IRF Quality Reporting Measures Information

The purpose of this page is to provide information on the measures reported by IRFs in accordance with the IRF QRP. On this page, you will find descriptions of each measure, links to measure specifications, measure updates and other measure related information. This page is updated as measure updates become available. 

What are the Inpatient Rehabilitation Facilities (IRF) quality reporting measures?

Measures adopted for and removed from the IRF QRP are listed below. Data for the IRF QRP measures are collected and submitted through three methods:

  • Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)
  • Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
  • Medicare Fee-For-Service Claims

The following measures are submitted using the IRF-PAI unless noted otherwise: 

IRF Measure #1: National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)

Use of a previous version of this measure was finalized in the FY 2012 IRF PPS Final Rule which was published in the Federal Register on 08/05/2011 (76 FR 47874).   The updated version of the CAUTI measure was adopted in the CY 2013 Hospital Outpatient Prospective Payment System Final Rule which was published in the Federal Register on November 15, 2012 (77 FR 68500).  Data collection for this measure began on 10/01/2012. The data for this measure is submitted via CDC/NHSN.

IRF Measure #2: Influenza Vaccination among Healthcare Personnel (NQF #0431)

This measure was finalized in the FY 2014 IRF Final Rule which was published in the Federal Register on August 6, 2013 (78 FR 47860). Data collection for this measure began on 10/01/2014. The data for this measure is submitted via CDC/NHSN.  

IRF Measure #3:  NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

This measure was finalized in the FY 2015 IRF Final Rule which was published in the Federal Register on August 6, 2014 (79 FR 45872). Data collection for this measure began 01/01/2015. The data for this measure is submitted via CDC/NHSN. 

IRF Measure #4:  Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47100). Data collection for this measure began 10/1/2016.

IRF Measure #5:  Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47111). Data collection for this measure began 10/1/2016.

IRF Measure #6:  IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (NQF #2633)

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47117). Data collection for this measure began 10/1/2016.

IRF Measure #7:  IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47118). Data collection for this measure began 10/1/2016.

IRF Measure #8:  IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47119). Data collection for this measure began 10/1/2016.

IRF Measure #9:  IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

This measure was finalized in the FY 2016 IRF Final Rule which was published in the Federal Register on August 6, 2015 (80 FR 47120). Data collection for this measure began 10/1/2016.

IRF Measure #10: Medicare Spending per Beneficiary (MSPB)–PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measure #11: Discharge to Community–PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measures #12: Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measure #13: Potentially Preventable Within Stay Readmission Measure

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52056). This is a claims-based measure and no additional data need to be submitted by the IRF.

IRF Measure #14: Drug regimen Review Conducted with Follow-Up for Identified Issues – PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52111). Data collection for this measure began 10/1/2018.

IRF Measure #15: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

This measure was finalized in the FY 2018 IRF PPS Final Rule which was published on August 3, 2017 (82 FR 36277). Data collection for this measure will begin 10/1/2018 using data elements that already exist on the IRF-PAI. This measure replaces Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678) as noted above. 

For more detailed information on data collection and submission deadlines, please refer to the IRF Quality Data Submission webpage. For more information on the data sets and quality reporting requirements, please reference the IRF-PAI and Section 4, the Quality Indicator section of the IRF Training Manual, located on the IRF-PAI and IRF QRP Manual webpage. 

Measures Removed from the IRF QRP

1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678) 

An application of this measure was finalized in the FY 2012 IRF PPS Final Rule which was published in the Federal Register on 08/05/2011 (76 FR 47874). The NQF-endorsed risk adjusted version of the measure was adopted in the FY 2014 IRF PPS Final Rule which was published in the Federal Register on 08/06/2013 (78 FR 47902). Data collection for this measure began on 10/01/2012.   As finalized in the FY 2018 IRF PPS Final Rule which was published in the Federal Register on 08/03/2017 (82 FR 36277), this measure was replaced by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 IRF QRP.       

2. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680)

This measure was finalized in the FY 2014 IRF Final Rule which was published in the Federal Register on August 6, 2013 (78 FR 47860). Data collection for this measure began on 10/01/2014. This measure was finalized for removal in the FY 2019 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2018 (83 FR 38576). Beginning 10/01/2018, IRFs should enter a dash (–) or any valid code for O0250A, O0250B, and O0250C until the next IRF-PAI is released.

3. NHSN Facility-wide Inpatient Hospital-onset Methicillin resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)

This measure was finalized in the FY 2015 IRF Final Rule which was published in the Federal Register on August 6, 2014 (79 FR 45872). Data collection for this measure began 01/01/2015. The data for this measure is submitted via CDC/NHSN. This measure was finalized for removal in the FY 2019 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2018 (78 FR 47860). Data collection for this measure ended 10/01/2018.

4. All Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Hospitals (NQF #2502) 

This measure was finalized in the FY 2014 IRF Final Rule which was published in the Federal Register on August 6, 2013 (78 FR 47860). This is a claims-based measure and no additional data need to be submitted by the IRF. As finalized in the FY 2018 IRF PPS Final Rule which was published in the Federal Register on 08/03/2017 (82 FR 36283), this measure was removed beginning with the FY 2019 IRF QRP.

Updates

October 18, 2019

The IRF QRP Table for Reporting Assessment-Based Measures and SPADES for the FY 2022 IRF QRP APU is now available in the Downloads section below. This table indicates the IRF-PAI data elements CMS will use for FY 2022 IRF QRP APU determinations.

September 06, 2019

IRF Quality Measure Calculations and Reporting User’s Manual V3.1

The IRF Quality Measure Calculations and Reporting User’s Manual V3.1 and associated change table and risk adjustment appendix are now available in the downloads section below.

This version of the IRF-PAI-based User’s Manual is effective on October 1, 2019 and provides detailed information for each quality measure, including quality measure definitions, inclusion and exclusion criteria, and measure calculation specifications. A Change Table has been added to highlight the changes from IRF Quality Reporting Program Measures Calculations and Reporting User’s Manual V3.0 to V3.1. Additionally, we have included a Risk Adjustment Appendix File for the IRF Quality Reporting Program Measures Calculations and Reporting User’s Manual V3.1, which contains the risk-adjustment values used to calculate the risk-adjusted quality measures.

We would like to describe several changes to the IRF Functional Outcome Measure specifications, including updates to the exclusion criteria, risk adjustors, and measure calculation algorithm as part of the Spring 2019 National Quality Forum maintenance endorsement review process.

Specification updates for all 4 IRF Functional Outcome Measures:

  1. Exclusion criteria: We are removing “discharged to another IRF” as an exclusion criterion from the incomplete stay definition. Rationale: The removal of this criterion means that the definition of an “incomplete stay” for this measure is aligned with other post-acute care function quality measures.
  2. Risk-Adjustors: We have updated the covariates included in the risk adjustment model by removing several comorbidities and adding low body mass index (BMI) and several comorbidities. Rationale: When examining the risk adjustment model using the 12-month national IRF-PAI data, we found that some comorbidities were no longer significant predictors of functional outcomes or the association between the comorbidity and functional outcomes was no longer consistent with the literature or clinical expectations. Following a literature review, we tested additional candidate risk adjusters and added low BMI and several comorbidities to the regression model. Adding these risk adjustors to the model will not add provider burden, because the data are already collected via the IRF-PAI.

Specification updates for the Change in Self-Care and Change in Mobility Measures only:

  1. Measure Calculation: The risk-adjustment procedure for these measures involves comparing patients’ observed change in function (self-care or mobility) scores with their expected change in function scores. We are revising this part of the measure calculation. The prior approach used the ratio of the observed to expected values and the ratio was multiplied by the national mean. The new approach uses the difference between the observed and expected values, and the difference value is added to the national mean. Rationale: We have developed an application of this measure for skilled nursing facilities (SNFs) and use the difference approach for the SNF measure given the potential for more variation in the observed and expected values due to a more heterogeneous SNF population. We are now updating this IRF functional outcome measure to use the difference approach so the IRF and SNF measure calculations are aligned.

Specification updates for the Change in Mobility and Discharge Mobility Measures only:

  1. Inclusion of wheelchair mobility for patients who are unable to walk. Rationale: Including wheelchair mobility activities to the mobility quality measures captures improvement in wheelchair mobility skills of patients who are unable to walk at admission and discharge. We received feedback about including wheelchair mobility activities for this measure from stakeholders.

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Page Last Modified:
10/17/2019 10:24 PM