The Centers for Medicare & Medicaid Services (CMS) established the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) to ensure that high-quality care is provided in Inpatient Rehabilitation Facilities (IRFs). The program involves a variety of quality measures collected through different methods, including IRF-PAI assessment-based measures, CDC NHSN measures and Medicare fee-for-service claims-based measures.

Current IRF-PAI Assessment-Based Measures

The IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment Instrument) is a key tool used to collect data for several quality measures. These measures are derived from data recorded on each IRF-PAI transmitted to CMS. The assessment-based measures include:

  • Measure #1 – Percent of Residents Experiencing One or More Falls with Major Injury: This measure, from section J of the IRF-PAI, tracks the number of falls resulting in major injury during the patient’s rehab stay.
  • Measure #2 – Discharge Self-Care Score for Medical Rehabilitation Patients: Captured in section GG, this measure evaluates the percentage of patients who have a total discharge self-care score that is at or above CMS’s expected value.
  • Measure #3 – Discharge Mobility Score for Medical Rehabilitation Patients: Also from section GG, this measure assesses the percentage of patients who have a total discharge mobility score that is at or above CMS’s expected value.
  • Measure #4 – Drug Regimen Review Conducted with Follow-Up for Identified Issues: Based on information in section N, this measure ensures that any clinically significant medication issues throughout the rehab stay are followed up within a 24-hour timeframe.
  • Measure #5 – Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury: This measure, from section M, tracks pressure ulcers that worsen or develop during the rehab stay.
  • Measure #6 – Transfer of Health Information to the Provider – Post-Acute Care: This measure assesses the transfer of health information when a patient is discharged to another provider.
  • Measure #7 – Transfer of Health Information to the Patient – Post-Acute Care: Evaluates the transfer of health information when the patient is discharged without a subsequent provider.
  • Measure #8 – Discharge Function Score: Data collection from codes entered in Section GG began in October 2023, calculating a new discharge score including both self-care and mobility activities, and reporting the percentage of patients that meet or exceed CMS’s expected value.
  • Measure #9 – COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date: Starting October 1, 2024, this measure will track the percentage of patients who are current with their COVID-19 vaccinations.

Current CDC NHSN Measures

These measures are reported through the CDC’s National Healthcare Safety Network (NHSN) rather than the IRF-PAI. They are typically submitted by the quality department or another designated department within the organization:

  • Measure #10 – Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure: Monitors the incidence of catheter-associated UTIs during the rehab stay.
  • Measure #11 – Influenza Vaccination Among Healthcare Personnel: Tracks the percentage of staff who have received the influenza vaccine.
  • Measure #12 – Facility-Wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure: Measures the rate of C. difficile infections occurring during the rehab stay.
  • Measure #13 – COVID-19 Vaccination Coverage Among Healthcare Personnel: Updated to ensure healthcare personnel are up to date with their COVID-19 vaccinations.

Current Medicare Fee-For-Service Claims-Based Measures

These measures are derived from data elements recorded on Medicare claims, including ICD-10 codes and billing information:

  • Measure #14 – Medicare Spending per Beneficiary – Post-Acute Care: Tracks spending per beneficiary during rehab stays.
  • Measure #15 – Discharge to Community – PAC IRF QRP: Measures the rate of discharge to the community based on discharge destination data.
  • Measure #16 – Potentially Preventable 30-Day Post Discharge Readmission Measure for IRF QRP: Monitors certain readmissions to acute care hospitals within 30 days post-discharge from rehab.
  • Measure #17 – Potentially Preventable Within Stay Readmission Measure: Tracks certain readmissions to acute care hospitals during the rehab stay.

Measures Removed from the IRF QRP

CMS has removed several measures from the IRF QRP to enhance the program’s efficiency and focus:

  • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function: This measure was removed as it was topped out, indicating IRFs were consistently completing functional assessments and setting patient goals.
  • IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients
  • IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients: These were replaced with the new discharge function score measure.

By continuously updating and refining these measures, CMS aims to improve patient outcomes, ensure high-quality care, and streamline the reporting process for Inpatient Rehabilitation Facilities.

Discharge Function Score Overview

In the FY 2024 final rule, CMS provided essential guidelines regarding the new Discharge Function Score measure, outlining the timeline for data collection and public reporting. This announcement introduced two specific time frames. With further clarification from CMS, these timelines and their purposes have become clearer.

Starting with the data collection period, CMS states that for the purposes of the FY 2025 QRP, data collection began October 1, 2023. Since the discharge function measure does not have any unique fields or reporting requirements and is derived from the IRF-PAI as-is, there is no observable change to data submissions.

Regarding public reporting, CMS clarified that the data displayed on Care Compare will utilize data from calendar year 2023 (January 1, 2023 through December 31, 2023). CMS has scheduled the release of provider preview reports for June 2024, with the expectation that the discharge function scores will be available to the public on Care Compare beginning with the September 2024 refresh.

This blog is part of a monthly series of webisodes where UDSMR experts focus on IRF industry insights. Click here to learn more about UDSMR services and education.

Click here to listen to our full webisode on IRF QRP Functional Outcomes Measures.

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