Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Public Reporting

Now available! Our new Provider Data Catalog makes it easier for you to search and download publicly reported data. We’ve also improved Medicare’s Compare sites.

Background

Section 3004(a) of the Affordable Care Act established the LTCH QRP. In addition, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the reporting of standardized patient assessment data on quality, resource use, and other measures by Post-Acute Care (PAC) providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and LTCHs.

Care Compare

Care Compare formats the reported data to be readily used by the public, which provides a snapshot of the quality of care for each LTCH. This tool helps families compare some key quality metrics, such as pressure ulcers and readmissions, for over 350 LTCHs across the nation.

Procedures for Requesting CMS Review of an LTCH’s Measure Data:

The Centers for Medicare & Medicaid Services (CMS) encourages LTCHs to review their data as provided in the Preview Reports. If an LTCH disagrees with performance data (numerator, denominator, or quality metric) contained within their Preview Report, they will have an opportunity to request review of that data by CMS. In order to make such a request, LTCH providers must adhere to the process outlined below:

  • Requests for CMS review of data may be submitted to CMS beginning on the day the provider preview reports are issued in LTCH Internet Quality Improvement and Evaluation System (iQIES) folders through 11:59:59 p.m. PST on day 30 of the preview period.
  • CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
  • LTCHs are required to submit their request to CMS via email with the subject line: “LTCH Public Reporting Request for Review of Data” and include the LTCH CMS Certification Number (CCN) (e.g., LTCH Public Reporting Request for Review of Data, XXXXXX). The request must be sent to the following email address: LTCHPRquestions@cms.hhs.gov.
  • The email request must include the following information:
    1. LTCH CCN
    2. LTCH Business Name
    3. LTCH Business Address
    4. CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address, i.e. not a post office box
    5. Information supporting the LTCH’s belief that the data contained within the LTCH’s Provider Preview Report is erroneous (numerator, denominator, or quality measure calculation), including, but not limited to, the following: quality measures affected, and aspects of quality measures affected (numerator, denominator, quality metric)
  • After submitting a request, LTCHs will receive an email confirming receipt of their request and may be asked to provide additional information to allow CMS to fully evaluate the request. Such requests from CMS will be sent to the contact person named above.
  • CMS will review all requests and provide a response outlining the decision via email. Please note that LTCH-identified errors in data resulting from inaccurate data submissions that an LTCH failed to correct will not be corrected. Also, CMS will not consider correcting quality measure calculations that providers find to be inaccurate due to missing data that was submitted beyond the applicable quarterly data submission deadline.
  • Data that CMS decides/agrees to correct will be corrected and displayed during the subsequent quarterly release of LTCH quality data on Care Compare.

Please note: The only method for submitting a request to CMS for review of your preview report data is via email. Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) in the request being submitted to CMS for review.


Updates

December 9, 2020

Care Compare Quarterly Refresh with LTCH QRP Data

The December 2020 quarterly refresh of the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) data is now available on the Long-term care hospitals webpage within Care Compare  and Provider Data Catalog (PDC).

The data for assessment-based measures are based on quality assessment data submitted by LTCHs to the Centers for Medicare & Medicaid Services (CMS) from Quarter 1 2019 through Quarter 4 2019 (01/01/2019 –12/31/2019), with the exception of Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support (National Quality Forum (NQF) #2632), which uses a two-year performance period and includes quality assessment data from Quarter 1 2018 through Quarter 4 2019 (01/01/2018 –12/31/2019).

This refresh also reflects data from the annual update of the claims-based measures data from Quarter 4 2017 through Quarter 3 2019 (10/01/2017 – 9/30/2019). Additionally, the Centers for Disease Control and Prevention (CDC) infections measures reflect data from Quarter 4 2018 through Quarter 3 2019 (10/01/2018-9/30/2019) and Quarter 4 2017 through Quarter 1 2018 (10/01/2017 – 3/31/2018) for the influenza measure.

Starting in December 2020, three additional LTCH QRP measures will be publicly reported on Care Compare and PDC:

  • Changes in Skin Integrity Post-Acute Care (PAC): Pressure Ulcer/Injury
  • Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support (NQF #2632)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC LTCH QRP

CMS will no longer publicly display the measure Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678) as finalized in the FY 2018 LTCH Prospective Payment System (PPS)/Inpatient Prospective Payment System (IPPS) Final Rule.

In summary, the following LTCH QRP measures will be displayed on Care Compare and PDC during the December 2020 refresh:

  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Q1 2019 – Q4 2019 (01/01/2019 – 12/31/2019)
  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF#0674)
    • Q1 2019 – Q4 2019 (01/01/2019 – 12/31/2019)
  • Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support (NQF #2632)
    • Q1 2018 – Q4 2019 (01/01/2018 – 12/31/2019)
  • Percent of Long-Term Care Hospital Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    • Q1 2019 – Q4 2019 (01/01/2019 – 12/31/2019)
  • 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)
    • Q1 2019 – Q4 2019 (01/01/2019 – 12/31/2019)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
    • Q1 2019 – Q4 2019 (01/01/2019 – 12/31/2019)
  • National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)
    • Q4 2018 – Q3 2019 (10/01/2018 – 9/30/2019)
  • National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure (NQF #0139)
    • Q4 2018 – Q3 2019 (10/01/2018 – 9/30/2019)
  • National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)
    • Q4 2018 – Q3 2019 (10/01/2018  –  9/30/2019)
  • Influenza Vaccination Coverage Among Healthcare Personnel (NQF #0431)
    • Q4 2017 – Q1 2018 (10/01/2017 – 03/31/2018)
  • Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) (NQF #3480)
    • Q4 2017 – Q3 2019 (10/01/2017 – 9/30/2019)
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
    • Q4 2017 – Q3 2019 (10/01/2017 – 9/30/2019)
  • Medicare Spending Per Beneficiary - Post Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
    • Q4 2017 – Q3 2019 (10/01/2017 – 9/30/2019)

Please visit the Long-term care hospital webpages within the Care Compare and Provider Data Catalog (PDC) websites, to view the updated quality data.

Note: The December 2020 refresh of the LTCH QRP data on the Care Compare site is the last scheduled refresh of this data until the December 2021 refresh. For additional information, please review the available LTCH QRP Public Reporting Tip Sheet (PDF) (PDF).

Important! LTCH Compare is retired, but you'll still be able to find the same information about LTCHs and other health care providers on Care Compare. The Provider Data Catalog also makes it easier for you to search and download our publicly reported data. Start using these tools today.

For questions about LTCH QRP Public Reporting, please email LTCHPRQuestions@cms.hhs.gov.

LTCH Quality Reporting Program Archives

Page Last Modified:
07/07/2021 11:50 AM