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by the NUMBERS
OUR IMPACT IN
2019
U N I V E R S A L H E A L T H S E R V I C E S , I N C .
BEHAVIORAL HEALTH DIVISION
Our Impact In 2019 – By The Numbers*U.S. DATA ONLY
Quality patient care is the cornerstone of the UHS Mission Statement.
To provide superior quality healthcare services that:
Patients recommend to family and friends, Physicians prefer for their patients, Purchasers select for their clients, Employees are proud of, and Investors seek for long-term returns.
Quality is embedded in the core principles of the organization as well.
Continuous Improvement in Measurable Ways• Identify key needs and assess how
well we meet those needs.• Continuously improve services and
measure progress.• People at all levels of the
organization participate in decision making and process improvement.
Compassion• Never lose sight of the fact that
we provide care and comfort to people in need.
• Patients and families who rely upon us receive respectful and dignified treatment at all times.
A Message from Karen Johnson The Clinical Services Department and Mental Health Outcomes are very pleased to share 2019 By the Numbers, highlighting the Division’s clinical and quality outcome successes. The past year saw an ever-increasing commitment to high-quality care and patient safety. This document reflects your unwavering attention to our mission - to take care of our patients.
Please take this document and share it with your facility staff. We do not always take the time to celebrate and this is certainly one way to remind them that their hard work matters.
Each day presents its unique challenges and offers an opportunity to continue our efforts to improve the lives of the individuals we treat. We are deeply grateful to each of you for maintaining that singular focus. It is a privilege to work with each of you to obtain and sustain these outstanding results.
Karen E. Johnson, MSW
Senior Vice President, Clinical Services & Behavioral Health Division Compliance Officer, Universal Health Services
3
Child Population At a Glance
Length Of Stay By Level Of Care
PATIENT PROFILEAverage Age 10 years
Sex 42% Female; 58% Male
Race 62% White; 27% African American; 2% Other; 9% UTD
Hispanic Ethnicity 15%
Diagnostic ComplexityAverage Number of Psychiatric Diagnoses 2.3
Average Number of Co-morbid Medical Conditions 0.7
Percent of Patients with at least one Co-morbid Medical Condition 42%
Length of StayAverage Length of Stay 13 days
INPATIENT 9 DAYS PHP 17 DAYS IOP 27 DAYS RESIDENTIAL 111 DAYS
Top 5 Primary Psychiatric Diagnoses
Mood Disorders
Childhood Onset Disorders
Anxiety & Other Nonpsychotic Disorders
Schizophrenia & Other Psychotic Disorders 2%2%
7%8%
81%
Disorders of Personality and Behavior
Patients Served By Level Of Care
IOP
PHP
Residential
Inpatient
2.3%
1.1%
82.7%
13.9%
4
Adolescent Population At a Glance3.5%
10.7%
7.0%
78.7%
PATIENT PROFILEAverage Age 15 years
Sex 59% Female; 41% Male
Race 69% White; 20% African American; 3% Other; 8% UTD
Hispanic Ethnicity 15%
Diagnostic ComplexityAverage Number of Psychiatric Diagnoses 2.3
Average Number of Co-morbid Medical Conditions 0.9
Percent of Patients with at least one Co-morbid Medical Condition 47%
Length of StayAverage Length of Stay 20 days
Mood Disorders
Anxiety & Other Nonpsychotic Disorders
Childhood Onset Disorders
Disorders of Personality and Behavior 1%2%3%6%
86%
Schizophrenia & Other Psychotic Disorders
IOP
PHP
Residential
Inpatient
Patients Served By Level Of Care
Length Of Stay By Level Of Care
Top 5 Primary Psychiatric Diagnoses
INPATIENT 9 DAYS PHP 16 DAYS IOP 27 DAYS RESIDENTIAL 139 DAYS
5
Schizophrenia & Other Psychotic Disorders 21%Psychoactive Substance Use 22%
Adult Population At a Glance
IOP
PHP
Residential
Inpatient
PATIENT PROFILEAverage Age 39 years
Sex 45% Female; 55% Male
Race 70% White; 20% African American; 2% Other; 8% UTD
Hispanic Ethnicity 10%
Diagnostic ComplexityAverage Number of Psychiatric Diagnoses 2.7
Average Number of Co-morbid Medical Conditions 2.2
Percent of Patients with at least one Co-morbid Medical Condition 64%
Length of StayAverage Length of Stay 12 days
Mood Disorders
Behavioral Syndromes with Physical Factors
6
Older Adult Population At a Glance
PATIENT PROFILEAverage Age 65 years
Sex 55% Female; 45% Male
Race 76% White; 17% African American; 2% Other; 5% UTD
Hispanic Ethnicity 6%
Diagnostic ComplexityAverage Number of Psychiatric Diagnoses 2.0
Average Number of Co-morbid Medical Conditions 5.1
Percent of Patients with at least one Co-morbid Medical Condition 90%
Length of StayAverage Length of Stay 12 days
Mood Disorders
Schizophrenia & Other Psychotic Disorders
Disorders Due to Physiological Conditions
Psychoactive Substance Use 5%7%
9%23%
56%
Non-Psychiatric Diagnosis
97.3%
0.3%2.4%
Inpatient
Patients Served By Level Of Care
IOP
PHP
Length Of Stay By Level Of Care
INPATIENT 11 DAYS PHP 11 DAYS IOP 40 DAYS
Top 5 Primary Psychiatric Diagnoses
7
Our Patients Improved
UHS BH Percent of Patients with Meaningful Improvement*
*Due to rounding, numbers may add up to more than 100%
In 2019, 171 UHS Behavioral Health facilities with 866 distinct programs captured clinical outcomes measures for approximately 267,263 patients. We continue to expand our support in 2020 for clinical outcomes measures. While most providers are focused only on patient satisfaction, our commitment to quantifying our clinical care using both clinician ratings and patient self-report tools allows UHS to benchmark, improve, and report on the high quality care provided.
We are pleased that UHS can demonstrate that approximately 75% of our patients exhibit statistically meaningful improvement using patient self-report rating scales. This is consistent with the literature on meaningful change in Behavioral Health. Patients have statistically meaningful improvement if their change is large enough to be attributable to treatment. Patients identified as having ‘No effect’ may have experienced positive change, however their change was not clearly evident as measured by the rating scale. Patients often report that they “feel better” after treatment and measures of statistically meaningful improvement help programs quantify those feelings of improvement. Potentially, all patients at a program can have statistically meaningful improvement.
CABA-Y (Child Inpatient)
CABA-Y (Adolescent Inpatient)
CABA-Y (Adolescent RTC)
BASIS-32TM (Adult Inpatient)
BASIS-32TM (Substance Abuse – Adult RTC)
87%
80%
76%
81%
84%
10%
16%
17%
13%
12%
3%
4%
7%
6%
4%
50% 100%0%
DeclineNo EffectImprovement
171
866
267,263
Facilities
Programs
Patients
8
Child Patient Improvement
BPRS-C-9 (Inpatient)
CABA-I (Inpatient)
CABA-I (Partial Hospitalization)
CABA-Y (Partial Hospitalization)
LESS SEVERE
LESS SEVERE
LESS SEVERE
MORE SEVERE
MORE SEVERE
MORE SEVERE
(N=3,516)
(N=2,425)
(N=1,013)
(N=1,774)
(N=2,891)8.5
0.4
0.5
0.5
28.3
1.3
1.0
0.9
(N=1,796)
(N=688)
(N=1,222)
The Brief Psychiatric Rating Scale for Children 9-item (BPRS-C-9) is a clinician’s rating of the level of severity of a patient’s functioning and symptoms obtained through a structured interview conducted with the patient. The BPRS-C-9 is scored on a scale of 0 to 54, where higher scores indicate greater severity. BPRS-C-9 change scores may range from -54 to 54, where positive scores indicate improvement, and higher positive scores indicate greater improvement.
Child and Adolescent Behavioral Assessment Informant (CABA-I): A questionnaire to assess problem behaviors based on patient informant responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
Child and Adolescent Behavioral Assessment Informant (CABA-I): A questionnaire to assess problem behaviors based on patient informant responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
Child and Adolescent Behavioral Assessment Youth (CABA-Y): A questionnaire to assess problem behaviors based on patient responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
91%
91%
78%
68%
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
0 25 302015105
0 1.21.00.80.60.40.2
ADMISSION
ADMISSION
ADMISSION
ADMISSION
DISCHARGE
DISCHARGE
DISCHARGE
DISCHARGE
0 0.60.2 0.4 0.8
1.4
1.0
LESS SEVERE MORE SEVERE0 1.00.60.2 0.4 0.8 1.2
9
Adolescent Patient Improvement
BPRS-C-9 (Inpatient)
CABA-I (Inpatient)
CABA-I (Partial Hospitalization)
CABA-Y (Partial Hospitalization)
LESS SEVERE
LESS SEVERE
MORE SEVERE
MORE SEVERE
(N=12,381)
(N=7,253)
(N=1,871)
(N=4,420)
(N=11,716)
(N=6,528)
(N=1,196)
(N=3,071)
The Brief Psychiatric Rating Scale for Children 9-item (BPRS-C-9) is a clinician’s rating of the level of severity of a patient’s functioning and symptoms obtained through a structured interview conducted with the patient. The BPRS-C-9 is scored on a scale of 0 to 54, where higher scores indicate greater severity. BPRS-C-9 change scores may range from -54 to 54, where positive scores indicate improvement, and higher positive scores indicate greater improvement.
Child and Adolescent Behavioral Assessment Informant (CABA-I): A questionnaire to assess problem behaviors based on patient informant responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
Child and Adolescent Behavioral Assessment Informant (CABA-I): A questionnaire to assess problem behaviors based on patient informant responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
Child and Adolescent Behavioral Assessment Youth (CABA-Y): A questionnaire to assess problem behaviors based on patient responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
LESS SEVERE MORE SEVERE
88%
88%
75%
63%
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
0 1.00.60.2 0.4 0.8 1.2
0 1.00.80.40.2 0.6
7.5
0 20 2515105
ADMISSION
DISCHARGE
0.4
1.1ADMISSION
DISCHARGE
0.5
1.1ADMISSION
DISCHARGE
0.5
0.8ADMISSION
DISCHARGE
24.3
30
LESS SEVERE MORE SEVERE0 1.21.00.80.60.40.2 1.4
10
72%
Adult Patient Improvement
BASIS-32TM (Inpatient)
PHQ-9 (Inpatient)
BASIS-32TM (Partial Hospitalization)
BASIS-32TM (Intensive Outpatient)
LESS SEVERE
LESS SEVERE
LESS SEVERE
LESS SEVERE
MORE SEVERE
MORE SEVERE
MORE SEVERE
MORE SEVERE
(N=44,165)
(N=24,925)
(N=8,078)
(N=3,769)
(N=49,670)0.7
4.9
0.9
0.8
1.8
14.0
1.5
1.4
(N=27,152)
(N=4,477)
(N=2,863)
Behavior and Symptom Identification Scale (BASIS-32): 32-item patient self-report instrument that provides an overall score and five individual factor scores: relation to self and others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis. The total scores range from 0 to 4, with higher scores indicating greater severity. Change scores range from -4 to +4, with higher scores indicating greater improvement. BASIS 32© McLean Hospital, used with permission.
Patient Health Questionnaire (PHQ-9): 9-item self-report measure of a patient’s level of depression over the past week obtained through either a structured interview conducted with the patient or the patient’s independent completion of the instrument. The PHQ-9 is scored on a scale of 0 to 27, where higher scores indicate greater severity. PHQ-9 change scores may range from -27 to 27, where positive scores indicate improvement, and higher positive scores indicate greater improvement.
Behavior and Symptom Identification Scale (BASIS-32): 32-item patient self-report instrument that provides an overall score and five individual factor scores: relation to self and others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis. The total scores range from 0 to 4, with higher scores indicating greater severity. Change scores range from -4 to +4, with higher scores indicating greater improvement. BASIS 32© McLean Hospital, used with permission.
Behavior and Symptom Identification Scale (BASIS-32): 32-item patient self-report instrument that provides an overall score and five individual factor scores: relation to self and others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis. The total scores range from 0 to 4, with higher scores indicating greater severity. Change scores range from -4 to +4, with higher scores indicating greater improvement. BASIS 32© McLean Hospital, used with permission.
81%
75%
65%
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
0 1.0 2.01.61.40.80.60.40.2
0 12108642
ADMISSION
ADMISSION
ADMISSION
ADMISSION
DISCHARGE
DISCHARGE
DISCHARGE
DISCHARGE
0 1.20.60.2 0.4 0.8 1.0
0 1.61.21.00.2 0.6 0.8 1.4
1.2 1.8
14 16
1.4 1.6 1.8
0.4
11
Residential & Substance Abuse Patient Improvement
Adult Residential
Adult Inpatient
Adult Partial Hospitalization
CABA-I (Adolescent Residential)
BASIS-32TM (Substance Abuse)
BASIS-32TM (Substance Abuse)
BASIS-32TM (Substance Abuse)
LESS SEVERE
LESS SEVERE
LESS SEVERE
LESS SEVERE
MORE SEVERE
MORE SEVERE
MORE SEVERE
MORE SEVERE
(N=3,103)
(N=1,489)
(N=6,224)
(N=4,006)
(N=2,785)
(N=1,033)
(N=5,975)
(N=2,522)
Child and Adolescent Behavioral Assessment Informant (CABA-I): A questionnaire to assess problem behaviors based on patient informant responses. The total scores range from 0 to 3, with higher scores indicating greater severity. Change scores range from -3 to +3, with higher scores indicating greater improvement.
Behavior and Symptom Identification Scale (BASIS-32): 32-item patient self-report instrument that provides an overall score and five individual factor scores: relation to self and others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis. The total scores range from 0 to 4, with higher scores indicating greater severity. Change scores range from -4 to +4, with higher scores indicating greater improvement. BASIS 32© McLean Hospital, used with permission.
Behavior and Symptom Identification Scale (BASIS-32): 32-item patient self-report instrument that provides an overall score and five individual factor scores: relation to self and others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis. The total scores range from 0 to 4, with higher scores indicating greater severity. Change scores range from -4 to +4, with higher scores indicating greater improvement. BASIS 32© McLean Hospital, used with permission.
Behavior and Symptom Identification Scale (BASIS-32): 32-item patient self-report instrument that provides an overall score and five individual factor scores: relation to self and others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis. The total scores range from 0 to 4, with higher scores indicating greater severity. Change scores range from -4 to +4, with higher scores indicating greater improvement. BASIS 32© McLean Hospital, used with permission.
86%
84%
76%
74%
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
OF PATIENTS IMPROVED
0 1.00.60.2 0.4 0.8 1.8
0 1.61.40.80.40.2 0.6
0.5
1.4
0 1.0 1.61.41.20.80.60.40.2
ADMISSION
DISCHARGE
0.5
1.5
0 1.61.00.80.60.40.2
ADMISSION
DISCHARGE
0.8
1.7ADMISSION
DISCHARGE
0.6
1.4ADMISSION
DISCHARGE
1.2 1.4
1.2 1.4 1.6
1.0 1.2
12
91%90%
86%
feel better at discharge than when admitted.
were satisfied with their treatment.
would recommend the facility to someone needing treatment.
Patient Satisfaction
UHS BH Patient Satisfaction Grand Mean On a scale of 1 to 5
2018
4.474.494.464.474.464.45
20172016201520142013
Patient satisfaction is critical to patient-centered care and an important indicator of provider success. Research suggests that higher patient satisfaction is associated with improved treatment outcomes. Communicating patient satisfaction results to patients and families contemplating treatment options and to payers contemplating coverage decisions is vital to providing confidence in our services.
The UHS Behavioral Health Division is committed to continually improving patient experience and satisfaction. 2019
4.47
13
Specialty Education
Our education programs provide continuation of schooling at our facilities while youth are receiving treatment. UHS provides personalized learning plans that meet each patient where they are when admitted and prepares them for a seamless transition back to their traditional school environment. Through individualized instruction, patients have access to a menu of curriculum options that includes direct instruction, remediation, credit recovery, online learning and post-secondary opportunities.
Best in Class Satisfaction
The Academic Staff Truly Cares About My Child
OF PARENTS OR GUARDIANS
AGREE
OF PARENTS OR GUARDIANS
AGREE
Satisfied With The Facility’s Education Program
87%
87%FEWER RESPONDENTS
FEWER RESPONDENTS
MORE RESPONDENTS
MORE RESPONDENTS
(N=1,266)
(N=1,280)87%
87%
0% 30%10% 20% 40% 50% 60% 70% 80% 90% 100%
0% 30%10% 20% 40% 50% 60% 70% 80% 90% 100%
High School Completions
211HS diplomas/GEDs
14
Serving Those Who Serve
Programs also treat personnel from the Reserves and National Guard; however, outcomes data volume is insufficient for reporting.
Primary Diagnostic Category
Army Navy Coast GuardMarineCorpsAir
Force
Primary diagnostic patterns vary by branch and personnel status. Mood disorders are more common among active duty personnel while substance use is more common among veterans. Active duty personnel also suffer more from anxiety disorders. Mood Disorders
Active Active Active Active Active RetiredRetiredRetiredRetiredRetired
Substance Use Anxiety Disorders
34%
23%
42% 49%37% 43% 47% 49% 50%
8%
52%38%
43%
27%
51%26%
46%
24%
67%
40% 54%
8%
36%
6%27%
5%
26% 25%8%
PCL-5 Meaningful Improvement
The PTSD Checklist for DSM-V (PCL-5) is a 20-item self-report measure of the 20 DSM-V PTSD symptoms.
73%
81%
18%
12%
8%
7%50%0% 100%
All Inpatient Military (N=2,904)
Military Inpatients with PTSD Diagnosis (N=1,280)
UHS, through its subsidiaries, operates a number of military-specific inpatient programs that treat active duty military personnel and veterans. Outcomes data provides a glimpse into this unique population’s mental health needs and how well those needs are being met.
*Due to rounding, numbers may add up to more than 100%
DeclineNo EffectImprovement
8%
15
45-Day Follow-Up:Improvement That LastsUHS has a voluntary opportunity for patients and families to share with our facilities how they are doing 45 days after discharge. This is a unique non-research-based longitudinal look at continuity of care, patient improvement, and satisfaction. Patient responses to the aftercare survey 45 days after discharge indicate that the vast majority of patients would recommend their treatment facility, are continuing on medications, and most importantly, are sustaining the improvements made during treatment.
Average severity scores for Adult Inpatients at Admission, Discharge, and 45-Day Follow-up shows that patients tend to maintain the majority of their improvement.
Average severity scores for Adolescent Inpatients at Admission, Discharge, and 45-Day Follow-up shows that patients tend to maintain the majority of their improvement.
BASIS-32TM Severity
CABA-I Severity
Admission (N=44,165)
Admission (N=7,253)
Discharge (N=49,670)
Discharge (N=6,528)
2.0
1.6
1.6
1.2
0.8
0.4
0.0
1.2
0.8
0.4
0.0Follow-up (N=569)
Follow-up (N=283)
Sustained Recovery
Sustained Recovery
LOW
ER S
EVER
ITY
HIG
HER
SEV
ERIT
YLO
WER
SEV
ERIT
YH
IGH
ER S
EVER
ITY
4,175
2,965
1,210
Follow-up Surveys
Adult/Older Adult Patients
Child/Adolescent Patients
16
BASIS-32TM (Adult Inpatient)
CABA-I (Child/Adolescent Inpatient)
Percent of Patients with Meaningful Improvement from Admission to Follow-Up*
82%
80%
11%
13%
7%
7%
50%0% 100%
*Due to rounding, numbers may add up to more than 100%
DeclineNo EffectImprovement
45 Days After Discharge...
88% of patients reported no suicidal thoughts or attempts89% of patients reported no re-hospitalization79% of patients recommend UHS versus other facilities73% of patients reported a positive quality of life67% of patients reported they were working or were students
Improvement That Lasts
17
Satisfaction That Lasts
86%
92%
89%
OF PATIENTSCONTACTED 45 DAYS
AFTER DISCHARGERATE PROGRAM WELL
OF PATIENTSCONTACTED 45 DAYS
AFTER DISCHARGEWOULD RECOMMEND
OF PATIENTSCONTACTED 45 DAYS
AFTER DISCHARGEREPORT PROGRAM
HELPED
Rate Overall Satisfaction Positively
Would Recommend Program
Report That The Program Helped
FEWER RESPONDENTS
FEWER RESPONDENTS
FEWER RESPONDENTS
MORE RESPONDENTS
MORE RESPONDENTS
MORE RESPONDENTS
(N=364,760)
(N=362,888)
(N=364,323)
(N=3,078)
(N=3,006)
(N=2,966)
Post Discharge Satisfaction: The patient follow-up survey includes a set of standardized questions that we ask patients across different programs, allowing for cross-program comparisons of satisfaction. Patient satisfaction scores are measured on a scale from 1 (Poor) to 5 (Excellent).
Patient responses to the aftercare survey indicate that the vast majority of patients continue to hold their treatment program in high regard.
Post Discharge Satisfaction: The patient follow-up survey includes a set of standardized questions that we ask patients across different programs, allowing for cross-program comparisons of satisfaction. Recommend scores are measured on a scale from 1 (Definitely Would Not) to 4 (Definitely Would).
89%
92%
86%
91%
86%
90%
DISCHARGE
DISCHARGE
DISCHARGE
FOLLOW-UP
FOLLOW-UP
FOLLOW-UP
0% 30%10% 20% 40% 50% 60% 70% 80% 90% 100%
0% 30%10% 20% 40% 50% 60% 70% 80% 90% 100%
0% 30%10% 20% 40% 50% 60% 70% 80% 90% 100%
Post Discharge Satisfaction: The patient follow-up survey includes a set of standardized questions that we ask patients across different programs, allowing for cross-program comparisons of satisfaction. Patient satisfaction scores are measured on a scale from 1 (Not at All) to 4 (A Great Deal).
18
Partnering With Community Professionals
Referral Source Satisfaction
UHS values our relationships with the professionals in the communities we serve and we strive to be responsive to their needs. We conduct referral source satisfaction surveys to help us continually improve as we aim to reach even higher goals.
As a result of our responsiveness, clinical expertise, nationally recognized specialty programs, and proven outcomes, 81% of professional referral sources indicate that UHS is their provider of choice.
UHS BH Referral Source Satisfaction Grand Mean
Ease Of Admission
Timeliness Of Disposition Information
Helpfulness Of Staff
Overall Care Coordination
Quality Of Patient Care
4.1
3.9
4.2
4.0
4.1
54321
Overall average score for all facilities out of a possible score of 5.
1,507 Referral source satisfaction surveys collected in 2019.
82% Survey respondents that indicated a UHS facility was their “provider of choice.”
19
Comparison groups include units in medical surgical facilities.
Comparative Performance
UHS Behavioral Health Outperforms Industry Benchmarks
The Hospital-Based Inpatient Psychiatric Services (HBIPS) “core” measures were developed by The Joint Commission (TJC), an organization that accredits hospitals, as a common point of performance comparison across Behavioral Health facilities. The HBIPS measures describe a set of “core” best practices for inpatient psychiatric care and performance rates for these measures are publicly reported. Hospitals that effectively integrate these processes into clinical and quality improvement practices should positively impact psychiatric patients.
The Inpatient Psychiatric Facility Quality Reporting (IPFQR) program was developed by the Centers for Medicare and Medicaid Services (CMS) as mandated by the Social Security and Affordable Care Acts. To meet program requirements, Inpatient Psychiatric Facilities (IPFs) collect and annually submit aggregate data as defined by CMS. CMS describes the program as giving “consumers care quality information to help them make more informed decisions about their healthcare options.”
When considering the publically reported chart-abstracted discharge measures, UHS typically outperforms the HBIPS and/or IPFQR comparison benchmarking for overall measures. UHS’s performance focus is clearly demonstrated by matching or outpacing the majority of measure set comparisons.
+ We respect the patient’s right to refuse these offerings. * IMM only applicable for Q4-Q1 discharges** METSCRN, TransRecPt and TransRecPrvdr are CMS-only measures
MEASURE GOAL UHS 2019 TJC Q2 2019 CMS 2018
HBIPS-1: Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed Increase in Rate 97.08% 95.02% N/A
HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification Increase in Rate 73.67% 62.56% 61.00%
SUB-2: Alcohol Use Brief Intervention Provided or Offered Increase in Rate 86.30% 80.06% 83.00%
SUB-2a+: Alcohol Use Brief Intervention Provided Increase in Rate 76.53% 72.63% 75.00%
SUB-3: Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge Increase in Rate 73.75% 51.69% 70.00%
SUB-3a+: Alcohol and Other Drug Use Disorder Treatment at Discharge Increase in Rate 59.68% 41.01% 59.00%
TOB-2: Tobacco Use Treatment Provided or Offered Increase in Rate 88.49% 76.77% 81.00%
TOB-2a+: Tobacco Use Treatment Provided Increase in Rate 33.73% 39.39% 46.00%
TOB-3: Tobacco Use Treatment Provided or Offered at Discharge Increase in Rate 71.94% 46.64% 57.00%
TOB-3a+: Tobacco Use Treatment Provided at Discharge Increase in Rate 6.76% 17.32% 18.00%
IMM-2*: Influenza Immunization Increase in Rate 79.79% * 83.00%
METSCRN: Patients discharged on 1+ antipsychotic medications with a metabolic screening Increase in Rate 83.41% ** 74.00%
TransRecPt: Transition Record with Specified Elements Received by Discharged Patients Increase in Rate 86.78% ** 63.00%
TransRecPrvdr: Timely Transmission of Transition Record to Next Provider Upon Discharge Increase in Rate 74.22% ** 55.00%
Universal Corporate CenterP.O. Box 61558
367 South Gulph RoadKing of Prussia, PA 19406
www.uhsinc.com
200734-0257 3/20
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