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Quality Reporting Program: Status Update & Activities Centers - - PowerPoint PPT Presentation

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Inpatient Rehabilitation Facility Quality Reporting Program: Status Update & Activities Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality Quality Measurement & Value-Based Incentives Group Division

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Inpatient Rehabilitation Facility Quality Reporting Program: Status Update & Activities

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Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality Quality Measurement & Value-Based Incentives Group Division of Chronic & Post Acute Care

March 11, 2019

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We, Kate Brooks, Charles Padgett, and Christine Grose, have no commercial relationships to disclose.

Continuing Medical Education Disclosure

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Overview of the IRF QRP

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Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)

  • Section 3004(b) of the Affordable Care Act (ACA) of 2010

amended section 1886(j)(7) of the Social Security Act, requiring the Secretary to establish quality reporting requirements for IRFs.

  • For fiscal year (FY) 2014, and each year after, if an IRF does

not submit the required quality data, the IRF will be subject to a 2 percentage point reduction in the annual payment update.

  • Additionally, the Improving Medicare Post-Acute Care

Transformation Act (IMPACT Act) of 2014 requires the submission of standardized data and quality measure data by long-term care hospitals, skilled nursing facilities, home health agencies, and IRFs.

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CMS Meaningful Measures

  • For additional information,

visit: https://www.cms.gov/Medi care/Quality-Initiatives- Patient-Assessment- Instruments/QualityInitiativ esGenInfo/MMF/General- info-Sub-Page.html

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  • Quality data for the IRF QRP are collected and

submitted using three methods:

  • 1. IRF Patient Assessment Instrument (IRF-PAI)
  • 2. Centers for Disease Control and Prevention

(CDC) National Health Safety Network (NHSN)

  • 3. Medicare claims (no additional data are required

to be submitted)

IRF QRP Measures

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FY 2019 IRF PPS Final Rule Updates

  • The final rule removed the following measures from the IRF

QRP:

  • National Healthcare Safety Network (NHSN) Facility-wide Inpatient

Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) beginning with the FY 2020 IRF QRP.

  • Beginning October 1, 2018, IRFs will no longer be required to submit

data on this measure for the purposes of the IRF QRP.

  • Percent of Residents or Patients Who Were Assessed and

Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) beginning with the FY 2021 IRF QRP.

  • Beginning October 1, 2018, IRFs should enter any of the valid codes or

a dash (–) for O0250A, O0250B, and O0250C until the next IRF-PAI is released.

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FY 2019 IRF PPS Final Rule Updates

  • Further, CMS finalized the following:
  • Clarified policies for provider notification of non-

compliance with IRF QRP requirements.

  • To display data on the four assessment-based functional
  • utcome measures on IRF Compare in CY 2020.
  • For more information, refer to the FY 2019 IRF PPS

final rule: https://www.gpo.gov/fdsys/pkg/FR- 2018-08-06/pdf/2018- 16517.pdf

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IRF-PAI Version 3.0

  • Effective for patients on or after October 1, 2019
  • FY 2019 IRF PPS final rule finalized the removal of the FIM™ items

and associated Function Modifiers.

  • Removed item O0250. Influenza Vaccine
  • IRF-PAI Version 3.0:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/IRF-Quality- Reporting/Downloads/Final-IRF-PAI-Version-30-Effective- October-1-2019-FY2020.pdf

  • Change Table: https://www.cms.gov/Medicare/Quality-

Initiatives-Patient-Assessment-Instruments/IRF-Quality- Reporting/Downloads/Final-IRF-PAI-Version-30-Change- Table.pdf

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Overview of the CASPER Reports and IRF Compare

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Overview of Reports

Review and Correct Report QM Reports Provider Preview Report

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Review and Correct Report

  • User on-demand reports (run your reports at any

time)

  • Displays quarterly reports: When reporting quarter

ends, the report is available the next business day

  • Available for providers to run with updated data

weekly (until the data correction deadline)

  • Displays data correction deadlines and whether the

data correction period is open or closed

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Upcoming Enhancements to the Review and Correct Report

  • Addition of a patient-level data table to supplement

facility-level data

  • Patient-level data will be available as comma-separated

values (CSV) flat file

  • Ability to sort patient-level data by fields such as:
  • Patient last name
  • Patient ID
  • Patient status
  • Ability to request report by individual quality measure
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Review and Correct Report Example

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Quality Measure (QM) Reports

  • Also referred to as Confidential feedback reports
  • User on-demand reports (run your reports at any time)
  • Available to providers for internal purposes only and not

for public display

  • Used for feedback to help providers to improve quality of

care

  • Contain QM information at the facility and patient levels

for a single reporting period

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QM Report: Facility-Level Example

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QM Report: Patient-Level Example

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How Quality Measure Reports May Be Helpful to Providers

  • Facility- and patient-level QM Reports are refreshed

monthly

  • Snapshot of performance for quality improvement

purposes based on data submitted and results risk- adjusted as applicable

  • The Review and Correct Report and QM Reports are

not static and do not “match”

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Provider Preview Report

  • Contains facility-level QM data
  • Automatically generated and saved into your facility’s

shared folder in the CASPER application

  • Displays results that will be posted on the IRF

Compare websites

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Provider Preview Report (cont. 2)

Important Notes:

  • Review the data about your facility
  • The order of the measures may not represent the order in which they will

be displayed on the Compare website

  • The titles of the measure(s) are not the consumer language titles that will

appear on the Compare website

  • The crosswalk between these titles is available on the Compare website
  • Email the Centers for Medicare & Medicaid Services (CMS) Public Reporting

Help Desk at IRFPRquestions@cms.hhs.gov with questions related to the report

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Provider Preview Report Example

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IRF Compare Website

www.medicare.gov/inpatientrehabilitationfacilitycompare/

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Assessment-Based Measures on IRF Compare Website Current Measures

IRF QRP https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/IRF-Quality-Reporting/ Measure Data Source Time Frame For Collection On IRF Compare Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) IRF-PAI 12 months Current Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) IRF-PAI 12 months (July 1- June 30) Current Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631) IRF-PAI 12 months Current Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674) IRF-PAI 12 months Current

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Assessment-Based Measures on IRF Compare Website Future Measures

IRF QRP https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/IRF-Quality-Reporting/ Measure Data Source Time Frame For Collection On IRF Compare Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury IRF-PAI 12 months Projected for October 2020 IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) IRF-PAI 12 months Projected for October 2020 IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634) IRF-PAI 12 months Projected for October 2020 IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2365) IRF-PAI 12 months Projected for October 2020 IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients(NQF #2636) IRF-PAI 12 months Projected for October 2020 Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC IRF QRP IRF-PAI 12 months Projected for October 2020

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CDC Measures on IRF Compare Website

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IRF QRP https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/IRF-Quality-Reporting/ Measure Data Source Time Frame For Collection On IRF Compare National Healthcare Safety Network (NHSN) Catheter- associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) CDC NHSN 12 months Current National Healthcare Safety Network (NHSN) Facility- wide Inpatient Hospital-onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) CDC NHSN 12 months Current National Healthcare Safety Network (NHSN) Facility- wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717) CDC NHSN 12 months Current Influenza Vaccination Coverage Among Healthcare Personnel (NQF #0431) CDC NHSN 12 months (July 1-June 30) Current

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Claims-Based Measures on IRF Compare Website

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IRF QRP https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/IRF-Quality-Reporting/ Measure Data Source Time Frame For Collection On IRF Compare Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Medicare FFS Claims 2 years To Be Determined Potentially Preventable Within Stay Readmission Measure for Inpatient Rehabilitation Facilities (IRF) Medicare FFS Claims 2 years To Be Determined Discharge to Community-Post Acute Care (PAC) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Medicare FFS Claims 2 years Current Medicare Spending Per Beneficiary-Post Acute Care (PAC) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Medicare FFS Claims 2 years Current

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Resources and Future Training

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CASPER Resources

  • A variety of CASPER report user guides are available
  • nline:
  • IRF-PAI User Guides & Training

https://www.qtso.com/irfpaitrain.html

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IRF QRP Resources

  • IRF QRP website:

https://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/IRF-Quality- Reporting/

  • IRF PPS website:

https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/InpatientRehabFacPPS/index.html

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IRF QRP Website

IRF Quality Reporting

Spotlight & Announcements Measures Information IRF-PAI & IRF QRP Manual Technical Information Training Public Reporting Data Submission Deadlines

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IRF Helpdesks (cont. 1)

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Stay Connected

  • To receive mailing list notices and announcements

about the IRF QRP, sign up at: https://public.govdelivery.com/accounts/USCMS/subs criber/new.

  • CMS Open Door Forums and listening sessions.

Notices about CMS Open Door Forums related to the IRF QRP are announced on the following web page: https://www.cms.gov/Medicare/Quality-Initiatives- Patient-AssessmentInstruments/IRF-Quality- Reporting/Spotlights-Announcements.html.

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Save the Date

In Person Training IRF QRP May 9-10 Kansas City, MO Registration information available soon

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