Avoiding Confusion between Payment and Quality Items on the New IRF-PAI, Part II: Other Implications Troy Hillman Manager, Analytical Services Uniform Data System for Medical Rehabilitation 2016 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. FIM, UDSMR, and the UDSMR logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Objectives Contrast CARE-based functional items with the FIM instrument Define the NQF-endorsed functional quality measures for use in the IRF QRP Differentiate competing measures 2 1
Contrast CARE-Based Functional Items with the FIM Instrument The most prominent difference between the CAREbased functional items and the FIM instrument that may affect interpretation of quality is the scales: CARE-Based Functional Items 06. Independent 05. Setup or clean-up assistance (Helper SETS UP or CLEANS UP) 04. Supervision or touching assistance (VERBAL CUES or TOUCHING/STEADYING) 03. Partial/moderate assistance (Helper does LESS THAN HALF the effort) 02. Substantial/maximal assistance (Helper does MORE THAN HALF the effort) 01. Dependent (Helper does ALL the effort) 07. Patient refused 09. Not applicable 88. Not attempted due to medical condition or safety concerns FIM Instrument 7 Complete Independence (Timely, Safely) 6 Modified Independence (Device) 5 Supervision (Subject = 100%) 4 Minimal Assistance (Subject = 75% or more) 3 Moderate Assistance (Subject = 50% or more) 2 Maximal Assistance (Subject = 25% or more) 1 Total Assistance (Subject less than 25%) 0 Activity does not occur 3 Contrast CARE-Based Functional Items with the FIM Instrument Measurement of the same functional construct, but with additional items: Item 39M of the existing IRF-PAI is labeled as Stairs, which includes going up and down twelve to fourteen stairs (one flight) indoors in a safe manner While this may suggest that the patient must try and perform all twelve to fourteen stairs in order to complete the assessment of this item, a review of The IRF-PAI Training Manual shows that certain exceptions already in place for this item allow the patient to perform this function on only four to six stairs, with or without a device 4 2
Contrast CARE-Based Functional Items with the FIM Instrument Measurement of the same functional construct, but with additional items: The proposed new functional items for quality measurement of stairs include: GG0170M, 1 step (curb) GG0170N, 4 steps GG0170O, 12 steps IRF staff are being asked to evaluate the patient s functional independence for each item independently 5 Contrast CARE-Based Functional Items with the FIM Instrument Measurement of the same functional construct, but with additional items: A similar issue is present with existing item 39L, Locomotion: Walk, Wheelchair, and the following new items: GG0170I, Walk 10 feet GG0170J, Walk 50 feet with two turns GG0170K, Walk 150 feet GG0170R, Wheel 50 feet with two turns GG0170S, Wheel 150 feet 6 3
Define the NQF-Endorsed Functional There are currently five NQF-endorsed quality measures for postacute care that are identified for use in the IRF QRP: 2631 Percent of Long-Term Care Hospital (LTCH) With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function 2633 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation 2634 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation 2635 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation 2636 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation 7 Define the NQF-Endorsed Functional 2631 Percent of Long-Term Care Hospital (LTCH) With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function To be implemented for LTCHs, SNFs, and IRFs Process measure determining the percentage of Medicare patients with complete functional assessment data and at least one self-care or mobility goal Requires entry and submission of an admission value for fifteen new IRF-PAI items and a numeric discharge goal value for at least one item Measure is not risk-adjusted 8 4
Define the NQF-Endorsed Functional 2631 Percent of Long-Term Care Hospital (LTCH) With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function Beginning with patients discharged on or after October 1, 2016, IRFs must use fourteen CARE-based items on the IRF-PAI to collect data for this quality measure: Three self-care items: 1. Eating 2. Oral hygiene 3. Toileting hygiene 9 Define the NQF-Endorsed Functional 2631 Percent of Long-Term Care Hospital (LTCH) With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function Beginning with patients discharged on or after October 1, 2016, IRFs must use fourteen CARE-based items on the IRF-PAI to collect data for this quality measure: Eleven mobility items: 1. Sit to lying 2. Lying to sitting on side of bed 3. Sit to stand 4. Chair/bed-to-chair transfer 5. Toilet transfer 10 5
Define the NQF-Endorsed Functional 2631 Percent of Long-Term Care Hospital (LTCH) With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function Beginning with patients discharged on or after October 1, 2016, IRFs must use fourteen CARE-based items on the IRF-PAI to collect data for this quality measure: Eleven mobility items: For patients or residents who are walking: 6. Walk 50 feet with two turns 7. Walk 150 feet For patients or residents who use a wheelchair: 8. Wheel 50 feet with two turns 9. Indicate the type of wheelchair/scooter used 10. Wheel 150 feet 11. Indicate the type of wheelchair/scooter used 11 Define the NQF-Endorsed Functional 2633 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Implemented for IRFs only This quality measure estimates the risk-adjusted mean change in selfcare score between admission and discharge among IRF Medicare patients Beginning with patients discharged on or after October 1, 2016, IRFs must collect and submit admission and discharge values for seven new IRF-PAI items to collect data for this quality measure: 1. Eating 2. Oral hygiene 3. Toileting hygiene 4. Shower/bathe self 5. Upper body dressing 6. Lower body dressing 7. Putting on/taking off footwear 12 6
Define the NQF-Endorsed Functional 2633 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Measure has multiple risk adjustment factors: Age group, impairment, admission scores, prior functioning and devices, BIMS, bladder/bowel incontinence, pressure ulcers, swallowing ability, specific comorbidities Excludes: Incomplete stays (unexpected discharge to acute care setting because of medical emergency, expired or leave AMA, discharged to another IRF, LOS less than three days) Independent at admission Discharged to hospice with the following medical conditions: coma; persistent vegetative state; complete tetraplegia; locked-in syndrome; severe anoxic brain damage, cerebral edema, or compression of brain 13 Define the NQF-Endorsed Functional 2634 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Implemented for IRFs only This quality measure estimates the risk-adjusted mean change in selfcare score between admission and discharge among IRF Medicare patients 14 7
Define the NQF-Endorsed Functional 2634 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Beginning with patients discharged on or after October 1, 2016, IRFs must use fifteen CARE-based items on the IRF-PAI to collect data for this quality measure: 1. Roll left and right 2. Sit to lying 3. Lying to sitting on side of bed 4. Sit to stand 5. Chair/bed-to-chair transfer 6. Toilet transfer 7. Car transfer 15 Define the NQF-Endorsed Functional 2634 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Beginning with patients discharged on or after October 1, 2016, IRFs must use fifteen CARE-based items on the IRF-PAI to collect data for this quality measure: For patients who are walking, complete the following items: 8. Walk 10 feet 9. Walk 50 feet with two turns 10. Walk 150 feet 11. Walking 10 feet on uneven surfaces 12. 1 step (curb) 13. 4 steps 14. 12 steps 15. Picking up object 16 8
Define the NQF-Endorsed Functional 2634 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Measure has multiple risk adjustment factors: Age group, impairment, admission scores, prior functioning and devices, BIMS, bladder/bowel incontinence, pressure ulcers, swallowing ability, specific comorbidities Excludes: Incomplete stays (unexpected discharge to acute care setting because of medical emergency, expired or leave AMA, discharged to another IRF, LOS less than three days) Independent at admission Discharged to hospice with the following medical conditions: coma; persistent vegetative state; complete tetraplegia; locked-in syndrome; severe anoxic brain damage, cerebral edema, or compression of brain 17 Define the NQF-Endorsed Functional 2635 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Implemented for IRFs only This quality measure estimates the percentage of IRF Medicare patients who meet or exceed an expected discharge self-care score Beginning with patients discharged on or after October 1, 2016, IRFs must collect and submit admission and discharge values for seven new IRF-PAI items to collect data for this quality measure: 1. Eating 2. Oral hygiene 3. Toileting hygiene 4. Shower/bathe self 5. Upper body dressing 6. Lower body dressing 7. Putting on/taking off footwear 18 9
Define the NQF-Endorsed Functional 2635 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Measure has multiple risk adjustment factors: Age group, impairment, admission scores, prior functioning and devices, BIMS, bladder/bowel incontinence, pressure ulcers, swallowing ability, specific comorbidities Excludes: Incomplete stays (unexpected discharge to acute care setting because of medical emergency, expired or leave AMA, discharged to another IRF, LOS less than three days) Discharged to hospice with the following medical conditions: coma; persistent vegetative state; complete tetraplegia; locked-in syndrome; severe anoxic brain damage, cerebral edema, or compression of brain Includes patients independent at admission 19 Define the NQF-Endorsed Functional 2636 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Implemented for IRFs only This quality measure estimates the percentage of IRF Medicare patients who meet or exceed an expected discharge mobility score 20 10
Define the NQF-Endorsed Functional 2636 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Beginning with patients discharged on or after October 1, 2016, IRFs must use fifteen CARE-based items on the IRF-PAI to collect data for this quality measure: 1. Roll left and right 2. Sit to lying 3. Lying to sitting on side of bed 4. Sit to stand 5. Chair/bed-to-chair transfer 6. Toilet transfer 7. Car transfer 21 Define the NQF-Endorsed Functional 2636 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Beginning with patients discharged on or after October 1, 2016, IRFs must use fifteen CARE-based items on the IRF-PAI to collect data for this quality measure: For patients who are walking, complete the following items: 8. Walk 10 feet 9. Walk 50 feet with two turns 10. Walk 150 feet 11. Walking 10 feet on uneven surfaces 12. 1 step (curb) 13. 4 steps 14. 12 steps 15. Picking up object 22 11
Define the NQF-Endorsed Functional 2636 Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Measure has multiple risk adjustment factors: Age group, impairment, admission scores, prior functioning and devices, BIMS, bladder/bowel incontinence, pressure ulcers, swallowing ability, specific comorbidities Excludes: Incomplete stays (unexpected discharge to acute care setting because of medical emergency, expired or leave AMA, discharged to another IRF, LOS less than three days) Discharged to hospice with the following medical conditions: coma; persistent vegetative state; complete tetraplegia; locked-in syndrome; severe anoxic brain damage, cerebral edema, or compression of brain Includes patients independent at admission 23 Define the NQF-Endorsed Functional Summary of functional quality measures: Only one functional quality measure implemented for all PAC sites, which is a process measure IRFs are burdened with additional functional items to support four IRF-only measures 24 12
Differentiate Competing Measures UDSMR has three NQF-endorsed measures that utilize existing IRF-PAI data, but they are not recognized by for use in the IRF QRP: 2286 Functional Change: Change in Self Care Score UDSMR 2321 Functional Change: Change in Mobility Score UDSMR 2287 Functional Change: Change in Motor Score UDSMR 25 Differentiate Competing Measures During the NQF endorsement process, four measures were identified as competing: 1. NQF #2633, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation () 2. NQF #2286, Functional Change: Change in Self Care Score (UDSMR) 3. NQF #2634, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation () 4. NQF #2321, Functional Change: Change in Mobility Score (UDSMR) 26 13
Differentiate Competing Measures Data NQF #2633, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation () Seven CARE-based items: 1. Eating 2. Oral hygiene 3. Toilet hygiene 4. Shower/bathe self 5. Upper body dressing 6. Lower body dressing 7. Putting on/taking off footwear NQF #2286, Functional Change: Change in Self Care Score (UDSMR) Eight IRF-PAI FIM items: 1. Eating 2. Grooming 3. Dressing: Upper Body 4. Dressing: Lower Body 5. Toileting 6. Bowel Management 7. Expression 8. Memory 27 Differentiate Competing Measures Inclusion/ Exclusion NQF #2633, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation () Medicare patients excluding incomplete stays (unexpected discharge to acute care setting because of medical emergency, expired or leave AMA, discharged to another IRF, LOS less than 3 days), independent at admission, discharged to hospice, patients with the following medical conditions (coma; persistent vegetative state; complete tetraplegia; locked-in syndrome; severe anoxic brain damage, cerebral edema, or compression of brain) NQF #2286, Functional Change: Change in Self Care Score (UDSMR) All patients, excluding expired cases 28 14
Differentiate Competing Measures Risk Adj. Measure Data NQF Voting NQF #2633, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation () Measure has multiple risk adjustment factors (age group, impairment, admission scores, prior functioning and devices, BIMS, bladder/bowel incontinence, pressure ulcers, swallowing ability, specific comorbidities) PAC-PRD IRF-only data from 2008 to 2010 Committee: Recommended % of councils approving: 57% % CSAC approving (original vote): 56% NQF #2286, Functional Change: Change in Self Care Score (UDSMR) Measure is CMG-adjusted to account for differences in impairment, function at admission, and age UDSMR data collected from IRFs, SNFs, and LTCHs since 2001 Committee: Recommended % of councils approving: 71% % CSAC approving (original vote): 100% 29 Differentiate Competing Measures Data NQF #2634, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation () Fifteen CARE-based items: 1. Roll left and right 2. Sit to lying 3. Lying to sitting on side of bed 4. Sit to stand 5. Chair/bed-to-chair transfer 6. Toilet transfer 7. Car transfer For patients who are walking: 8. Walk 10 feet 9. Walk 50 feet with two turns 10. Walk 150 feet 11. Walking 10 feet on uneven surfaces 12. 1 step (curb) 13. 4 steps 14. 12 steps 15. Picking up object NQF #2321, Functional Change: Change in Mobility Score (UDSMR) Four IRF-PAI FIM items: 1. Transfers: Bed, Chair, Wheelchair 2. Transfers: Toilet 3. Locomotion: Walk, Wheelchair 4. Locomotion: Stairs 30 15
Differentiate Competing Measures Inclusion/ Exclusion NQF #2634, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation () Medicare patients excluding incomplete stays (unexpected discharge to acute care setting because of medical emergency, expired or leave AMA, discharged to another IRF, LOS less than 3 days), independent at admission, discharged to hospice, patients with the following medical conditions (coma; persistent vegetative state; complete tetraplegia; locked-in syndrome; severe anoxic brain damage, cerebral edema, or compression of brain) NQF #2321, Functional Change: Change in Mobility Score (UDSMR) All patients, excluding expired cases 31 Differentiate Competing Measures Risk Adj. Measure Data NQF Voting NQF #2634, Inpatient Rehabilitation Facility (IRF) Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation () Measure has multiple risk adjustment factors (age group, impairment, admission scores, prior functioning and devices, BIMS, bladder/bowel incontinence, pressure ulcers, swallowing ability, specific comorbidities) PAC-PRD IRF-only data from 2008 to 2010 Committee: Recommended % of councils approving: 57% % CSAC approving (original vote): 56% NQF #2321, Functional Change: Change in Mobility Score (UDSMR) Measure is CMG-adjusted to account for differences in impairment, function at admission, and age UDSMR data collected from IRFs, SNFs, and LTCHs since 2001 Committee: Recommended % of councils approving: 71% % CSAC approving (original vote): 100% 32 16
Differentiate Competing Measures 2287 Functional Change: Change in Motor Score UDSMR Measure submitted for use in IRFs, SNFs, LTCHs, and HHAs and currently endorsed for use in IRF setting Change in Rasch-derived values of motor function (self-care and mobility) from admission to discharge among adult patients treated at an IRF who were discharged alive Measure is CMG-adjusted to account for differences in: Impairment Function at admission Age Includes patients from all payer sources Excludes expired cases 33 Differentiate Competing Measures 2287 Functional Change: Change in Motor Score UDSMR Utilizes twelve FIM items collected as part of the existing IRF-PAI: 1. Eating 2. Grooming 3. Dressing: Upper Body 4. Dressing: Lower Body 5. Toileting 6. Bowel Management 7. Expression 8. Memory 9. Transfers: Bed, Chair, Wheelchair 10. Transfers: Toilet 11. Locomotion: Walk, Wheelchair 12. Locomotion: Stairs 34 17
Summary Are you aware of the NQF process and the different NQF-endorsed functional quality measures? Are you prepared for the October 2016 implementation of s IRF QRP functional measures? Will you be able to differentiate performance between quality measures based on the CARE tool and those based on the FIM instrument? Will you be able to explain which quality measures better represent your facility s performance? 35 36 18
Contacting UDSMR Troy Hillman: thillman@udsmr.org 716-817-7869 Analytical Services Group: asg@udsmr.org 716-817-7870 37 Thank You! 38 19