Dazed and Confused: Initial Results from the IRF QRP Data

Dazed and Confused: Initial Results from the IRF QRP Data Troy Hillman Manager, Analytical Services Uniform Data System for Medical Rehabilitation 2017 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. FIM, UDSMR, and the UDSMR Annual Conference logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Overview IRF QRP quality measures Current Future Time frames and deadlines IRF-PAI quality measure data review Influenza vaccination Pressure ulcers Falls with major injury Process measure Self-care Mobility 2 1

Current IRF QRP Measures For the FY 2019 annual payment update (APU), IRFs will be required to submit/analyze data for seventeen quality measures that utilize information from different data sources Eight quality measures derived from data submitted via the IRF-PAI Four quality measures derived from data submitted via the CDC NHSN portal Five quality measures derived from claims data 3 Current IRF QRP Measures Eight quality measures derived from data submitted via the IRF-PAI: 1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) 2. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680) 3. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674) 4 2

Current IRF QRP Measures Eight quality measures derived from data submitted via the IRF-PAI: 4. Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) 5. IRF Functional Outcome Measure: Change in Self Score for Medical Rehabilitation Patients (NQF #2633) 6. IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634) 5 Current IRF QRP Measures Eight quality measures derived from data submitted via the IRF-PAI: 7. IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) 8. IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) 6 3

Current IRF QRP Measures Four quality measures derived from data submitted via the CDC NHSN portal: 1. National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) 2. Influenza Vaccination among Healthcare Personnel (NQF #0431) 3. NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) 4. NHSN Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717) 7 Current IRF QRP Measures Five quality measures derived from claims data: 1. All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (NQF #2502) Will be removed from IRF QRP and public display by October 2018 2. Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP 3. Potentially Preventable within Stay Readmission Measure for Inpatient Rehabilitation Facilities 4. Discharge to Community PAC IRF QRP 5. Medicare Spending per Beneficiary Post-Acute Care (MSPB-PAC) Inpatient Rehabilitation Facility Resource Use Measure 8 4

IRF QRP Timelines and Deadlines CMS s IRF QRP website provides details on the measures and associated time frames included in the APUs https://www.cms.gov/medicare/quality- Initiatives-Patient-Assessment-Instruments/IRF- Quality-Reporting/Downloads/IRF-QRP- Submission-Deadlines-FY-2019-Payment- Determination-002.pdf 9 IRF QRP Timelines and Deadlines 10 5

IRF QRP Timelines and Deadlines 11 IRF QRP Timelines and Deadlines 12 6

IRF QRP Timelines and Deadlines 13 IRF QRP Timelines and Deadlines 14 7

Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: Drug Regimen Review Conducted with Follow- Up for Identified Issues Post-Acute Acute Care (PAC) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) October 2018 implementation Three new IRF-PAI items Two admission items One discharge item 15 Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: Drug Regimen Review Conducted with Follow- Up for Identified Issues Post-Acute Acute Care (PAC) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Percentage of patients where: 1. The facility conducted a drug regimen review at admission (N2001= [0,1]) or patient not taking any medications (N2001= [9]); and 2. If potential clinically significant medication issues were identified at admission (N2001 = [1]), then the facility contacted a physician (or physician-designee) by midnight of the next calendar day and completed prescribed/recommended actions in response to the identified issues (N2003= [1]); and 3. The facility contacted a physician (or physician-designee) and completed prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since admission (N2005 = [1]) or no potential clinically significant medications issues were identified since admission (N2005 = [9]). 16 8

Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: Transfer of Information: 1. at Post-Acute Care Admission, Start, or Resumption of Care from Other Providers/Settings 2. at Post-Acute Care Discharge or End of Care to Other Providers/Settings NQF MAP 2016 2017 recommendation to refine and resubmit measures Second-phase pilot was scheduled for March 2017 to May 2017 17 Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: The development of functional process and outcome quality measure to meet the IMPACT Act of 2014 Cross-Setting Quality Measure Domain: Function Status, Cognitive Function, and Changes in Function and Cognitive Function Confusion Assessment Method (CAM), Behavioral Symptoms, and Patient Health Questionnaire 2 (PHQ-2 ) proposed but removed from implementation (for now) 18 9

Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: Development and Maintenance of Post-Acute Care Cross-Setting Standardized Patient Assessment Data https://www.cms.gov/medicare/quality-initiatives- Patient-Assessment-Instruments/Post-Acute-Care- Quality-Initiatives/IMPACT-Act-of-2014/-IMPACT- Act-Standardized-Assessment-National-Testing-.html National beta test to evaluate candidate standardized patient assessment data elements will begin in fall 2017 Fourteen markets Initial data elements included over seventy items, with an initial estimate of 35 50 minutes to administer the assessment once 19 Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: Development and Maintenance of Post-Acute Care Cross-Setting Standardized Patient Assessment Data Public Comment 2 opportunity ended June 26, 2017 Over two hundred new data elements Cognitive Function and Mental Status Medical Conditions: Continence Medical Conditions: Pain Impairments of Hearing and Vision Medication Reconciliation Care Preferences PROMIS 20 10

Future IRF QRP Measures The following measures have been finalized for future use or are in the development process for consideration for future use: Patient Experience of Care Initial testing completed in 2016 IRF Mode Experiment being conducted on volunteer facilities who provide RTI with lists of patients who were discharged in April and May 2017 Current survey is twelve pages long with a total of fifty-eight questions For more info: https://irffield.rti.org/ 21 Influenza Vaccination This measure is being reported four different ways: 1. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) Includes the following: A. Patient received the influenza vaccine during the most recent influenza vaccination season either in the facility (O0250A = 1) or outside the facility (O0250C = 2); or B. Patient was offered and declined the influenza vaccine (O0250C = 4); or C. Patient was ineligible due to medical contraindication(s) (O0250C = 3) 22 11

Influenza Vaccination This measure is being reported four different ways: 1. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) UDSMR IRF average = 91.4% 234 IRFs at 100% Additional 363 IRFs at or above average value 16 IRFs at less than 50% 23 Influenza Vaccination This measure is being reported four different ways: 2. Percent of Residents or Patients Who Received the Seasonal Influenza Vaccine (Short Stay) Includes only the following: A. Patient received the influenza vaccine during the most recent influenza vaccination season either in the facility (O0250A = 1) or outside the facility (O0250C = 2); UDSMR IRF average = 62.0% 10 IRFs at 100% Additional 484 IRFs at or above average value 169 IRFs at less than 50% 24 12

Influenza Vaccination This measure is being reported four different ways: 3. Percent of Residents or Patients Who Were Offered and Declined the Seasonal Influenza Vaccine (Short Stay) Includes only the following: A. Patient was offered and declined the influenza vaccine (O0250C = 4) UDSMR IRF average = 27.4% 369 IRFs at or above average value 525 IRFs below average value 25 Influenza Vaccination This measure is being reported four different ways: 4. Percent of Residents or Patients Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine (Short Stay) Includes only the following: 1. Patient was ineligible due to medical contraindication(s) (O0250C = 3) UDSMR IRF average = 1.9% 275 IRFs at or above average value 619 IRFs below average value 366 IRFs with 0% 26 13

Pressure Ulcers Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) Currently measured using: M0800A: Stage 2 M0800B: Stage 3 M0800C: Stage 4 UDSMR IRF average = 0.6% 392 IRFs at 0% Additional 169 IRFs at or below average value About 145 IRFs at or above 1.2% 27 Pressure Ulcers Future state to change measure: Beginning with October 2018 discharges Modified Pressure Ulcer Measure Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury Includes unstageable pressure ulcers Uses the M0300 IRF-PAI items, not M0800 items (which will be removed) Calculated difference between the number present at discharge and the number of these present at admission For example, for stage 2, the difference between discharge items M0300B1 and M0300B2 28 14

Pressure Ulcers Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury Future state statistics: UDSMR IRF average = 1.4% 210 IRFs at 0% Additional 337 IRFs at or below average value About 118 IRFs at or above 2.8% 29 Falls with Major Injury Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674) Measure based only on item J1900C, Number of falls since admission, major injury UDSMR IRF average = 0.15% 1.5 patients out of every 1000 607 IRFs at 0% Additional 36 IRFs at or below average value About 183 IRFs at or above 0.30% 3 patients out of every 1,000 30 15

Additional Falls Information Percentage of patients with falls since admission (J1800 = 1) UDSMR IRF average = 7.49% Percentage of patients with one or more falls with no injury (J1900A 1) UDSMR IRF average = 5.59% Percentage of patients with one or more falls with minor injury (J1900B 1) UDSMR IRF average = 0.86% No IRFs identify any 31 Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) UDSMR IRF average = 98.7% 545 IRFs at 100% Additional 239 IRFs at or above average value 36 IRFs below 95.00% Potential risk for not meeting data completeness threshold Most issues are caused by the use of dashes on admission and discharge items, not goals 32 16

Self-Care: IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) Difference between admission and discharge compared to national expected value IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) Discharge value compared to national expected value 33 Self-Care: Both measures use the following seven self-care items: 1. Eating (GG0130A) 2. Oral hygiene (GG0130B) 3. Toileting hygiene (GG0130C) 4. Shower/bathe self (GG0130E) 5. Upper body dressing (GG0130F) 6. Lower body dressing (GG0130G) 7. Putting on/taking off footwear (GG0130H) 34 17

Self-Care: Items coded with the following values are recoded to a value of 1 for calculation purposes: 07, Patient refused 09, Not applicable 88, Not attempted due to medical condition or safety concerns Dash (-): Not assessed 35 Self-Care: IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) UDSMR IRF average = 11.5 Approximately 1.5 points per item Raw value, not adjusted 439 IRFs at or above average value 9 IRFs at less than 7.0 7.00 = 1 point of change per item 36 18

Self-Care: IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) UDSMR IRF average = 34.2 Approximately level 5 on all items Raw value, not adjusted 491 IRFs at or above average value 9 IRFs at or less than 28.00 28.00 level 4 on all items 37 Self-Care: Potential issues: Inconsistency with FIM items Not attempted vs. assessed Disagreement in functional ability Effects on payment or quality 38 19

GG0130C Self-Care: Toileting Hygiene - Admission Not assessed Dependent Substantial / maximal Partial / moderate Supervision or touching Setup or clean-up Independent Patient refused Not applicable Not attempted due to medical condition or safety concerns - 01 02 03 04 05 06 07 09 88 Total Activity does not occur 0 26 1,061 336 194 165 60 38 449 374 1,036 3,739 Total 1 37 48,079 30,309 13,144 7,361 2,018 1,429 1,791 1,159 3,693 109,020 Maximal 2 9 1,516 19,316 10,375 6,925 1,762 1,167 569 358 918 42,915 39F FIM Instrument Self-Care: Toileting - Admission Moderate Minimal 3 13 540 1,848 18,963 8,434 1,843 1,199 438 303 683 34,264 4 17 403 550 11,270 27,342 3,730 2,743 645 379 709 47,788 Supervision 5 11 139 150 586 5,881 2,827 1,359 289 162 352 11,756 Modified Independence 6 1 26 25 67 177 160 471 56 19 39 1,041 Complete Independence 7 0 6 8 20 41 23 181 21 20 18 338 Total 114 51,770 52,542 54,619 56,326 12,423 8,587 4,258 2,774 7,448 250,861 GG0130C Self-Care: Toileting Hygiene - Discharge Not assessed Dependent Substantial / maximal Partial / moderate Supervision or touching Setup or clean-up Independent Patient refused Not applicable Not attempted due to medical condition or safety concerns - 01 02 03 04 05 06 07 09 88 Total Activity does not occur 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Total 1 20 13,087 6,097 1,863 1,275 516 562 286 215 765 24,686 Maximal 2 3 775 6,940 1,913 1,231 458 582 37 18 92 12,049 39F FIM Instrument Self-Care: Toileting - Discharge Moderate Minimal 3 1 359 1,148 8,739 2,467 928 1,389 34 22 85 15,172 4 12 269 568 6,712 14,641 2,695 4,222 51 38 118 29,326 Supervision 5 12 207 366 1,529 25,899 13,684 14,490 99 46 162 56,494 Modified Independence 6 10 102 165 679 2,847 2,971 79,754 86 46 122 86,782 Complete Independence 7 8 39 68 232 905 449 24,498 84 13 54 26,350 Total 66 14,838 15,352 21,667 49,265 21,701 125,497 677 398 1,398 250,859 20

Mobility: IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634) Difference between admission and discharge compared to national expected value IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) Discharge value compared to national expected value 41 Mobility: Both measures use the following fifteen mobility items: 1. Roll left and right (GG0170A) 2. Sit to lying (GG0170B) 3. Lying to sitting on side of bed (GG0170C) 4. Sit to stand (GG0170D) 5. Chair/bed-to-chair transfer (GG0170E) 6. Toilet transfer (GG0170F) 7. Car transfer (GG0170G) 42 21

Mobility: Both measures use the following fifteen mobility items: For patients who are walking: 8. Walk 10 feet (GG0170I) 9. Walk 50 feet with two turns (GG0170J) 10. Walk 150 feet (GG0170K) 11. Walking 10 feet on uneven surfaces (GG0170L) 12. 1 step (curb) (GG0170M) 13. 4 steps (GG0170N) 14. 12 steps (GG0170O) 15. Picking up object (GG0170P) 43 Mobility: Items coded with the following values are recoded to a value of 1 for calculation purposes: 07, Patient refused 09, Not applicable 88, Not attempted due to medical condition or safety concerns Dash (-): Not assessed 44 22

Mobility: IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634) UDSMR IRF average = 28.3 Approximately 2 points per item Raw value, not adjusted 435 IRFs at or above average value 5 IRFs at less than 15.00 15.00 = 1 point of change per item 45 Mobility: IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) UDSMR IRF average = 63.0 Approximately level 4 on all items Raw value, not adjusted 468 IRFs at or above average value 5 IRFs at or less than 45.0 45.00 level 3 on all items 46 23

Mobility: Potential issues: Patients who do not walk at discharge Nearly 7% of Medicare cases do not complete the eight items related to walking, steps, and picking up objects These items are coded with a value of 1 for quality measurement 47 Mobility: Potential issues: Use of 07, 09, 88, and dash (-) at discharge Item Cases % Roll left and right (GG0170A) 6,209 2.5% Sit to lying (GG0170B) 1,916 0.8% Lying to sitting on side of bed (GG0170C) 1,888 0.8% Sit to stand (GG0170D) 4,346 1.7% Chair/bed-to-chair transfer (GG0170E) 1,016 0.4% Toilet transfer (GG0170F) 5,989 2.4% Car transfer (GG0170G) 70,723 28.2% 48 24

Mobility: Potential issues: Use of 07, 09, 88, and dash (-) at discharge Item Cases % Walk 10 feet (GG0170I) 5,202 2.1% Walk 50 feet with two turns (GG0170J) 21,471 8.5% Walk 150 feet (GG0170K) 49,747 19.8% Walking 10 feet on uneven surfaces (GG0170L) 64,635 25.7% 1 step (curb) (GG0170M) 43,062 17.1% 4 steps (GG0170N) 49,623 19.8% 12 steps (GG0170O) 96,312 38.3% Picking up object (GG0170P) 74,059 29.5% 49 Mobility: Potential issues: Inconsistency with FIM items Not attempted vs. assessed Disagreement in functional ability Effects on payment or quality 50 25

GG0170F Mobility: Toilet transfer - Admission Not assessed Dependent Substantial / maximal Partial / moderate Supervision or touching Setup or clean-up Independent Patient refused Not applicable Not attempted due to medical condition or safety concerns - 01 02 03 04 05 06 07 09 88 Total Activity does not occur 0 47 1,213 623 663 280 18 21 895 600 5,023 9,383 Total 1 31 26,210 14,521 10,699 3,244 158 176 1,196 950 5,034 62,219 Maximal 2 10 1,038 18,256 17,626 5,471 246 204 745 593 1,887 46,076 39J FIM Instrument Transfers: Toilet - Admission Moderate Minimal 3 26 392 2,777 38,359 12,510 512 403 773 832 2,032 58,616 4 39 231 581 23,690 37,364 1,384 891 813 866 1,806 67,665 Supervision 5 6 24 38 453 4,138 1,025 410 157 133 240 6,624 Modified Independence 6 1 8 7 73 152 41 170 28 26 36 542 Complete Independence 7 0 3 3 10 25 4 24 9 3 4 85 Total 160 29,119 36,806 91,573 63,184 3,388 2,299 4,616 4,003 16,062 251,210 GG0170F Mobility: Toilet transfer - Discharge Not assessed Dependent Substantial / maximal Partial / moderate Supervision or touching Setup or clean-up Independent Patient refused Not applicable Not attempted due to medical condition or safety concerns - 01 02 03 04 05 06 07 09 88 Total Activity does not occur 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Total 1 18 6,196 2,280 1,177 609 81 200 446 397 1,920 13,324 Maximal 2 2 503 3,789 1,513 578 62 85 46 65 202 6,845 39J FIM Instrument Transfers: Toilet - Discharge Moderate Minimal 3 3 189 997 8,023 2,280 294 396 62 73 202 12,519 4 31 160 433 12,444 24,643 2,260 3,805 151 191 419 44,537 Supervision 5 13 63 134 2,091 37,860 12,516 14,352 145 292 433 67,899 Modified Independence 6 27 31 51 828 5,538 2,194 87,133 121 326 299 96,548 Complete Independence 7 1 1 1 30 340 106 8,950 48 28 28 9,533 Total 95 7,143 7,685 26,106 71,848 17,513 114,921 1,019 1,372 3,503 251,205 26

Summary Stay aware of IRF QRP quality measures Know the associated timelines and deadlines Track performance against comparisons Consistency, where possible, may be key Monitor use of dash and not attempted codes Advocate! Tell your story Send issues or comments to CMS Get to know your members of Congress 53 Questions? Troy Hillman: thillman@udsmr.org 716-817-7869 54 27