its release. No date has been specified to begin public reporting of hospice quality data. 

Program Goals: Hospice care uses an interdisciplinary approach to deliver medical, nursing, social, psychological, emotional, and spiritual services through the use of a broad spectrum of professional and other caregivers and volunteers. The goal of hospice care is to make the hospice patient as physically and emotionally comfortable as possible, with minimal disruption to normal activities, while remaining primarily in the home environment.

Critical Program Objectives: Statutory Requirements

• As of July 1, 2014, all Medicare-certified hospices are required to submit an HIS-Admission record and HIS-Discharge record for each patient admission to their hospice.
• The HIS is a patient-level data collection tool developed as part of the HQRP, which can be used to collect data to calculate 6 National Quality Forum-endorsed (NQF) Measures and 1 modified NQF Measure: 
1. NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen
2. NQF #1634 Pain Screening
3. NQF #1637 Pain Assessment
4. NQF #1638 Dyspnea Treatment
5. NQF #1639 Dyspnea Screening
6. NQF #1641 Treatment Preferences
7. Modified NQF #1647 Beliefs/Values Addressed (if desired by the patient)

• Include measures addressing concepts such as goal attainment, patient engagement, care coordination, depression, caregiver’s role, and timely referral to hospice.   

• Develop an outcome measure addressing pain. 
• Select measures that address care coordination, communication, timeliness/responsiveness of care, and access to the healthcare team on a 24-hour basis.  

Program Update:

• FY 2015 Hospice Final Rule: 
• CMS finalized the Hospice Item Set (HIS) in last year’s rule to meet the quality reporting requirements for hospices for the FY 2016 payment determination (data submission takes effect on or after July 1, 2014) and each subsequent year. HIS to be used by all hospices to collect and submit standardized data items about each patient admitted to hospice. 
• The CAHPS Hospice Survey has a Jan 1, 2015 implementation date. (Participation requirements for the survey begin January 1, 2015 for the FY 2017 annual payment update.)

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

Program Type: Pay for Performance, Public Reporting

Incentive Structure: Under this program, payments to dialysis facilities are reduced if facilities do not meet or exceed the required total performance score, which is the sum of the scores for established individual measures during a defined performance period. Payment reductions are on a sliding scale, which could amount to a maximum of two percent per year.  Facility performance in the End Stage Renal Disease Quality Incentive Program (ESRD QIP) is publicly reported through three mechanisms: Performance Score Certificate, the Dialysis Facility Compare website, and ESRD QIP Dialysis Facility Performance Information. 

Program Goals: Improve the quality of dialysis care and produce better outcomes for beneficiaries. 

Critical Program Objectives: Statutory Requirements

• Program measure set should include measures of anemia management that reflect labeling approved by the Food and Drug Administration (FDA), dialysis adequacy, patient satisfaction, iron management, bone mineral metabolism, and vascular access. 

• Measure set expand beyond dialysis procedures to include nonclinical aspects of care such as care coordination, medication reconciliation, functional status, patient engagement, pain, falls, and measures covering comorbid conditions such as depression. 
• Explore whether the clinically focused measures could be combined in a composite measure for assessing optimal dialysis care. 

• Outcome measures are preferred
• Inclusion of pediatric measures to assess the pediatric population that has been largely excluded from the existing measures
• Identify appropriate data elements and sources to support measures

Program Update:

• Final rule for End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2015:   
• Final measure set for the PY 2017 ESRD QIP
• Continue using measures finalized for the PY 2016 program measure set except one measure: the Hemoglobin Greater than 12 g/dl, which CMS has finalized to remove because it is topped out.
• Adopt the Standardized Readmission Ratio (SRR) clinical measure, which is currently under review by NQF (NQF#2496) and addresses care coordination. MAP had supported the direction of the measure concept in the 2013 pre-rulemaking.
• Final measure set for the PY 2018 ESRD QIP
• Continue using measures finalized for the PY 2017 program measure set with the exception of the ICH CAHPS reporting measure, which will be converted to a clinical measure, 0258 In-center hemodialysis CAHPS Survey.
• Adopt three new measures which are based on NQF-Endorsed measures that MAP supported in 2014 (NQF #0420, NQF #0418, NQF #0431).  CMS is finalizing to adopt the following measures as a reporting measure until such time that they can collect the baseline data needed to score it as a clinical measure:
• Pain Assessment and Follow-Up, a reporting measure.
• Depression Screening and Follow-Up, a reporting measure
• NHSN Healthcare Personnel Influenza Vaccination, a reporting measure
• Adopt two additional new measures including: Percentage of pediatric peritoneal dialysis patient-months with spKt/V greater than or equal to 1.8, which was conditionally supported by MAP in 2014, and Standard Transfusion Ratio which MAP had supported the direction of in the 2013 pre-rulemaking.
• Dialysis Facility Compare Star Ratings 
• CMS has finalized the methodology for its Dialysis Facility Compare (DFC) Star Rating Program and is providing all Medicare-participating dialysis facilities a 15 day review period to review their data and star rating before they are posted on Dialysis Facility Compare in January 2015.
• The DFC Star Rating is based on the following nine measures, which will be grouped into three domains for evaluation purposes:
• Standardized Mortality Ratio (SMR) (NQF #0369)
• Standardized Hospitalization Ratio (SHR) (NQF#1463)
• Standardized Transfusion Ratio (STrR)
• Percentage of adult hemodialysis (HD) patients who had enough wastes removed from their blood during dialysis (NQF #0249)
• Percentage of pediatric hemodialysis (HD) patients who had enough wastes removed from their blood during dialysis (NQF #1423)
• Percentage of adult peritoneal dialysis (PD) patients who had enough wastes removed from their blood during dialysis (NQF #0318)
• Percentage of adult dialysis patients who had hypercalcemia (NQF #1454)
• Percentage of adult dialysis patients who received treatment through arteriovenous fistula (NQF #0257)
• Percentage of adult patients who had a catheter left in vein longer than 90 days for their regular hemodialysis treatment (NQF #0256)
• CMS will stop publicly reporting two quality measures from the DFC website, the URR dialysis adequacy measure and the Hemoglobin greater than 12 g/dl. These measures no longer provide meaningful information because they are topped out.