Dexanne B. Clohan, MDSVP & Chief Medical OfficerHealthSouth

November 14, 2014

IRF Quality Measurement: A Physiatrist’s View

CMS IRF Quality Reporting Program (QRP)QRP Initiated:

(1) new or worsened

pressure ulcers and (2)

catheter-associated

urinary tract infections

New QRP Measures:

(3) Flu vaccines for healthcare personnel

and (4) patients, (5) 30-day,

all-cause unplanned readmission

Future QRP Measures:

(6) MRSA infections(7) CDI infections

What Will Get Measured Next?•Function•Fall rates•Skin Integrity

Reimbursement Effects

All quality data submitted to CMS must meet accuracy and completeness thresholds in order to avoid penalty:

Penalty is theoretically “all or nothing” – failing to submit one of the seven QRP measures accurately and completely will result in payment reduction

Penalty is a reduction to a hospital’s Medicare reimbursement update by 2% for the next fiscal year

October 1, 2012 October 1, 2014 January 1, 2015

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New Thresholds ImposedIRF PPS FY 2015 Final Rule

• Catheter-Related Infections – 100% Completion – CMS must receive 12

months of data from the NHSN system.

• Pressure Ulcers– 95% Completion – IRF-PAIs must include

required QRP data.– 75% Accuracy – CMS will randomly select

5 patient records from 260 IRF providers.• IRF-PAIs completed January 1, 2014-

September 30, 2014* will be audited for accuracy for FY2016.

*Abbreviated 9 month period a result of CY to FY transition

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• CMS still adjusting their own documentation requirements• Requires accurate, complete, and consistent documentation

by clinicians• CMS QRP rules go beyond standard clinical practice

Documentation

• CMS revised existing measures• CMS is adding new measures at fast pace

Continued Changes

• Patchwork system created by CMS for reporting is not efficient

• Multiple reporting methods have different timelines and definitions

• Reportable events are rare

Complexity

• Increased proportion of clinicians’ time spent on paperwork• More clinical time being spent on low incidence measuresEffect on Staff

Why is QRP challenging?

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• Reported through IRF-PAI (Inpatient Rehabilitation Facility – Patient Assessment Instrument)

Based on CMS Fiscal Year (Oct-Sept)– Pressure Ulcers– Patient Influenza Vaccination Rates

• Reported through the NHSN (Managed by the CDC)

Based on Calendar Year (Jan-Dec)– Catheter-related infections– Personnel Influenza Vaccination Rates– Antibiotic-Resistant Infections

• MRSA infections • CDI

• Collected via Claims Data– 30-Day Acute Readmission Rates

Multiple Reporting Methods

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Reportable Events

Clinical Care

Only reportable events should be reported

•Physician diagnosis•Clinical treatment•Billing codes

Meet all criteria and timelines

The QRP Guide: Everything You Need to Know to be CMS Compliant

• A comprehensive and user-friendly document to help manage the task of understanding and complying with this rule

• contains information regarding the prevention, identification, and reporting of QRP measures.

• Compiles guidelines, rules and best practices from all sources involved in the inpatient rehab QRP, including:

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HealthSouth’s Approach

IRF PPS Rule

CMS training

CDC guidelines

NHSN guidelines

IRF-PAI manual

IRF-PAI transmission

Training

• Clinical & Reporting– On-site meetings– Online HealthStream courses– Training webinars (recorded and posted)– QRP Guide– QRP@HealthSouth.com email address

Who is Involved?

• Chief Nursing Officer and Quality Director ultimately responsible for documentation and reporting

• Infection Control/Wound Care, Employee Health, Human Resources have role in gathering and reporting QRP data

• HIMS staff enter data into IRF-PAI• Medical staff have oversight for

clinical care and medical documentation

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Data Analysis

• CMS has released limited QRP reports through QIESnet, but data can be monitored via IRF-PAI submissions and NHSN reports

• Strive to improve QRP compliance and clinical quality. Eventually, QRP will shift to pay-for-performance

• Look for ---or create--- benchmarks10

Patient Safety Impact

• Engage staff in prevention of pressure ulcers, CAUTIs, and increase in flu vaccinations with a focus on the patient

• Share the data regarding events, vaccination rates, or the lack thereof!

• Stabilize processes for assessments and documentation in the medical record to allow staff to enhance clinical practice- not just documentation.

Regulatory

Burden

Patient Benefit