NQF

Agenda Synopsis

Full Agenda

Measure Index

• CoreQ: Short Stay Discharge Measure (Public comments received:7; MUC ID: MUC17-258)
  
  

Full Measure Information

Measure Specifications

• NQF Number (if applicable): 2614
  
  
• Description: The measure calculates the percentage of individuals discharged in a six-month time period from a SNF, within 100 days of admission, who are satisfied. This patient reported outcome measure is based on the CoreQ: Short Stay Discharge questionnaire that utilizes four items. The following are the four items: 1. In recommending this facility to your friends and family, how would you rate it overall? (Poor, Average, Good, Very Good, or Excellent) 2. Overall, how would you rate the staff? (Poor, Average, Good, Very Good, or Excellent) 3. How would you rate the care you receive? (Poor, Average, Good, Very Good, or Excellent) 4. How would you rate how well your discharge needs were met? (Poor, Average, Good, Very Good, or Excellent)
  
  
• Numerator: The numerator is the sum of the individuals in the facility that have an average satisfaction score of greater than or equal to 3 for the four questions on the CoreQ: Short Stay Discharge questionnaire that utilizes four items. The following are the four items: 1. In recommending this facility to your friends and family, how would you rate it overall? (Poor, Average, Good, Very Good, or Excellent) 2. Overall, how would you rate the staff? (Poor, Average, Good, Very Good, or Excellent) 3. How would you rate the care you receive? (Poor, Average, Good, Very Good, or Excellent) 4. How would you rate how well your discharge needs were met? (Poor, Average, Good, Very Good, or Excellent)
  
  
• Denominator: The denominator includes all of the patients that are admitted to the SNF, regardless of payor source, for post-acute care, that are discharged within 100 days; who receive the survey (e.g. people meeting exclusions do not receive a questionnaire) and who respond to the CoreQ: Short Stay Discharge questionnaire within two months of receiving the questionnaire.
  
  
• Exclusions: Exclusions made at the time of sample selection and the following: (1) Patients who died during their SNF stay; (2) Patients discharged to a hospital, another SNF, psychiatric facility, inpatient rehabilitation facility or long term care hospital; (3) Patients with court appointed legal guardian for all decisions; (4) Patients discharged on hospice; (5) Patients who left the nursing facility against medical advice (AMA); (6) Patients who have dementia impairing their ability to answer the questionnaire defined as having a BIMS score on the MDS 3.0 as 7 or lower. [Note: we understand that some SNCCs may not have information on cognitive function available to help with sample selection. In that case, we suggest administering the survey to all residents and assume that those with cognitive impairment will not complete the survey or have someone else complete on their behalf which in either case will exclude them from the analysis.] Additionally, once the survey is administered, the following exclusions are applied: (a) Patients who responded after the two-month response period; and (b) Patients whose responses were filled out by someone else. (Note this does not include cases where the resident solely had help such as reading the questions or writing down their responses.) Surveys returned as un-deliverable are also excluded from the denominator.
  
  
• HHS NQS Priority: Patient and Family Engagement, Communication and Care Coordination
  
  
• HHS Data Source: Administrative Clinical Data, Other
  
  
• Measure Type: Patient Reported Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status: Endorsed
  
  
• Changes to Endorsed Measure Specifications?: The MUC list indicates the measure has been modified from its endorsed version.
  
  
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Support
  
  
• Preliminary analysis summary
  • Contribution to program measure set:MAP has stressed the important of patient centered care. This measure would address a MAP PAC/LTC Core Concept of patient experience that is not currently addressed in the program measure set.
  • Impact on quality of care for patients:Patient satisfaction is a high-priority domain for performance improvement across Medicare pay-for-reporting and pay-for-performance programs. As there is a substantial performance gap across most skilled nursing facilities tested, the positive impact on quality of care brought about by this performance measure is likely to be substantial.
  
  
  
• Does the measure address a critical quality objective not adequately addressed by the measures in the program set? Yes. At present, the SNF QRP does not include any patient-reported outcome measures, nor any measures directly addressing patient satisfaction. Moreover, one of the four questions in the survey addresses satisfaction with discharge, a component of quality CMS has identified as a high-priority domain.
  
  
• Is the measure evidence-based and is either strongly linked to outcomes or an outcome measure? The measure is a patient-reported outcome measuring satisfaction across four items: 1) recommendation to friends and family, 2) overall rating, 3) care rating, and 4) discharge needs met rating. . The measure is a patient-reported outcome measuring satisfaction across four items: 1) recommendation to friends and family, 2) overall rating, 3) care rating, and 4) discharge needs met rating. The measure result is a non-weighted percentage score: • The numerator is the number of patients who are discharged from a SNF, within 100 days of admission, who are satisfied. • The denominator is all patients that are admitted to the SNF, regardless of payor source, for post-acute care, that are discharged within 100 days; who receive the survey (e.g. people meeting exclusions do not receive a questionnaire) and who respond to the CoreQ: Short Stay Discharge questionnaire within the time window. • Satisfied individuals are those that have an average satisfaction score of =>3 for the four questions on the CoreQ: Short Stay Discharge questionnaire
  
  
• Does the measure address a quality challenge? Yes. Testing of the measure score indicated there is a significant performance gap. The median score is 82.5 (out of 100), indicating substantial room for improvement. Moreover, performance is largely clustered around the median - 75th percentile performance is at 88.6, so even top performers have the potential to improve patient satisfaction.
  
  
• Does the measure contribute to efficient use of resources and/or support alignment of measurement across programs? Yes. Patient satisfaction surveys are currently in use across several Medicare programs, including the HCAHPS survey used in the Hospital Inpatient Quality Reporting Program and the Hospital Value-Based Purchasing Program and the Home Health CAHPS survey used in the Home Health Quality Reporting Program. During the NQF endorsement review of this measure, it was noted that this measure could potentially compete with the Nursing Home CAHPS survey. However, the measures derived from NH CAHPS have lost NQF endorsement and AHRQ has noted a lack of resources to maintain them. This MUC is derived from an instrument that contains four items, making it brief compared to other patient satisfaction surveys. The develop notes that this measure has already integrated into existing systems as a consequence of the testing regimen. However, it may be necessary for nursing home to work with a vendor to collect the required data. During the endorsement review the developer noted there were no fees associated with the use of the measure. The developer did not indicate if there are fees associated with the use of the survey.
  
  
• Can the measure can be feasibly reported? Yes. The data sources for the measure are the CoreQ: Short Stay Discharge questionnaire and Resident Assessment Instrument Minimum Data Set (MDS) version 3.0. The developer notes that satisfaction survey vendors have already incorporated the MUC’s data elements in their software. The ACHA website lists customer satisfaction vendors using the CoreQ.
  
  
• Is the measure reliable and valid for the level of analysis, program, and/or setting(s) for which it is being considered? Yes. NQF #2614 is endorsed for the facility level of analysis. NQF# 2614 was evaluated as part of the third phase of the 2015-2017 Person and Family-Centered Care project. The PFCC Standing Committee voted by margins of 78% and 83% to advance the measure based on NQF’s criteria for reliability and validity, respectively. During the review of scientific acceptability, committee members raised concerns that patients who have dementia impairing their ability to answer the questionnaire defined as having a BIMS score on the MDS as 7 or lower were excluded from the measure and that these exclusions could limit the generalizability of the survey. The developer agreed that cognitive impairment does have an effect in this setting and that by having everyone use the BIMs score, which is used to get a snapshot of how well someone is functioning cognitively at a given moment, allows for a more consistent approach across all nursing home residents. A standardized approach helps reduce the incidence of gaming. Ultimately, the Committee was in agreement with the indirect standardization procedure used in this measure to adjust for the impairment type of the patient, functional status at admission, and age at admission. The measure does not use another risk adjustment approach to address additional clinical or social risk factors.
  
  
• Measure development status: Fully Developed
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Endorsed
  
  

Rationale for measure provided by HHS
Collecting satisfaction information from skilled nursing facility (SNF) patients is more important now than ever. We have seen a philosophical change in healthcare that now includes the patient and their preferences as an integral part of the system of care. The Institute of Medicine (IOM) endorses this change by putting the patient as central to the care system (IOM, 2001). For this philosophical change to person-centered care to succeed, we have to be able to measure patient satisfaction for these three reasons: (1) Measuring satisfaction is necessary to understand patient preferences. (2) Measuring and reporting satisfaction with care helps patients and their families choose and trust a health care facility. (3) Satisfaction information can help facilities improve the quality of care they provide. The implementation of person-centered care in SNFs has already begun, but there is still room for improvement. The Centers for Medicare and Medicaid Services (CMS) demonstrated interest in consumers’ perspective on quality of care by supporting the development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for patients in nursing facilities (Sangl et al., 2007). Further supporting person-centered care and resident satisfaction are ongoing organizational change initiatives. These include: the Advancing Excellence in America’s Nursing Homes campaign (2006), which lists person-centered care as one of its goals; Action Pact, Inc., which provides workshops and consultations with nursing facilities on how to be more person-centered through their physical environment and organizational structure; and Eden Alternative, which uses education, consultation, and outreach to further person-centered care in nursing facilities. All of these initiatives have identified the measurement of resident satisfaction as an essential part in making, evaluating, and sustaining effective clinical and organizational changes that ultimately result in a person-centered philosophy of care. The importance of measuring resident satisfaction as part of quality improvement cannot be stressed enough. Quality improvement initiatives, such as total quality management (TQM) and continuous quality improvement (CQI), emphasize meeting or exceeding “customer” expectations. William Deming, one of the first proponents of quality improvement, noted that “one of the five hallmarks of a quality organization is knowing your customer’s needs and expectations and working to meet or exceed them” (Deming, 1986). Measuring resident satisfaction can help organizations identify deficiencies that other quality metrics may struggle to identify, such as communication between a patient and the provider. As part of the U.S. Department of Commerce renowned Baldrige Criteria for organizational excellence, applicants are assessed on their ability to describe the links between their mission, key customers, and strategic position. Applicants are also required to show evidence of successful improvements resulting from their performance improvement system. An essential component of this process is the measurement of customer, or resident, satisfaction (Shook & Chenoweth, 2012). The CoreQ: Short Stay Discharge questionnaire can strategically help nursing facilities achieve organizational excellence and provide high quality care by being a tool that targets a unique and growing patient population. Over the past several decades, care in nursing facilities has changed substantially. Statistics show that more than half of all elders cared for in nursing homes are now discharged home (approximately 1.6 million residents; CMS, 2009). Moreover, when satisfaction information from current residents (i.e., long stay residents) is compared with those of elders discharged home, substantial differences exist (Castle, 2007). This indicates that long stay and short stay residents are different populations with different needs in the nursing facilities. Moreover, residents are more likely to follow medical advice when they rate their care as satisfactory (Hall, Milburn, Roter, & Daltroy, 1998). Thus, the CoreQ: Short Stay Discharge questionnaire measure is needed to improve the care for short stay SNF patients. Furthermore, improving the care for short stay nursing home patients is tenable. A review of the literature on satisfaction surveys in nursing facilities (Castle, 2007) concluded that substantial improvements in resident satisfaction could be made in many nursing facilities by improving care (i.e., changing either structural or process aspects of care). This was based on satisfaction scores ranging from 60 to 80% on average. It is worth noting, few other generalizations could be made because existing instruments used to collect satisfaction information are not standardized. Thus, bench-marking scores and comparison scores (i.e., best in class) were difficult to establish. The CoreQ: Short Stay Discharge measure has considerable relevance in establishing benchmarking scores and comparison scores. This measure’s relevance is furthered by recent federal legislative actions. The Affordable Care Act of 2010 requires the Secretary of Health and Human Services (HHS) to implement a Quality Assurance & Performance Improvement Program (QAPI) within nursing facilities. This means all nursing facilities have increased accountability for continuous quality improvement efforts. In CMS’s “QAPI at a Glance” document there are references to customer-satisfaction surveys and organizations utilizing them to identify opportunities for improvement. Lastly, the new “Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities” proposed rule includes language purporting the importance of satisfaction and measuring satisfaction. CMS states “CMS is committed to strengthening and modernizing the nation’s health care system to provide access to high quality care and improved health at lower cost. This includes improving the patient experience of care, both quality and satisfaction, improving the health of populations, and reducing the per capita cost of health care.” There are also other references in proposed rules speaking to improving resident satisfaction and increasing person-centered care (Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, 2015). The CoreQ: Short Stay Discharge measure has considerable applicability to both of these initiatives. References: Castle, N.G. (2007). A literature review of satisfaction instruments used in long-term care settings. Journal of Aging and Social Policy, 19(2), 9-42. CMS (2009). Skilled Nursing Facilities Non Swing Bed - Medicare National Summary. http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/NationalSum2007.pdf CMS, University of Minnesota, and Stratis Health. QAPI at a Glance: A step by step guide to implementing quality assurance and performance improvement (QAPI) in your nursing home. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf. Deming, W.E. (1986). Out of the crisis. Cambridge, MA. Massachusetts Institute of Technology, Center for Advanced Engineering Study. Hall J, Milburn M, Roter D, Daltroy L. Why are sicker patients less satisfied with their medical care? Tests of two explanatory models. Health Psychol. 1998;17(1):70-75. Institute of Medicine (2001). Improving the Quality of Long Term Care, National Academy Press, Washington, D.C., 2001. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Department of Health and Human Services. 80 Fed. Reg. 136 (July 16, 2015) (to be codified at 42 CFR Parts 405, 431, 447, et al.). MedPAC. (2015). Report to the Congress: Medicare Payment Policy. http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf. Sangl, J., Bernard, S., Buchanan, J., Keller, S., Mitchell, N., Castle, N.G., Cosenza, C., Brown, J., Sekscenski, E., and Larwood, D. (2007). The development of a CAHPS instrument for nursing home residents. Journal of Aging and Social Policy, 19(2), 63-82. Shook, J., & Chenoweth, J. (2012, October). 100 Top Hospitals CEO Insights: Adoption Rates of Select Baldrige Award Practices and Processes. Truven Health Analytics. http://www.nist.gov/baldrige/upload/100-Top-Hosp-CEO-Insights-RB-final.pdf.

Summary of NQF Endorsement Review

• Year of Most Recent Endorsement Review: 2017
  
  
• Project for Most Recent Endorsement Review: Person and Family Centered Care Project 2016-2017
  
  
• Review for Importance: 1a. Evidence, 1b. Performance Gap)1a. Evidence: Y-17; N-1; 1b. Performance Gap: H-7; M-10; L-1; I-0Rationale: • Committee members noted that this is a very significant measure for those who go into a nursing home or a SNF who will not stay indefinitely or for a long period of time. Measuring patient satisfaction and the rate of discharges back into the community is very important to measurement as including the patient and their preferences is becoming an integral part of healthcare’s changing landscape. Additionally, measuring and reporting satisfaction with carehelps patients and their families choose and trust a healthcare facility and can help facilities improve the quality of the care they provide. • One committee member had a question about the scale being used for this measure and felt that the choice of the response scale (poor, average, good, very good, and excellent) seemed heavily weighted towards positive responses. The developer explained that they did focus groups and cognitive testing of different response scales from ten points down to four point Likert scales and found that no matter how they captured responses, they had different satisfaction scores but the relative ranking remained the same. • Overall, committee members liked that there was a conceptual framework at the beginning of the measure submission form that linked the measure with information on additional improvement programs, organizational change initiatives, and policies that are going on both atthe federal level and the facility level.
  
  
• Review for Scientific Acceptability: 2a. Reliability: H-6; M-8; L-4; I-0 2b. Validity: H-6; M-9; L-3; I-0 Rationale: • One committee member felt that the exclusions may limit the generalizability to a small proportion of facility nursing home patients. • There was additional concern around the consistency of implementation across facilities and the possibility that scores could be compromised by the low response rate. 27 • Committee members also questioned the test/retest reliability at the patient level and sample size. The developer explained that the data elements were tested using a test-retest methodology: the survey was sent out and responses received from 853 patients; 100 were resurveyed one month later. The developer responded to these concerns by saying that while morbidity does occur, and may affect the data, there is an emphasis on making sure that both the voice of the patient and the voice of the family are heard. • There was also discussion around cognitive impairment and the effect this has on the survey’s overall responses. The developer agreed that cognitive impairment does have an effect in this setting and that by having everyone use the BIMs score, which is used to get a snapshot of how well someone is functioning cognitively at a given moment, allows for a more consistent approach across all nursing home residents. A standardized approach helps reduce the incidence of gaming. • One committee member had a question on the methodology used to reduce the number of items in the tool and how they got from 22 to 4 items without losing some precision. The developer responded that the process was extremely iterative and was done hundreds of times. The purpose of this was to try and get to the items that were capturing the most satisfaction information that did not overlap with other items and if two items correlated very highly, it made sense to drop one of them. • All members agreed with the decision not to risk adjust as it is inappropriate to control out differences based on sociodemographic factors. • Cognitive testing was done with family members, residents, and with short stay residents. The developers collected more than 100 responses from each population at facilities in Pittsburgh. This testing was conducted by reading questions and having the testing groups respond back based on what they thought was being asked and if they felt it could be asked differently. The committee indicated providing the results of this testing, although supplemental, would have been useful information.
  
  
• Review for Feasibility: 3. Feasibility: H-5; M-13; L-0; I-0(3a. Clinical data generated during care delivery; 3b. Electronic sources; 3c. Susceptibility to inaccuracies/unintended consequences identified 3d. Data collection strategy can be implemented)Rationale:• The committee agreed that this tool is timely as there is currently no required experience ofcare reporting or measurement in the SNF population.• Members appreciated that this tool is brief especially since the staffing in this area tends to bevery sparse.
  
  
• Review for Usability: 4. Usability and Use: H-5; M-11; L-2; I-0(Used and useful to the intended audiences for 4a. Accountability and Transparency; 4b. Improvement;and 4c. Benefits outweigh evidence of unintended consequences)Rationale:• The committee did not have any concerns or questions about the use and usability.285. Related and Competing Measures• This measure was identified as related with #2615: CoreQ: Long-Stay Resident Measure and#2616: CoreQ: Long-Stay Family Measure, submitted by the same developer.
  
  
• Review for Related and Competing Measures: 5. Related and Competing Measures• No related or competing measures noted.
  
  
• Endorsement Public Comments: 6. Public and Member Comment• No comments were received on this measure.
  
  
• Endorsement Committee Recommendation: 7. Consensus Standards Approval Committee (CSAC) Review (October 18, 2016): Y-16; N-0Decision: Approved for endorsement
  
  

Program Index

• Inpatient Rehabilitation Facility Quality Reporting Program 
  
  
• Skilled Nursing Facility Quality Reporting Program 
  
  
• Home Health Quality Reporting Program 
  
  
• Long-Term Care Hospital Quality Reporting Program 
  
  
• Hospice Quality Reporting Program 
  
  

Full Program Summaries

Program History and Structure: The Quality Reporting Program (QRP) for Inpatient Rehabilitation Facilities (IRFs) was established in accordance with section 1886(j) of the Social Security Act as amended by section 3004(b) of the Affordable Care Act. The IRF QRP applies to all IRF facilities that receive the IRF PPS (e.g., IRF hospitals, IRF units that are co-located with affiliated acute care facilities, and IRF units affiliated with critical access hospitals [CAHs]). Data sources for IRF QRP measures include Medicare FFS claims, the Center for Disease Control’s National Health Safety Network (CDC NHSN) data submissions, and Inpatient Rehabilitation Facility - Patient Assessment instrument (IRF-PAI) records. The IRF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, IRFs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable IRF Prospective Payment System (PPS) payment update. Plans for future public reporting of IRF QRP measures are under development. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following four domains as high-priority for future measure consideration:

1. Making Care Affordable: An important consideration for the IRF QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiencybased measures such as a Medicare Spending per Beneficiary measure concept.

2. Communication/Care Coordination: Assessing resident care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.

3. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the IRF QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Medication reconciliation conceptually highlights care transitions and resident follow-up. Therefore, a medication reconciliation quality measure for IRF patients is being considered for future quality measure development. 

4. Communication/Care Coordination: Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many patients for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, a discharge to community measure for IRFs is being considered for the future use in the IRF QRP.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Improving Medicare Post-Acute Care Transitions Act of 2014 (The IMPACT Act) added Section 1899B to the Social Security Act establishing the Skilled Nursing Facility Quality Reporting Program (SNF QRP). Facilities that submit data under the SNF PPS are required to participate in the SNF QRP, excluding units that are affiliated with critical access hospitals (CAHs). Data sources for SNF QRP measures include Medicare FFS claims as well as Minimum Data Set (MDS) assessment data. The SNF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2018, providers that fail to submit required quality data to CMS will have their annual updates reduced by 2.0 percentage points. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Home Health Quality Reporting Program (HH QRP) was established in accordance with section 1895 (b)(3)(B)(v)(II) of the Social Security Act. Home Health Agencies (HHAs) are required by the Act to submit quality data for use in evaluating quality for Home Health agencies. Section 1895(b) (3)(B)(v)(I) of the Act also requires that HHAs that do not submit quality data to the Secretary be subject to a 2 percent reduction in the annual payment update, effective in calendar year 2007 and every subsequent year. Data sources for the HH QRP include the Outcome and Assessment Information Set (OASIS) and Medicare FFS claims. Data is publically reported on the Home Health Compare website. The HH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for future measure consideration:

1. Patient and Family Engagement: Functional status and functional decline are important to assess for residents in HH settings. Patients who receive care while in a HH may have functional limitations and may be at risk for further decline in function due to limited mobility and ambulation. Therefore, measures to assess functional status are in development.
2. Making Care Safer: Safety for individuals in a home-based setting is an important priority for the HH QRP as persons in home health settings are at risk for major injury due to falls, new or worsened pressure ulcers, pain, and functional decline. Therefore, these concepts will be considered for future measure development.
3. Making Care Affordable: An important consideration for the HH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiencybased measures such as a Medicare Spending per Beneficiary measure concept.
4. Communication/Care Coordination: Assessing an individual’s care transitions and rehospitalizations is important. Discharge to a community setting is an important health care outcome for patients in post-acute settings, offering a multi-dimensional view of preparation for community life, including the cognitive, physical, and psychosocial elements involved in a discharge to the community. Being discharged to the community is an important outcome for many individuals for whom the overall goals of care include optimizing functional improvement, returning to a previous level of independence, and avoiding institutionalization. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
5. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the HH QRP. The World Health Organization regards implementing medication reconciliation as a standard operating protocol necessary to reduce the potential for ADEs that cause harm to patients.  Preventing and responding to ADEs is of critical importance as ADEs account for significant increases in health services utilization and costs. Therefore, a medication reconciliation quality measure for individuals in a home health setting is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) was established in accordance with section 1886(m) of the Social Security Act, as amended by Section 3004(a) of the Affordable Care Act. The LTCH QRP applies to all LTCHs facilities designated as an LTCH under the Medicare program. Data sources for LTCH QRP measures include Medicare FFS claims, the Center for Disease Control and Prevention’s National Health Safety Network (CDC’s NHSN) data submissions, and the LTCH Continuity Assessment Record and Evaluation Data Sets (LCDS). The LTCH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, LTCHs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable Prospective Payment System (PPS) increase factor. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for LTCH QRP future measure consideration:

1. Effective Prevention and Treatment: Having measures related to ventilator use, ventilator- associated event and ventilator weaning rate are a high priority for CMS as prolonged mechanical ventilator use is quite common in LTCHs and respiratory diagnosis with ventilator support for 96 or more hours is the most frequently occurring diagnosis.
2. Effective Prevention and Treatment (Aim: Healthy People/Healthy Communities): In discussions with LTCH providers, it was noted that mental health status is an important measure of care for LTCH patients. CMS is considering a Depression Assessment & Management quality measure.
3. Patient and Family Engagement: While rehabilitation and restoring functional status are not the primary goals of patient care in the LTCH setting, functional outcomes remain an important indicator of LTCH quality as well as key to LTCH care trajectories. Providers must be able to provide functional support to patients with impairments. Thus, metrics showing change in self- care and mobility function are under development.
4. atient and Family Engagement: CMS would like to explore measures that will evaluate the patient’s experiences of care as this is a high priority of providers. Therefore, the HCAHPS and Care Transition quality measure (CTM)-3 is being considered.
5. Making Care Affordable: An important consideration for the LTCH QRP is to better assess medical costs based on PAC episodes of care. Therefore, CMS is considering developing efficiency-based measures such as a Medicare Spending per Beneficiary measure concept.
6. Communication/Care Coordination: Assessing patient care transitions and rehospitalizations are important. Therefore, CMS is considering developing measures that assesses discharge to the community and potentially preventable readmissions.
7. Communication/Care Coordination: Infrastructure and processes for care coordination are important for the LTCH QRP. Therefore, a medication reconciliation quality measure for LTCH patients is being considered for future quality measure development. Medication reconciliation conceptually highlights care transitions and resident follow-up.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Hospice Quality Reporting Program (HQRP) was established in accordance with section 1814(i) of the Social Security Act, as amended by section 3004(c) of the Affordable Care Act. The HQRP applies to all hospices, regardless of setting. Proposed data sources for future HQRP measures include the Hospice Item Set and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. HQRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, Hospices that fail to submit quality data will be subject to a 2.0 percentage point reduction to their annual payment update.

High Priority Domains for Future Measure Consideration:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Index of Measures (by Program)

• CoreQ: Short Stay Discharge Measure (Public comments received:7; MUC ID: MUC17-258)
  
  

Full Comments (Listed by Measure)

• What will happen to the other SNF quality measures if the single measure being proposed is enacted? (Submitted by: Qualis Health)
  
  
• Need to Exclude any resident/patient who during the short stay has a Prognosis less than 6 months or elects hospice during the course of stay. The language reads: (4) Patients discharged on hospice; My question is if the resident is ‘discharged on hospice does that mean they are D/Ced from the facility? There is nothing on the MDS at the time of D/C that indicates they are going to ‘hospice’... I also question if a BIMS of 7 or less is too low. Low risk B&B QM which is alo a 7 on the BIMs & have residents with a higher BIMS not capable of finding the bathroom or calling the staff if they even know they need to go. So not sure the cut off should be at 7. . (Submitted by: Focused Post Acute Care)
  
  
• Exclusion language reads: (4) Patients discharged on hospice; What about the resident who goes home on a palliative plan of care because they do NOT elect the insurance benefit of ''hospice'. I believe these residents should be excluded as well. Also if they had a Prognosis less than 6 months during their time in the nursing home as well. (Submitted by: Melody Malone)
  
  
• Exclusion Language reads: 6) Patients who have dementia impairing their ability to answer the questionnaire defined as having a BIMS score on the MDS 3.0 as 7 or lower. Any BIMS question that results in less than 15 requires cueing. I believe any resident in the denominator, defined as: who respond to the CoreQ: Short Stay Discharge questionnaire within two months of receiving the questionnaire, who required cueing on the BIMS will not be able to adequately complete the survey. Therefore I recommend the BIMS score be 15. (Submitted by: Melody Malone)
  
  
• AOTA supports the development and execution of patient experience measures related to SNF. Patient satisfaction surveys tend to be more subjective. AOTA supports the use of the patient satisfaction scores from CoreQ, but recommends replacing with a patient experience measure as soon as reasonable. (Submitted by: American Occupational Therapy Association)
  
  
• We support the use of this measure. (Submitted by: Ascension)
  
  
• CMS is currently testing a Patient Experience of Care Survey in other Post-Acute Care settings. Consideration of this measure for the SNF QRP would potentially implement a patient satisfaction measure that would be inconsistent with the work CMS is currently piloting for the IMPACT Act. While providers would prefer the reduced burden the 4 question CoreQ may provide in comparison to the 58 question Patient Experience of Care Survey, has the CoreQ demonstrated meaningful differentiation of quality between providers? Endorsement of this measure was based upon testing from a limited number of SNF providers. Has additional testing been performed to provide evidence of meaningful variability between providers? (Submitted by: Uniform Data System for Medical Rehabilitiation)
  
  

Navigating the Discussion Guide

• How do I get back to the section I was just looking at?
  The easiest way is to use the back button on your browser. Other options are using your backspace button (which works for many browsers on laptops), or using the permanent links at the upper right hand corner of the discussion guide. But the back button is the best choice in most situations.
  
  
• Can I print the discussion guide out?
  You can, but we don't recommend it. Besides using a lot of paper (probably a couple hundred pages at least), you'll lose all the links that allow you to move around the document. For instance, if you're scrolling through the agenda and want to see more information about a particular measure, the electronic format will allow you to click a link, read more, and then bo back. If you're on paper, there will be a lot of flipping through paper.
  
  
• If I can't print this out, how can I read it on the plane?
  Although the Discussion Guide opens in a web browser, an internet connection is not required to view the file.
  
  
• How do I know that I'm looking at the most recent version?
  At the top left corner of the discussion guide is a version number. At the beginning of the in person meetings, the NQF staff will ask everyone to load the most recent discussion guide version and will check that everyone has the same version loaded.
  
  
• What electronic devices can I use to view the discussion guide?
  We tried to make this as universal as possible, so it should work on your laptop (PC, Mac, Linux), your tablet (iPad, Android), or your phone (iPhone, Android). It should also work on many types of browsers (IE, Firefox, Chrome, Safari, Opera, Dolphin,....). Please let us know if you have any problems, and we'll troubleshoot with you (and improve the discussion guide for the next go around).
  
  
• Why do I see weird characters in some places?
  Because we're joining data from many different sources, we do find some technical challenges. This generally shows up as strange characters--extra question marks, accented characters, or otherwise unusual items. We've been able to fix many of these problems, but not all. We ask that you bear with us as we improve this over time!
  
  

Content

• What is included in the discussion guide?
  There are four sections within this document:
  • Agenda, with summaries of each measure under consideration
  • Full information about each measure, including its specifications, preliminary analysis of how this measure can advance the program's goals, and the rationale by HHS for being included in the list
  • Summaries for each federal health program being considered
  • Public comments that have been received to date (Note that the discussion guide may be released before the public comment period is finished, in which case there will just be a placeholder for where comments will go)
  
  
• How are the meeting discussions organized?
  The meeting sessions are organized around consent calendars, which are groups of measures being considered for a particular program or groups of measures for a particular condition or topic area. For each measure being discussed, this document will show you the description, the public comments (if any), the summary of the preliminary analysis, and the result of the preliminary analysis algorithm.

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