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IPFQR Program Fiscal Year 2018 Data Review Evette Robinson, MPH Project Lead, Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor (SC) November 9, 2017
Webinar Chat Questions As a reminder, we do not use the raised-hand feature in the chat tool during webinars. Please submit any questions that are pertinent to the webinar topic to us via the chat tool. o Questions that are not addressed during today s meeting will be addressed in a questions-and-answers document to be published at a later date. If you have questions unrelated to the current webinar topic, we recommend that you first search for your question in the QualityNet Hospital Inpatient Questions and Answers tool, accessed directly at https://cms-ip.custhelp.com/app/homeipf/p/831. o If you do not find an answer, submit your question to us via the same tool. We will respond as soon as possible. 11/09/2017 6
Purpose This presentation provides a review of the Fiscal Year (FY) 2018 IPFQR Program measure and non-measure data results and acknowledges the top performing and most improved participants in the IPFQR Program. 11/09/2017 7
Learning Objectives At the conclusion of this presentation, attendees will understand the FY 2018 measure and nonmeasure data results for the IPFQR Program. In addition, attendees will learn how CMS identifies top performing and most improved IPFs. 11/09/2017 8
Acronyms APU CCN CY CMS EHR FFS FR FUH FY HBIPS HIQR Annual Payment Update CMS Certification Number calendar year Centers for Medicare & Medicaid Services electronic health record fee-for-service final rule Follow-Up After Hospitalization for Mental Illness Fiscal Year Hospital-Based Inpatient Psychiatric Services Hospital Inpatient Quality Reporting HISP IMM-2 IPPS IPFQR NHSN ONC SA SC SUB TOB VIQR Health Information Service Provider Influenza Immunization Inpatient Prospective Payment System Inpatient Psychiatric Facility Quality Reporting National Healthcare Safety Network The Office of the National Coordinator for Health Information Technology Security Administrator support contractor Substance Use Tobacco Use Value, Incentives, and Quality Reporting 11/09/2017 9
IPFQR Program Fiscal Year 2018 Data Review FY 2018 Measure and Non-Measure Results 11/09/2017 10
HBIPS-2 and HBIPS-3 Measure Results: Mean Values NOTE: Lower rates for the HBIPS-2 and HBIPS-3 measures indicate better performance. 11/09/2017 11
HBIPS-2 and HBIPS-3 Measure Results: Median Values NOTE: Lower rates for the HBIPS-2 and HBIPS-3 measures indicate better performance. 11/09/2017 12
HBIPS-5 Measure Results NOTE: Higher rates for the HBIPS-5 measures indicate better performance. 11/09/2017 13
SUB-1, SUB-2/-2a Measure Results NOTE: Higher rates for the SUB-1 and SUB-2/-2a measures indicate better performance. 11/09/2017 14
TOB-1, TOB-2/-2a, TOB-3/-3a Measure Results NOTE: Higher rates for the TOB-1, TOB-2/-2a, and TOB-3/-3a measures indicate better performance. 11/09/2017 15
Flu Season Measure Results NOTE: Higher rates for the Influenza Vaccination Coverage Among Healthcare Personnel and IMM-2 measures indicate better performance. 11/09/2017 16
FUH Measure Results NOTE: Higher percentages for the FUH measure indicate better performance. 11/09/2017 17
Assessment of Patient Experience of Care Measure Results 11/09/2017 18
Use of EHR by Type and HISP Measure Results 11/09/2017 19
CY 2016 Non-Measure Data Non-measure data that IPFs collected in CY 2016 and reported this year will be presented here for informational purposes only. The non-measure data will not appear in the Hospital Compare Preview Report nor be publically reported. CMS will use this information to assess measures submissions for accuracy and to contribute to the development of new measures. 11/09/2017 20
Distribution of CY 2015 and CY 2016 Discharges from IPFs 11/09/2017 21
CY 2015 and CY 2016 Total Discharges by Age Group 100.00% 80.00% 74.50% 74.99% Percentage of IPFs (%) 60.00% 40.00% 20.00% 10.72% 10.69% 11.60% 11.24% 0.00% 3.18% 3.07% CY 15 CY 16 CY 15 CY 16 CY 15 CY 16 CY 15 CY 16 1-12 Years 13-17 Years 18-64 Years 65 Years and Over Age Strata by CY 11/09/2017 22
CY 2015 and CY 2016 Total Discharges by Diagnostic Group 11/09/2017 23
CY 2015 and CY 2016 Total Discharges by Payer 11/09/2017 24
IPFQR Program Fiscal Year 2018 Data Review FY 2018 IPF Performance and Improvement Review 11/09/2017 25
Recognition for FY 2018 Performance and Improvement CMS would like to acknowledge the top performing and most improved IPFs in the nation. Top 20 Performing IPFs o Methodology CMS identified IPFs with the best performance rates and ranked them from highest to lowest. For example, a top ranking IPF would have 0% rates for the HBIPS-2 and HBIPS-3 measures and 100% rates for the HBIPS-5, SUB-1, and SUB-2/-2a measures. o Better performance is indicated by: Lower rates for the HBIPS-2 and HBIPS-3 measures. Higher rates for the HBIPS-5, SUB-1, SUB-2/-2a measures. 20 Most Improved IPFs o Methodology IPFs were ranked from greatest difference in rates from FY 2017 to FY 2018 to lowest. o Performance improvement is indicated by: Decrease in the HBIPS-2 and HBIPS-3 measures rate from FY 2017 to FY 2018. Increase in the HBIPS-5, SUB-1, SUB-2/-2a measures rate from FY 2017 to FY 2018. 11/09/2017 26
Recognition for FY 2018 Performance and Improvement Only IPFs that submitted the following responses to the structural measures were eligible for recognition on the highest performing and most improved lists. Structural Measure Question Answer Use of an Electronic Health Record Use of an Electronic Health Record Assessment of Patient Experience of Care Please select which of the following statements best describes your facility s highest level of typical use of an EHR System (excluding the billing system) during the reporting period. Did the transfers of health information at times of transitions in care include the exchange of interoperable health information with a health information service provider (HISP)? Did your facility routinely assess patient experience of care using a standardized collection protocol and a structured instrument? ONC HIT Certified EHR technology Yes Yes 11/09/2017 27
FY 2018 Top 20 Performing IPFs State IPF Unit CCN Hospital Name FL 10S166 DOCTORS HOSPITAL OF SARASOTA FL 10S246 LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTE FL 10S110 OSCEOLA REGIONAL MEDICAL CENTER FL 10S260 ST LUCIE MEDICAL CENTER GA 11S164 COLISEUM MEDICAL CENTERS, LLC, DBA IN 15S046 TERRE HAUTE REGIONAL HOSPITAL KS 17S086 STORMONT VAIL HOSPITAL KY 18S127 FRANKFORT REGIONAL MEDICAL CENTER MS 25S100 BAPTIST MEM HOSP/ GOLDEN TRIANGLE INC MS 25S004 NORTH MISSISSIPPI MEDICAL CENTER NC 34S001 CAROLINAS MEDICAL CENTER-NORTHEAST NH 30S017 PARKLAND MEDICAL CENTER TX 45S766 U.T. SOUTHWESTERN UNIVERSITY HOSPITAL - ZALE LIPSHY UT 46S001 UTAH VALLEY HOSPITAL VA 49S020 JOHN RANDOLPH MEDICAL CENTER VA 49S141 SPOTSYLVANIA REGIONAL MEDICAL CENTER VA 49S112 CJW MEDICAL CENTER VA 49S118 HENRICO DOCTORS' HOSPITAL WY 53S014 CHEYENNE REGIONAL MEDICAL CENTER WY 53S008 SAGEWEST HEALTH CARE Note: The data are sorted by state, not rank. 11/09/2017 28
FY 2018 20 Most Improved IPFs State IPF Unit CCN Hospital Name AL 01S113 MOBILE INFIRMARY MEDICAL CENTER AZ 03S002 BANNER - UNIVERSITY MEDICAL CENTER PHOENIX AZ 03S022 MARICOPA MEDICAL CENTER CA 05S380 GOOD SAMARITAN HOSPITAL CO 064023 WEST SPRINGS HOSPITAL FL 10S006 ORLANDO HEALTH FL 10S157 LAKELAND REGIONAL MEDICAL CENTER IL 14S148 MEMORIAL MEDICAL CENTER, AN AFFILIATE OF MEMORIAL HEALTH SYSTEM IN 154021 GRANT-BLACKFORD MENTAL HEALTH, INC MI 23S270 BEAUMONT HOSPITAL - TAYLOR MN 24S001 NORTH MEMORIAL MEDICAL CENTER NC 34S014 NOVANT HEALTH FORSYTH MEDICAL CENTER NC 34S040 VIDANT MEDICAL CENTER NC 34S061 UNIVERSITY OF NORTH CAROLINA HOSPITAL NJ 31S009 CLARA MAASS MEDICAL CENTER OH 36S155 SOUTHWEST GENERAL HEALTH CENTER OR 38S047 ST CHARLES MEDICAL CENTER - BEND PA 39S164 UPMC PRESBYTERIAN SHADYSIDE RI 41S006 NEWPORT HOSPITAL TX 45S015 DALLAS COUNTY HOSPITAL DISTRICT Note: The data are sorted by state, not rank. 11/09/2017 29
IPFQR Program Fiscal Year 2018 Data Review Helpful Resources 11/09/2017 30
Helpful Resources: Links CMS recommends that IPFs refer to the updated IPFQR Program Manual for information pertaining to the IPFQR Program. This document, and other helpful resources and tools, can be found on the QualityNet and Quality Reporting Center websites. QualityNet > Inpatient Psychiatric Facilities > Resources o https://www.qualitynet.org/dcs/contentserver?c=page&pagename=qne tpublic%2fpage%2fqnettier2&cid=1228772864255 Quality Reporting Center > IPFQR Program > Resources and Tools o http://www.qualityreportingcenter.com/inpatient/ipf/tools/ 11/09/2017 31
Helpful Resources: Links IPFQR Program General Resources Q&A Tool Email Support Website https://cms- IP.custhelp.com Monthly Web Conferences www.qualityreporting Center.com IPFQualityReporting @hcqis.org ListServes www.qualitynet.org www.qualityreportingce nter.com Hospital Contact Change Form Hospital Contact Change Form Phone Support (866) 800-8765 Secure Fax (877) 789-4443 11/09/2017 32
Helpful Resources: Save the Dates Upcoming IPFQR Program Educational Webinars December 2017 January 2018 IPFQR Program Manual and Paper Tools Review Collecting and Entering Healthcare Personnel Influenza Vaccination Data 11/09/2017 33
Disclaimer This presentation was current at the time of publication and/or upload onto the Quality Reporting Center and QualityNet websites. Medicare policy changes frequently. Any links to Medicare online source documents are for reference use only. In the case that Medicare policy, requirements, or guidance related to this presentation change following the date of posting, this presentation will not necessarily reflect those changes; given that it will remain as an archived copy, it will not be updated. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. Any references or links to statutes, regulations, and/or other policy materials included in the presentation are provided as summary information. No material contained therein is intended to take the place of either written laws or regulations. In the event of any conflict between the information provided by the presentation and any information included in any Medicare rules and/or regulations, the rules and regulations shall govern. The specific statutes, regulations, and other interpretive materials should be reviewed independently for a full and accurate statement of their contents. 11/09/2017 34