LTCH QUALITY REPORTING PROGRAM

Transcription

1 4 LTCH QUALITY REPORTING PROGRAM GENERAL INFORMATION...3 LTCH FACILITY-LEVEL QUALITY MEASURE REPORT...5 LTCH PATIENT-LEVEL QUALITY MEASURE REPORT...18 LTCH REVIEW AND CORRECT REPORT /2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-1 CASPER Reprting LTCH Prvider User s Guide

2 NOTE: Unless therwise nted, PDF is the recmmended utput frmat fr the reprts described herein. Excel and CSV utput frmats may result in a reprt that is nt visually aesthetic. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-2 CASPER Reprting LTCH Prvider User s Guide

3 GENERAL INFORMATION Lng Term Care Hspital (LTCH) Quality Reprting Prgram (QRP) reprts are requested n the CASPER Reprts page (Figure 4-1). Figure 4-1. CASPER Reprts Page LTCH Quality Reprting Prgram Categry 1. Select the LTCH Quality Reprting Prgram link frm the Reprt Categries frame n the left. A list f the individual LTCH QRP reprts yu may request displays in the right-hand frame. NOTE: Only thse reprt categries t which yu have access are listed in the Reprt Categries frame. 2. Select the desired underlined reprt name link frm the right-hand frame. One r mre CASPER Reprts Submit pages are presented prviding criteria ptins with which yu specify the infrmatin t include in yur reprt. These ptins may differ fr each reprt. 3. Chse the desired criteria and select the Submit r Next buttn. NOTE: LTCH Quality Reprting Prgram reprts access detailed infrmatin and may require a significant amunt f time t prcess. Once yu submit yur reprt request(s), yu may cnsider exiting the CASPER Reprting applicatin, and viewing the cmpleted reprt(s) at a later time. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-3 CASPER Reprting LTCH Prvider User s Guide

4 4. Refer t Sectin 2, Functinality, f the CASPER Reprting LTCH Prvider User s Guide fr assistance in viewing, printing, saving and exprting the reprts yu request. NOTE: LTCH Quality Reprting Prgram reprts are autmatically purged after 60 days. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-4 CASPER Reprting LTCH Prvider User s Guide

5 LTCH FACILITY-LEVEL QUALITY MEASURE REPORT The LTCH Facility-Level Quality Measure Reprt prvides facility-level quality measure values fr a select 12-mnth perid. LTCH quality measure values are cmpiled frm the fllwing surces: LTCH Cntinuity Assessment Recrd and Evaluatin (CARE) data Centers fr Disease Cntrl and Preventin (CDC) Natinal Healthcare Safety Netwrk (NHSN) data Medicare Fee-Fr-Service (FFS) claims and Eligibility Files The CASPER Reprts Submit criteria page (Figure 4-2) fr the LTCH Facility-Level Quality Measure Reprt presents Begin Date, End Date, and Influenza Seasn Dates criteria ptins. Figure 4-2. LTCH Facility-Level Quality Measure Reprt CASPER Reprts Submit Page Begin Date and End Date values define the date range f the measure calculatins t select fr the reprt. A drp-dwn list prvides the end dates f the calendar quarters fr which pressure ulcer measure calculatins are available. The default value is the end date f the mst recently calculated quarter. Yu may select a different quarter end date frm the list. Begin Date is a read-nly field that displays the first day f the 12-mnth perid ending with the specified End Date. The Influenza Seasn Dates field is a read-nly display f the influenza seasn dates in effect during the perid identified by the End Date and Begin Date. NOTE: The influenza seasn reprting perid is always July 1 thrugh June 30. The earliest influenza seasn fr which measure data are available is 07/01/2014 thrugh 06/30/2015. If the selected End Date is prir t earliest influenza seasn fr which measure data exists, the Influenza Seasn Dates field is blank. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-5 CASPER Reprting LTCH Prvider User s Guide

6 The LTCH Facility-Level Quality Measure Reprt (Figure 4-3) presents the fllwing: Facility ID (fr LTCH CARE-based measures nly) CMS Certificatin Number (CCN) Prvider Name City/State Reprt Perid: The beginning and ending reprting year dates crrespnding t the user-selected End Date criterin. N/A indicates the user-selected End Date is prir t the date nted in the 1st Quarter End Date Available clumn f Table 4-A. NOTE: Fr the patient influenza measures, the Reprt Perid dates are the influenza seasn dates in effect fr the user-selected quarter end date (End Date). The influenza seasn reprting perid seasn is always July 1 thrugh June 30. Fr the healthcare persnnel influenza vaccinatin measure, N/A indicates the reprt is being requested between 3/31 and 5/16 fr the previus data cllectin perid. NOTE: Healthcare persnnel influenza vaccinatin measure data is cllected between Octber 1 and March 31 and is available fr reprting the fllwing May 16. Healthcare persnnel influenza vaccinatin measure data frm the prir flu seasn display until the new data are available. Medicare Fee-Fr-Service data are reprted fr a tw-year perid. Data was calculated n Fr LTCH CARE data, this is the date the data were calculated fr the 12-mnth perid indicated in the Reprt Perid field. Fr CDC NHSH data and Medicare FFS claims data, this is the date the data were laded int the QIES natinal database. Cmparisn Grup Perid: The date range used t calculate natinal rates fr cmparisn with facility rates during the reprt perid. Natinal rates are based upn stays within this date range. These dates crrespnd t the Reprt Perid dates. Displayed fr nn-medicare Fee- Fr-Service Claims measures nly. Reprt Run Date: The date that the reprt was run. Reprt Versin Number: The versin f the reprting system sftware used t prduce the reprt. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-6 CASPER Reprting LTCH Prvider User s Guide

7 Figure 1. Table 4-A. Quality Measure Dates Measure Name Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt Stay) (NQF #0678) Percent f Residents r Patients Wh Were Assessed and Apprpriately Given the Seasnal Influenza Vaccine (Shrt Stay) (NQF #0680) Residents r Patients Wh Received the Seasnal Influenza Vaccine (NQF #0680A) Residents r Patients Wh Were Offered and Declined the Seasnal Influenza Vaccine (NQF #0680B) Residents r Patients Wh Did Nt Receive, Due t Medical Cntraindicatin, the Seasnal Influenza Vaccine (NQF #0680C) Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) Applicatin f Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) LTCH Functinal Outcme Measure: Change in Mbility Amng Patients Requiring Ventilatr Supprt (NQF #2632) Applicatin f Percent f Residents Experiencing One r Mre Falls with Majr Injury (Lng Stay) (NQF #0674) Natinal Healthcare Safety Netwrk (NHSN) Catheter-Assciated Urinary Tract Infectin (CAUTI) Outcme Measure (NQF #0138) Natinal Healthcare Safety Netwrk (NHSN) Central Line-assciated Bldstream Infectin (CLABSI) Outcme Measure (NQF #0139) Natinal Healthcare Safety Netwrk (NHSN) Facility-wide Inpatient Hspital-nset Methicillin-resistant Staphylcccus aureus (MRSA) Bacteremia Outcme Measure (NQF #1716) Surce Earliest Date Data Available 1st Quarter End Date Available Asmt 10/1/2012 9/30/2013 Asmt 7/1/2014 6/30/2015 Asmt 7/1/2014 6/30/2015 Asmt 7/1/2014 6/30/2015 Asmt 7/1/2014 6/30/2015 Asmt 4/1/2016 3/31/2017 Asmt 4/1/2016 3/31/2017 Asmt 4/1/2016 3/31/2017 Asmt 4/1/2016 3/31/2017 CDC 1/1/ /31/2015 CDC 1/1/ /31/2015 CDC 01/01/ /31/2016 1st Reprting Year Available 10/01/ /30/ /01/ /30/ /01/ /30/ /01/ /30/ /01/ /30/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-7 CASPER Reprting LTCH Prvider User s Guide

8 Measure Name Natinal Healthcare Safety Netwrk (NHSN) Facility-wide Inpatient Hspital-nset Clstridium difficile Infectin (CDI) Outcme Measure (NQF #1717) Influenza Vaccinatin Cverage Amng Healthcare Persnnel (NQF #0431) Natinal Healthcare Safety Netwrk Ventilatr-Assciated Event (VAE) Outcme Measure All-Cause Unplanned Readmissin Measure fr 30 Days Pst Discharge frm Lng-Term Care Hspitals (LTCHs) (NQF #2512) Ptentially Preventable 30-Day Pst- Discharge Readmissin Measure fr Lng-Term Care Hspital Quality Reprting Prgram Discharge t Cmmunity-Pst Acute Care (PAC) Lng-Term Care Hspital Quality Reprting Prgram Medicare Spending Per Beneficiary (MSPB) - Pst-Acute Care (PAC) Lng-Term Care Hspital Quality Reprting Prgram Surce Earliest Date Data Available 1st Quarter End Date Available CDC 01/01/ /31/2016 CDC 10/01/ /31/2016 CDC 1/1/ /31/2016 Claims 1/1/2013 3/31/2016 Claims 1/1/ /31/2017 Claims 1/1/ /31/2017 Claims 1/1/ /31/2017 1st Reprting Year Available 01/01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/2016 The main bdy f the reprt prvides the fllwing infrmatin fr the measure(s) indicated: LTCH CARE pressure ulcer measure (Page 1): Table Legend Nte: Dashes represent a value that culd nt be cmputed. Dashes display in the Facility Observed Percent and Facility Adjusted Percent clumns when the denminatr is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set. Measure Name Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt Stay) (NQF #0678) CMS Measure ID: The unique identificatin number assigned by CMS t each measure. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-8 CASPER Reprting LTCH Prvider User s Guide

9 Numeratr: The number f stays in the LTCH that triggered the measure during the reprt perid. Denminatr: The ttal number f qualified stays in the LTCH that did nt meet the exclusin criteria during the reprt perid. Facility Observed Percent: The percentage f patients wh culd have the QM and actually triggered it. It is cmputed by dividing the numeratr by the denminatr. Facility Risk-Adjusted Percent: A cmputed rate whereby patient characteristics and the natinal average bserved rate are applied t the Facility Observed Percent. Cmparisn Grup: Natinal Average: The natinwide average f the measure fr the Cmparisn Grup Perid. LTCHs can cmpare their facility perfrmance t the natinal average. NOTE: Fr reprt End Dates 9/30/2018 and beynd, the results fr the 7/01/2017 6/30/2018 perid are displayed. LTCH CARE influenza vaccinatin measures (Page 2): Table Legend Nte: Dashes represent a value that culd nt be cmputed. A dash displays in the Facility Percent clumn when the denminatr is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Measure Name Percent f Residents r Patients Wh Were Assessed and Apprpriately Given the Seasnal Influenza Vaccine (Shrt Stay) (NQF #0680) Residents r Patients Wh Received the Seasnal Influenza Vaccine (NQF #0680A) Residents r Patients Wh Were Offered and Declined the Seasnal Influenza Vaccine (NQF #0680B) Residents r Patients Wh Did Nt Receive, Due t Medical Cntraindicatin, the Seasnal Influenza Vaccine (NQF #0680C) CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Numeratr: The number f stays in the LTCH that triggered the measure during the reprt perid. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-9 CASPER Reprting LTCH Prvider User s Guide

10 Denminatr: The ttal number f qualified stays in the LTCH that did nt meet the exclusin criteria during the reprt perid. Facility Percent: The percentage f patients wh culd have the QM and actually triggered it, and is cmputed by dividing the numeratr by the denminatr. Cmparisn Grup: Natinal Average: The natinwide average f the measure fr the Cmparisn Grup Perid. LTCHs can cmpare their facility perfrmance t the natinal average. NOTE: Fr Reprt Perids including dates 7/01/2018 and beynd, flu measure data is displayed as N/A. As f 7/01/2018 flu items are n lnger in the LTCH CARE data set. LTCH CARE utcmes/prcesses perfrmed measures (Page 3): Table Legend Nte: Dashes represent a value that culd nt be cmputed. A dash displays in the Facility Percent clumn when the denminatr is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Measure Name Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) Applicatin f Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) Applicatin f Percent f Residents Experiencing One r Mre Falls with Majr Injury (Lng Stay) (NQF #0674) CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Numeratr: The number f stays in the LTCH that triggered the measure during the reprt perid. Denminatr: The ttal number f qualified stays in the LTCH that did nt meet the exclusin criteria during the reprt perid. Facility Percent: The percentage f patients wh culd have the QM and actually triggered it, and is cmputed by dividing the numeratr by the denminatr. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-10 CASPER Reprting LTCH Prvider User s Guide

11 Cmparisn Grup: Natinal Average: The natinwide average f the measure fr the Cmparisn Grup Perid. LTCHs can cmpare their facility perfrmance t the natinal average. LTCH CARE change in functinal status (ventilatr supprt) measure (Page 4): Table Legend Nte: Dashes represent a value that culd nt be cmputed. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Measure Name LTCH Functinal Outcme Measure: Change in Mbility Amng Patients Requiring Ventilatr Supprt (NQF #2632) CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Denminatr: The ttal number f qualified stays in the LTCH that did nt meet the exclusin criteria during the reprt perid. Average Admissin Scre: The average scre n admissin f the quality measure. Average Discharge Scre: The average scre n discharge f the quality measure. Average Observed Change: The average bserved change (discharge admissin) in scre. Average Risk-Adjusted Change: A cmputed change in scre value whereby patient characteristics and the natinal average are applied t the Average Observed Change. Cmparisn Grup: Natinal Average: The natinwide average f the measure fr the Cmparisn Grup Perid. LTCHs can cmpare their facility perfrmance t the natinal average. CDC Natinal Healthcare Safety Netwrk (NHSN) infectin measures (Pages 5 and 6): Table Legend: [a]: Standardized infectin rati (SIR) = rati f reprted t predicted infectins; lwer SIR is better [b]: (Lwer Limit, Upper Limit) [c]: Natinal benchmark = 1 Nte: Dashes represent a value that culd nt be cmputed. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-11 CASPER Reprting LTCH Prvider User s Guide

12 Nte: CDC measures d nt have CASPER Patient-Level Quality Measure reprts Nte: CDC data nt available fr a reprt perid end date prir t 12/31/2015 Surce: Centers fr Disease Cntrl and Preventin Natinal Healthcare Safety Netwrk (CDC NHSN) Measure Name Natinal Healthcare Safety Netwrk (NHSN) Catheter-Assciated Urinary Tract Infectin (CAUTI) Outcme Measure (NQF #0138) Natinal Healthcare Safety Netwrk (NHSN) Central lineassciated Bldstream Infectin (CLABSI) Outcme Measure (NQF #0139) Natinal Healthcare Safety Netwrk (NHSN) Facility-wide Inpatient Hspital-nset Methicillin-resistant Staphylcccus aureus (MRSA) Bacteremia Outcme Measure (NQF #1716) Natinal Healthcare Safety Netwrk (NHSN) Facility-wide Inpatient Hspital-Onset Clstridium difficile Infectin (CDI) Outcme Measure (NQF #1717) Natinal Healthcare Safety Netwrk (NHSN) Ventilatr-Assciated Event (VAE) Outcme Measure CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Reprted Number f Infectins r Events: The number f reprted infectins r events in the LTCH fr the perid. Device r Patient Days: The ttal number f days in the LTCH assciated with the device r ttal number f patient days. Used t calculate the Predicted Number f Infectins. Predicted Number f Infectins r Events: Device r Patient Days multiplied by the natinal rate. Standardized Infectin Rati (SIR): Reprted Number f Infectins r Events in the LTCH divided by the Predicted Number f Infectins r Events fr the LTCH. 95% Cnfidence Interval [displayed as (lwer limit, upper limit)]: 95% cnfidence level interval fr the SIR. Cmparisn Grup: Natinal SIR: The reprted number f infectins r events in the natin divided by the predicted number f infectins r events in the natin fr the Cmparisn Grup Perid. This allws prviders t cmpare their SIR t the natinal SIR. Cmparative Perfrmance Categry: A cmparisn f the perfrmance f the LTCH t the natinal benchmark depicted as ne f the fllwing: Better than the Natinal Benchmark 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-12 CASPER Reprting LTCH Prvider User s Guide

13 N Different than the Natinal Benchmark Wrse than the Natinal Benchmark CDC Natinal Healthcare Safety Netwrk (NHSN) infectin measures (Page 7): Table Legend: Nte: Dashes represent a value that culd nt be cmputed. Dashes ccur in the Facility Percent clumn when the denminatr is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Nte: CDC measures d nt have CASPER Patient-Level Quality Measure reprts. Surce: Centers fr Disease Cntrl and Preventin Natinal Healthcare Safety Netwrk (CDC NHSN) Measure Name Influenza Vaccinatin Cverage Amng Healthcare Persnnel (NQF #0431) CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Numeratr: The number f healthcare persnnel in the LTCH wh received the influenza vaccinatin during the reprt perid. Denminatr: The ttal number f healthcare persnnel in the LTCH that did nt meet the exclusin criteria during the reprt perid. Facility Percent: The percentage f healthcare persnnel in the LTCH wh received the influenza vaccinatin, cmputed by dividing the numeratr by the denminatr. Cmparisn Grup: Natinal Average: The natinwide average f the measure fr the Cmparisn Grup Perid. LTCHs can cmpare their facility perfrmance t the natinal average. Medicare FFS claims measures (Pages 8): Table Legend: Nte: Dashes represent a value that culd nt be cmputed. Dashes ccur in the Observed Readmissin Rate, Risk Standardized Readmissin Rate, and Cmparative Perfrmance Categry clumns when the Number f Eligible Stays is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Nte: Claims-based measures d nt have CASPER Patient-Level Quality Measure reprts. Surce: Medicare Fee-Fr-Service Claims 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-13 CASPER Reprting LTCH Prvider User s Guide

14 Measure Name Ptentially Preventable 30-Day Pst-Discharge Readmissin Measure fr Lng-Term Care Hspital Quality Reprting Prgram CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Number f Readmissins: The number f patients with an unplanned r ptentially preventable readmissin in the 30-day pst-discharge perid. Number f Eligible Stays: The ttal number f stays in the LTCH that did nt meet the exclusin criteria. Observed Readmissin Rate: The number f pst-discharge unplanned r ptentially preventable readmissins in the LTCH divided by number f eligible stays in the LTCH. Risk Standardized Readmissin Rate (RSRR): A risk adjustment f the Observed Readmissin Rate that accunts fr patient characteristics and a statistical estimate f the LTCH effect beynd patient mix. Natinal Observed Readmissin Rate: The number f pst-discharge unplanned r ptentially preventable readmissins in the natin divided by number f eligible stays in the natin. Cmparative Perfrmance Categry: A cmparisn f the perfrmance f the LTCH t the natinal benchmark depicted as ne f the fllwing: Better than the Natinal Rate N Different frm the Natinal Rate Wrse than the Natinal Rate NOTE: Effective 10/1/2018 the All-Cause Unplanned Readmissin Measure fr 30 Days Pst Discharge frm Inpatient Rehabilitatin Facilities (NQF #2512) measure is n lnger reprted. Medicare FFS claims discharge t the cmmunity measure (Page 9): Table Legend: Nte: Dashes represent a value that culd nt be cmputed. Dashes ccur in the Observed Discharge t Cmmunity Rate, Risk Standardized Discharge t Cmmunity Rate, and Cmparative Perfrmance Categry clumns when the Number f Eligible Stays is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. Nte: Claims-based measures d nt have CASPER Patient-Level Quality Measure reprts. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-14 CASPER Reprting LTCH Prvider User s Guide

15 Surce: Medicare Fee-Fr-Service Claims Measure Name Discharge t Cmmunity-Pst Acute Care (PAC) Lng-Term Care Hspital Quality Reprting Prgram CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Number f Discharges t Cmmunity: The number f patients discharged t the cmmunity. Number f Eligible Stays: The ttal number f stays in the LTCH that did nt meet the exclusin criteria. Observed Discharge t Cmmunity Rate: The number f discharges t the cmmunity frm the LTCH divided by number f eligible stays in the LTCH. Risk Standardized Discharge t Cmmunity Rate: A risk adjustment f the Observed Discharge t Cmmunity Rate that accunts fr patient characteristics and a statistical estimate f the LTCH effect beynd patient mix. Natinal Observed Discharge t Cmmunity Rate: The number f discharges t the cmmunity in the natin divided by number f eligible stays in the natin. Cmparative Perfrmance Categry: A cmparisn f the perfrmance f the LTCH t the natinal benchmark depicted as ne f the fllwing: Better than the Natinal Rate N Different frm the Natinal Rate Wrse than the Natinal Rate Medicare FFS claims Medicare spending measure (Page 10): Table Legend: [a]: The treatment perid is the time during which the patient receives care services frm the attributed LTCH, and includes Part A, Part B, and Durable Medical Equipment, Prsthetics, Orthtics and Supplies (DMEPOS) claims. [b]: The assciated services perid is the time during which any Medicare Part A and Part B services ther than thse in the treatment perid are cunted twards the episde spending. Nte: Dashes represent a value that culd nt be cmputed. Dashes ccur in the Average Spending Per Episde and MSPB Amunt-Average Risk-Adjusted Spending clumns when the Number f Eligible Episdes is zer. N/A = Nt Available Indicates n result value exists fr the measure(s) fr the requested perid. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-15 CASPER Reprting LTCH Prvider User s Guide

16 Nte: Claims-based measures d nt have CASPER Patient-Level Quality Measure reprts. Surce: Medicare Fee-Fr-Service Claims and Eligibility Files Measure Name Medicare Spending Per Beneficiary (MSPB) - Pst-Acute Care (PAC) Lng-Term Care Hspital Quality Reprting Prgram Cmparisn Grup: Measure values and calculatins are prvided fr the LTCH and, as a cmparisn, all LTCHs in the natin. CMS Measure ID: The unique identificatin number assigned by CMS t each measure. Number f Eligible Episdes: Ttal number f episdes in the facility that did nt meet the exclusin criteria. Average Spending Per Episde Spending During Treatment Perid: Average spending per episde during the treatment perid - nn-risk-adjusted. The treatment perid starts at the day f admissin and ends at discharge. Spending During Assciated Services Perid: Average spending per episde during assciated services perid - nn-risk-adjusted. The assciated services perid fr LTCH-standard episdes starts at the day f admissin and ends 30 days after the last day f the episde s treatment perid. The assciated services perid fr LTCH-site neutral episdes starts at the end f the treatment perid and ends 30 days after the last day f the episde s treatment perid. Ttal Spending During Episde: Average spending per episde during the treatment perid plus average spending per episde during the assciated services perid - nn-risk-adjusted. MSPB Amunt Average Risk-Adjusted Spending: Average risk-adjusted Medicare spending acrss all episdes fr the LTCH. Natinal Median: Average risk-adjusted Medicare spending acrss all episdes fr all LTCHs. MSPB Scre: The rati f the prvider s MSPB Amunt t the episde-weighted median MSPB Amunt acrss all LTCH prviders. MSPB Scre calculatin is perfrmed separately fr LTCH Standard and Site Neutral episdes t ensure that they are cmpared nly t ther episdes f the same type. The final MSPB Scre cmbines the ratis f the episde types t cnstruct ne prvider scre. NOTE: The LTCH Facility-Level Quality Measure Reprt may cntain prtected privacy infrmatin that shuld nt be released t the public. Any alteratin t this reprt is strictly prhibited. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-16 CASPER Reprting LTCH Prvider User s Guide

17 Figure 4-3. LTCH Facility-Level Quality Measure Reprt * * Fictitius, sample data are depicted. The reprt is srted by State Cde and CCN. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-17 CASPER Reprting LTCH Prvider User s Guide

18 LTCH PATIENT-LEVEL QUALITY MEASURE REPORT The LTCH Patient-Level Quality Measure Reprt identifies each patient with a qualifying Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) assessment recrd used t calculate the facility-level quality measure values fr a select 12-mnth perid. The reprt displays each patient s name and indicates hw/if the patient s assessment affected the LTCH s quality measures. NOTE: The LTCH Patient-Level Quality Measure Reprt nly prvides patient-level infrmatin fr the quality measures assciated with LTCH CARE assessment recrds and des nt prvide patient-level infrmatin fr the CDC NHSN r Medicare FFS quality measures. The CASPER Reprts Submit criteria page (Figure 4-4) fr the LTCH Patient-Level Quality Measure Reprt presents Begin Date, End Date, and Influenza Seasn Dates criteria ptins. Figure 4-4. LTCH Patient-Level Quality Measure Reprt CASPER Reprts Submit Page Begin Date and End Date values define the date range f the measure calculatins t select fr the reprt. A drp-dwn list prvides the end dates f the calendar quarters fr which pressure ulcer measure calculatins are available. The default value is the end date f the mst recently calculated quarter. Yu may select a different quarter end date frm the list. Begin Date is a read-nly field that displays the first day f the 12-mnth perid ending with the specified End Date. The Influenza Seasn Dates field is a read-nly display f the influenza seasn dates in effect during the perid identified by the End Date and Begin Date. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-18 CASPER Reprting LTCH Prvider User s Guide

19 NOTE: The influenza seasn reprting perid is always July 1 thrugh June 30. The earliest influenza seasn fr which measure data are available is 07/01/2014 thrugh 06/30/2015. If the selected End Date is prir t earliest influenza seasn fr which measure data exists, the Influenza Seasn Dates field is blank. The LTCH Patient-Level Quality Measure Reprt (Figure 4-5) presents the fllwing: Facility ID CMS Certificatin Number (CCN) Prvider Name City/State Reprt Perid Reprt Run Date Reprt Versin Number The remainder f the reprt prvides the fllwing infrmatin and measure status at the patient level fr the measure(s) indicated: Quality Measures: Undesirable Outcmes/Prcesses Nt Perfrmed: Status Legend: X: Triggered NT: Nt triggered E: Excluded frm analysis based n quality measure exclusin criteria N/A = Nt Available Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Patient Name Patient ID: The unique ID assigned t the patient in the natinal database Admissin Date: The patient s admissin date frm the admissin assessment f the stay. Discharge Date: The patient s discharge date frm the discharge assessment f the stay. Quality Measure Name Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt Stay) (NQF #0678) 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-19 CASPER Reprting LTCH Prvider User s Guide

20 NOTE: Fr reprt End Dates 9/30/2018 and beynd, results fr the 7/01/2017 6/30/2018 perid are displayed fr the Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt Stay) (NQF #0678) measure. Applicatin f Percent f Residents Experiencing One r Mre Falls with Majr Injury (Lng Stay) (NQF #0674) Quality Measures: Desirable Outcmes/Prcesses Perfrmed: Status Legend: X: Triggered NT: Nt triggered E: Excluded frm analysis based n quality measure exclusin criteria N/A = Nt Available Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Patient Name Patient ID: The unique ID assigned t the patient in the natinal database Admissin Date: The patient s admissin date frm the admissin assessment f the stay. Discharge Date: The patient s discharge date frm the discharge assessment f the stay. Quality Measure Name Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) Applicatin f Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) Quality Measures: Patient Seasnal Influenza Vaccinatin Measure Status Legend Y: Yes N: N E: Excluded frm analysis based n quality measure exclusin criteria N/A = Nt Available Table Legend 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-20 CASPER Reprting LTCH Prvider User s Guide

21 [a]: Submeasures fr the Percent f Residents f Patients Wh Were Assessed and Apprpriately Given the Seasnal Influenza Vaccine (Shrt Stay) Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Patient Name Patient ID Admissin Date: The patient s admissin date frm the admissin assessment f the stay. Discharge Date: The patient s discharge date frm the discharge assessment f the stay. Quality Measure Name Percent f Residents r Patients Wh Were Assessed and Apprpriately Given the Seasnal Influenza Vaccine (Shrt Stay) (NQF #0680) Residents r Patients Wh Received the Seasnal Influenza Vaccine (NQF #0680A) Residents r Patients Wh Were Offered and Declined the Seasnal Influenza Vaccine (NQF #0680B) Residents r Patients Wh Did Nt Receive, Due t Medical Cntraindicatin, the Seasnal Influenza Vaccine (NQF #0680C) NOTE: Fr Reprt Perids including dates 7/01/2018 and beynd, flu measure data is nt displayed. As f 7/01/2018 flu items are n lnger in the LTCH CARE data set. Quality Measures: Change in Functinal Scres: Status Legend: E: Excluded frm analysis based n quality measure exclusin criteria N/A = Nt Available Nte: Values are change in scres frm admissin t discharge Surce: Lng-Term Care Hspital (LTCH) Cntinuity Assessment Recrd and Evaluatin (CARE) Data Set Patient Name Patient ID: The unique ID assigned t the patient in the natinal database Admissin Date: The patient s admissin date frm the admissin assessment f the stay. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-21 CASPER Reprting LTCH Prvider User s Guide

22 Discharge Date: The patient s discharge date frm the discharge assessment f the stay. Quality Measure Name LTCH Functinal Outcme Measure: Change in Mbility Amng Patients Requiring Ventilatr Supprt (NQF #2632) NOTE: The LTCH Patient-Level Quality Measure Reprt cntains prtected privacy infrmatin that shuld nt be released t the public. Any alteratin t this reprt is strictly prhibited. Figure 4-5. LTCH Patient-Level Quality Measure Reprt * * Fictitius, sample data are depicted. The reprt recrds are srted by State Cde, CCN, Patient Last Name, Patient First Name ascending, Discharge Date, and Admissin Date descending. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-22 CASPER Reprting LTCH Prvider User s Guide

23 LTCH REVIEW AND CORRECT REPORT The LTCH Review and Crrect Reprt allws LTCH prviders t review their quality measure (QM) data t identify if there are any crrectins r changes necessary prir t the quarter's data submissin deadline, which is 4.5 mnths after the end f the quarter. NOTE: Crrectin perids fr each quarter end as fllws: Q1 (1/1-3/31) August 15 Q2 (4/1-6/30) Nvember 15 Q3 (7/1-9/30) February 15 Q4 (10/1-12/31) May 15 The LTCH Review and Crrect Reprt prvides a breakdwn, by measure and by quarter, f the prvider s QM data fr fur rlling quarters, except fr NQF #2632 fr which there are eight rlling quarters. The reprt als identifies the pen/clsed status f each quarter s data crrectin perid as f the reprt run date. NOTE: Quality Measure calculatins are perfrmed weekly and n the first day f each quarter. The CASPER Reprts Submit criteria page (Figure 4-6) fr the LTCH Review and Crrect Reprt presents Begin Date, End Date, and Influenza Seasn Dates criteria ptins. Figure 4-6. LTCH Review and Crrect Reprt CASPER Reprts Submit Page Begin Date and End Date values define the date range f the QM calculatins t select fr the reprt. A drp-dwn list assciated with the End Date field prvides the calendar quarters fr which calculated quality measure data is available. The default value is the mst recently cmpleted calculated quarter. Yu may select a different quarter frm the list. Begin Date is a read-nly field that displays the first quarter f the 4-quarter perid ending with the specified End Date. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-23 CASPER Reprting LTCH Prvider User s Guide

24 NOTE: Until QM data fr mre than 4 quarters is available, the Begin Date is Q NOTE: Only qualifying patient stays with a discharge recrd cntaining a Discharge Date between the Begin Date and End Date are included in the QM calculatins fr the reprt. The LTCH Review and Crrect Reprt (Figure 4-7) presents the fllwing: CMS Certificatin Number (CCN) Prvider Name Street Address Line 1 Street Address Line 2 City State ZIP Cde Cunty Name Telephne Number The remainder f the reprt details each measure. The fllwing fields are cmmn t all measures: Reprting Quarter: The quarter and calendar year fr which the data were cllected r, fr NQF #0680, the quarter and influenza seasn fr which the data were cllected NOTE: Since Quarter 1 f the influenza seasn is between 7/1 and 9/30, which is befre the start f the influenza vaccinatin seasn (10/1), n data will exist fr Quarter 1 f the influenza seasn. Start Date: Beginning date f the reprting quarter End Date: Ending date f the reprting quarter Data Crrectin Deadline: The date after which the data fr the reprting quarter are frzen NOTE: Crrectins f the data fr a reprting quarter made after the Data Crrectin Deadline will nt affect QM results. Data Crrectin Perid as f Reprt Run Date: 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-24 CASPER Reprting LTCH Prvider User s Guide

25 Open = As f the Reprt Run Date, the data crrectin deadline f the reprting quarter is either tday r in the future; data may still be crrected Clsed = As f the Reprt Run Date, the data crrectin deadline is in the past; data can n lnger be crrected and affect the QM results The fllwing unique infrmatin is prvided fr the measure(s) indicated: Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt Stay) (NQF #0678) CMS Measure ID: L Table Legend: Dash (-): Data nt available r nt applicable Number f Patient Stays that Triggered the Quality Measure in yur LTCH Number f Eligible Patients Discharged frm yur LTCH Yur LTCH s Observed Perfrmance Rate NOTE: Fr reprt End Dates Q and beynd, results fr the Q Q perid are displayed fr the Percent f Residents r Patients with Pressure Ulcers That Are New r Wrsened (Shrt Stay) (NQF #0678) measure. Effective 7/01/2018 cllectin f the measure data was discntinued. Percent f Residents r Patients Wh Were Assessed and Apprpriately Given the Seasnal Influenza Vaccine (Shrt Stay) (NQF #0680) CMS Measure ID: L Table Legend: * Based n influenza seasn which starts n July 1 st and ends n June 30 th (i.e. Quarter 1 f the influenza seasn starts n July 1 st and ends n September 30 th ). ** There are n discharges fr the assciated influenza vaccinatin seasn during this perid f the influenza seasn Dash (-): Data nt available r nt applicable Number f Patient Stays that Triggered the Quality Measure in yur LTCH Number f Eligible Patients Discharged frm yur LTCH Yur LTCH s Observed Perfrmance Rate 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-25 CASPER Reprting LTCH Prvider User s Guide

26 NOTE: Fr Reprt Quarters including dates 7/01/2018 and beynd, flu measure data is displayed with dashes. As f 7/01/2018 flu items are n lnger in the LTCH CARE data set. Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) CMS Measure ID: L Table Legend: Dash (-): Data nt available r nt applicable Number f Patient Stays that Triggered the Quality Measure in yur LTCH Number f Eligible Patients Discharged frm yur LTCH Yur LTCH s Observed Perfrmance Rate Applicatin f Percent f Lng-Term Care Hspital (LTCH) Patients With an Admissin and Discharge Functinal Assessment and a Care Plan That Addresses Functin (NQF #2631) CMS Measure ID: L Table Legend: Dash (-): Data nt available r nt applicable Number f Patient Stays that Triggered the Quality Measure in yur LTCH Number f Eligible Patients Discharged frm yur LTCH Yur LTCH s Observed Perfrmance Rate Applicatin f Percent f Residents Experiencing One f Mre Falls with Majr Injury (Lng Stay) (NQF #0674) CMS Measure ID: L Table Legend: Dash (-): Data nt available r nt applicable Number f Patient Stays that Triggered the Quality Measure in yur LTCH Number f Eligible Patients Discharged frm yur LTCH Yur LTCH s Observed Perfrmance Rate LTCH Functinal Outcme Measure: Change in Mbility Amng Patients Requiring Ventilatr Supprt (NQF #2632) CMS Measure ID: L Table Legend: 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-26 CASPER Reprting LTCH Prvider User s Guide

27 * Average Observed Change in Mbility Scre - (Average Discharge Mbility Scre Average Admissin Mbility Scre). Dash (-): Data nt available r nt applicable Number f Eligible Patients Discharged frm yur LTCH Yur LTCH s Average Observed Change in Mbility Scre Figure 4-7. LTCH Review and Crrect Reprt * * Fictitius, sample data are depicted. 09/2018 v1.04 Certificatin And Survey Prvider Enhanced Reprts LTCH QRP 4-27 CASPER Reprting LTCH Prvider User s Guide