LTCH Quality Public Reporting

Background 

Section 3004(a) of the Affordable Care Act established the Long-Term Care Hospital (LTCH) Quality Reporting Program (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 providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals.

LTCH Compare

LTCH Compare formats the reported data to be readily used by the public, which provides a snapshot of the quality of care for each facility. This tool helps families compare some key quality metrics, such as pressure ulcers and readmissions, for over 400 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 and may be submitted 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 CMS Certification Number (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
    5. Information supporting the LTCH’s belief that the data contained within the LTCH’s 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)
  • LTCHs will receive an email confirming receipt of their request.
  • 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.  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 LTCH 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

    March 12, 2020

    LTCH Provider Preview Reports- Now Available

    Long-Term Care Hospital (LTCH) Provider Preview Reports have been updated and are now available.  The data contained within the Preview Reports is based on quality data submitted by LTCHs between Quarter 4 – 2018 and Quarter 3 – 2019, and reflects what will be published on LTCH Compare during the June 2020 refresh of the website.  Providers have 30 days (3/12/20 to 4/13/20) to review their performance data. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

    As a reminder, data for the quality measure Percent of Residents or Patients that have New or Worsened Pressure Ulcers (short stay), will continue to reflect data collected between Quarter 3 2017 – Quarter 2 2018.  This data will continue to be publicly displayed until such time as the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, is publicly displayed in fall 2020, as finalized in the FY 2018 IPPS/LTCH PPS Final Rule.

    LTCHs can access their preview report by logging in to iQIES at https://iqies.cms.gov/. At the main screen, select Reports; then ‘My Reports’.

    For more information:

    March 11, 2020

    LTCH Compare Quarterly Refresh- Now Available

    The March 2020 quarterly Long-Term Care Hospital (LTCH) Compare refresh is now available.  This LTCH Compare update reflects quality data submitted by LTCHs between Quarter 3 – 2018 and Quarter 2 – 2019.

    As a reminder, data for the quality measure Percent of Residents or Patients that have New or Worsened Pressure Ulcers (short stay), will continue to reflect data collected between Quarter 3 2017 – Quarter 2 2018.  This data will continue to be publicly displayed until such time as the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, is publicly displayed in fall 2020, as finalized in the FY 2018 IPPS/LTCH PPS Final Rule.

    As of the March 2020 refresh, CMS will no longer publicly display the measure Percent of residents or patients who were assessed and appropriately given the seasonal influenza vaccine (short stay), as finalized in the FY 2019 IPPS/LTCH PPS Final Rule.

    In summary, the following quality measures will be displayed on LTCH Compare during the December 2019 refresh:

    • Percent of residents or patients with pressure ulcers that are new or worsened (short stay)
      • Q3 2017 – Q2 2018 (7/01/2017 – 6/30/2018)
    • Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
      • ‎Q3 2018 – Q2 2019 (7/01/18 – 6/30/19)
    • Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
      • ‎ Q3 2018 – Q2 2019 (7/01/18 – 6/30/19)
    • Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
      • Q3 2018 – Q2 2019 (7/01/18 – 6/30/19)
    • National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure
      • Q2 2018 – Q1 2019 (4/01/‎2018 -- ‎3/‎31‎/‎2019)
    • National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) outcome measure
      • Q2 2018 – Q1 2019 (4/01/‎2018 -- ‎3/‎31‎/‎2019)
    • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) outcome measure
      • Q2 2018 – Q1 2019 (4/01/‎2018 -- ‎3/‎31‎/‎2019)
    • Influenza Vaccination Coverage Among Healthcare Personnel
      • ‎Q3 2016 – Q2 2017 (7‎/‎01‎/‎2016 -- ‎6/30‎/‎2017)
    • Percent of residents or patients who were assessed and appropriately given the seasonal influenza vaccine (short stay)
      • ‎ Q3 2016 – Q2 2017 (7‎/‎01‎/‎2016 -- ‎6/30‎/‎2017)
    • Potentially Preventable 30-Day Post-Discharge Readmission Measure for Long-Term Care Hospital Quality Reporting Program
      • Q4 2016 – Q3 2018 (10/1/2016 – 9/30/2018)
    • Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program
      • ‎Q4 2015 – Q3 2017 (10‎/‎01‎/‎2015 - ‎09‎/‎30‎/‎2017)
    • Medicare Spending Per Beneficiary Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program
      • Q4 2016 – Q3 2018 (10/1/2016 – 9/30/2018)

    Please visit the LTCH Compare website to view the updated quality data.

    For more information:

     

    December 12, 2019

    LTCH Compare Quarterly Refresh- Now Available

    The December 2019 quarterly Long-Term Care Hospital (LTCH) Compare refresh is now available.  This LTCH Compare update reflects quality data submitted by LTCHs between Quarter 2  2018 and Quarter  – 2019.  CMS has additionally included the annual update to the Discharge to Community quality measure.

    As a reminder, data for the quality measure Percent of Residents or Patients that have New or Worsened Pressure Ulcers (short stay), will continue to reflect data collected between Quarter 3 2017 and Quarter 2 2018.  This data will continue to be publicly displayed until such time as the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, is publicly displayed in fall 2020, as finalized in the FY 2018 Inpatient Prospective Payment System (IPPS/LTCH Prospective Payment System (PPS) Final Rule.

    As of the December 2019 refresh, CMS will no longer publicly display the National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia outcome measure, as finalized in the FY 2019 IPPS/LTCH PPS Final Rule.

     In summary, the following quality measures will be displayed on LTCH Compare during the December 2019 refresh:

    • Percent of residents or patients with pressure ulcers that are new or worsened (short stay)
      • Q3 2017 – Q2 2018 (7/01/2017 – 6/30/2018)
    • Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
      • ‎Q2 2018 – Q1 2019 (4/01/2018 – 3/31/2019)
    • Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
      • ‎ Q2 2018 – Q1 2019 (4/01/2018 – 3/31/2019)
    • Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
      • Q2 2018 – Q1 2019 (4/01/2018 – 3/31/2019)
    • National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure
      • ‎Q1 2018 – Q4 2018 (1/01/‎2018 - ‎12/‎31‎/‎2018)
    • National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) outcome measure
      • Q1 2018 – Q4 2018 (1/01/‎2018 - ‎12/‎31‎/‎2018)
    • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) outcome measure
      • Q1 2018 – Q4 2018 (1/01/‎2018 -‎12/‎31‎/‎2018)
    • Influenza Vaccination Coverage Among Healthcare Personnel
      • ‎Q3 2016 – Q2 2017 (7‎/‎01‎/‎2016 - ‎6/30‎/‎2017)
    • Percent of residents or patients who were assessed and appropriately given the seasonal influenza vaccine (short stay)
      • ‎ Q3 2016 – Q2 2017 (7‎/‎01‎/‎2016 - ‎6/30‎/‎2017)
    • Potentially Preventable 30-Day Post-Discharge Readmission Measure for Long-Term Care Hospital Quality Reporting Program
      • Q4 2016 – Q3 2018 (10/1/2016 – 9/30/2018)
    • New!  Discharge to Community-Post Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program
      • ‎Q4 2015 – Q3 2017 (10‎/‎01‎/‎2015 - ‎09‎/‎30‎/‎2017)
    • Medicare Spending Per Beneficiary Post - Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program
      • Q4 2016 – Q3 2018 (10/1/2016 – 9/30/2018)

     

    Please visit the LTCH Compare website to view the updated quality data.

     

    For more information:

     

     

    Page Last Modified:
    04/22/2020 02:22 PM