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

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 of Chronic & Post Acute Care March 11, 2019 1

Continuing Medical Education Disclosure We, Kate Brooks, Charles Padgett, and Christine Grose, have no commercial relationships to disclose. 2

Overview of the IRF QRP

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.

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

IRF QRP Measures • 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) 6

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.

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 outcome 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

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

Overview of the CASPER Reports and IRF Compare

Overview of Reports Review Provider and QM Preview Reports Correct Report Report

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

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

Review and Correct Report Example

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

QM Report: Facility-Level Example

QM Report: Patient-Level Example

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”

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

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

Provider Preview Report Example

IRF Compare Website www.medicare.gov/inpatientrehabilitationfacilitycompare / 22

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 Time Frame For On IRF Compare Source Collection Percent of Residents or Patients with Pressure Ulcers That Are New or IRF-PAI 12 months Current Worsened (Short Stay) (NQF #0678) Percent of Residents or Patients Who Were Assessed and Appropriately IRF-PAI 12 months (July 1- Current Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) June 30) Application of Percent of Long-Term Care Hospital (LTCH) Patients With IRF-PAI 12 months Current an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631) Application of Percent of Residents Experiencing One or More Falls with IRF-PAI 12 months Current Major Injury (Long Stay) (NQF #0674) 23

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 Time Frame For On IRF Compare Source Collection IRF-PAI 12 months Projected for Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury October 2020 IRF Functional Outcome Measure: Change in Self-Care Score for Medical IRF-PAI 12 months Projected for Rehabilitation Patients (NQF #2633) October 2020 IRF Functional Outcome Measure: Change in Mobility Score for Medical IRF-PAI 12 months Projected for Rehabilitation Patients (NQF #2634) October 2020 IRF Functional Outcome Measure: Discharge Self-Care Score for Medical IRF-PAI 12 months Projected for October 2020 Rehabilitation Patients (NQF #2365) IRF Functional Outcome Measure: Discharge Mobility Score for Medical IRF-PAI 12 months Projected for October 2020 Rehabilitation Patients(NQF #2636) Drug Regimen Review Conducted with Follow-Up for Identified Issues – IRF-PAI 12 months Projected for PAC IRF QRP October 2020 24

CDC Measures on IRF Compare Website 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- CDC NHSN 12 months Current associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) National Healthcare Safety Network (NHSN) Facility- CDC NHSN 12 months Current wide Inpatient Hospital-onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) National Healthcare Safety Network (NHSN) Facility- CDC NHSN 12 months Current wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717) Influenza Vaccination Coverage Among Healthcare CDC NHSN 12 months (July 1-June 30) Current Personnel (NQF #0431) 25