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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 (PAC) providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals.

LTCH Compare

LTCH Compare takes reported data and puts it into a format that can be used more readily by the public to get a snapshot of the quality of care each facility provides. For instance, this tool will help families compare some key quality metrics, such as pressure ulcers and readmissions, for over 400 LTCHs across the nation.

The following quality measures are currently reported on LTCH Compare:

  • All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge From Long-Term Care Hospitals (NQF #2512)
  • Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF # 0678)
  • National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI)   Outcome Measure (NQF # 0138)
  • National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure (NQF #0139)
  • Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccination (NQF #0680)
  • Measure suppressed by CMS due to measure calculation error
    • Influenza Vaccination among Healthcare Personnel (NQF #0431)
    • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)
    • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

    Procedures for requesting CMS review of an LTCH’s measure data: 

    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 CASPER 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:
    • LTCH CMS Certification Number (CCN)
    • LTCH Business Name
    • LTCH Business Address
    • CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
    • 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:

    December 12, 2018

    LTCH Compare Quarterly Refresh

    The December 2018 quarterly Long-term Care Hospital (LTCH) Compare refresh, including updated quality measure results based on data submitted to CMS between Quarter 1 2017 – Quarter 4 2017, is now available.

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

    December 3, 2018

    LTCH Provider Preview Reports- Now Available – December 3, 2018

    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 2 – 2017 and Quarter 1 – 2018, and reflects what will be published on LTCH Compare during the March 2019 refresh of the website. Providers have until January 2, 2019 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. 

    For more information:

    September 27, 2018

    LTCH Compare Quarterly Refresh – September 27, 2018

    The September 2018 quarterly Long-term Care Hospital (LTCH) Compare refresh, including new quality measure results based on data submitted to CMS between Q4 2016 – Q3 2017, is now available. We invite you to visit LTCH Compare to view the data. 

    The following five new quality measures will be newly reported on LTCH Compare:

    Assessment-based measures:

    1. Percent of LTCH Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    2. Application of Percent of LTCH Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    3. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)

    Claims-based measures:

    1. Medicare Spending Per Beneficiary-PAC LTCH QRP
    2. Discharge to Community-PAC LTCH QRP

    CMS has decided not to publish a 6th quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time.   Additional time would allow for more testing to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure. The additional testing will ensure that the future publicly reported measure is thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality.   While we conduct this additional testing, CMS will not post reportable data for this measure, including each LTCH’s performance, as well as the national rate.

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

    September 7, 2018 

    LTCH Provider Preview Reports- Now Available

    Long-term Care Hospital (LTCH) Provider Preview Reports have been updated and are now available.  Providers have until October 8, 2018 to review their performance data on quality measures based on Quarter 1 -2017 to Quarter 4 - 2017 data, prior to the December 2018 LTCH Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate. 

    The following five new quality measures will be newly reported on LTCH Compare:

    Assessment-based measures:

    1. Percent of LTCH Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    2. Application of Percent of LTCH Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    3. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)

    Claims-based measures:

    1. Medicare Spending Per Beneficiary-PAC LTCH QRP
    2. Discharge to Community-PAC LTCH QRPCMS has decided not to publish a 6th quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time.   Additional time would allow for more testing to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure. The additional testing will ensure that the future publicly reported measure is thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality.   While we conduct this additional testing, CMS will not post reportable data for this measure, including each LTCH’s performance, as well as the national rate.

    For more information:

    August 1, 2018

    ATTENTION ALL LTCHS!!!

    LTCH Provider Preview Report Correction for the Discharge to Community (DTC) Measure Data.

    Please note that your previous Provider Preview Report for the Discharge to Community - Post

    Acute Care (PAC) Long-Term Care Hospital Quality Reporting Program (L018.01) measure

    contained an error. Your Discharge to community preview data that was released in June 2018 incorporated your risk-standardized rate and performance category based only on 7 of the 8 required quarters of data. Data from October through December 2016 (Q1 FY 2017) were inadvertently omitted. 

    CMS has reissued the LTCH Provider Preview Reports containing the corrected Discharge to Community (DTC) measure data, and your corrected reports are now available via your CMS CASPER system folders. We have redistributed this report for the purposes of the 30-day preview period in advance of public reporting for the September 2018 LTCH Compare Refresh. LTCH providers will have a full 30 days to preview the corrected DTC data. The preview period will begin on August 1, 2018 and will continue through August 31, 2018. Any inquiries related to the corrected data must be submitted to CMS no later than 11:59:59 p.m. ET on August 31, 2018.  

    Please note that this version contains only the corrected DTC measure data.

    Please submit any inquiries regarding this report to LTCHPRquestions@cms.hhs.gov.

    For guidance on accessing your Provider Preview Report we refer you to the following document, which is available in the Downloads section of this webpage below.

    June 6, 2018

    LTCH Compare Quarterly Refresh Available

    The June 2018 quarterly Long-term Care Hospital (LTCH) Compare refresh, including quality measure results based on data submitted to CMS between Q3 2016 – Q2 2017, is now available. Visit LTCH Compare to view the data. 

    June 1, 2018 

    LTCH Provider Preview Reports- Now Available

    Long-term Care Hospital (LTCH) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 4 -2016 to Quarter 3 - 2017 data, prior to the September 2018 LTCH Compare refresh, during which this data will be publicly displayed.

    Providers have until July 1, 2018 to review their performance data.

    Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

    The updates include two additional assessment-based measures and three new claims-based measures. 

    New LTCH Assessment-based measures:

    • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)
    • 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)

    New LTCH Claims-based measures:

    • Medicare Spending Per Beneficiary-Post Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
    • Discharge to Community- Post Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
    • Potentially Preventable 30-Days Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)

    The update also includes the removal of the All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Long-Term Care Hospitals measure.

    For more information:

    March 07, 2018 

    LTCH Provider Preview Reports- Now Available

    Long-term Care Hospital (LTCH) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 3 -2016 to Quarter 2 - 2017 data, prior to the June 2018 LTCH Compare refresh, during which this data will be publicly displayed.

    CMS identified an error with data calculation which has led to suppression of the measure, Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680) on the LTCH preview report for March 2018.

    Providers have until April 5, 2018 to review their performance data.

    Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

    For more information:

    March 02, 2018

    The March 2018 quarterly Long-term Care Hospital (LTCH) Compare refresh, including quality measure results based on data submitted to CMS between Q2 2016 – Q1 2017, is now available. Visit LTCH Compare to view the data. 

    January 16, 2018

    LTCH Preview Reports: Flu Measure Error

    CMS identified an error with the data displayed on the LTCH Provider Preview Reports released on December 4, 2017, and related to the March 2018 refresh of the LTCH Compare website.  The December 2017 Preview Reports incorrectly included data from a reporting period different than that identified in the reports’ headers.  This error affected the following quality measures: 

    1. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680)
    2. Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431).

    The LTCH Provider Preview Report headers indicated that data for these measures represented patient assessment data for admissions and/or discharges that occurred between the dates of July 1, 2015 and June 30, 2016.  However, the data displayed on the reports was for the period July 1, 2016 through June 30, 2017.  Because of this discrepancy, CMS will be suppressing the display of this data for these two measures in the March 2018 LTCH Compare refresh.  Providers that have questions about this suppression should submit their inquiries to the LTCH Public Reporting helpdesk: LTCHPRquestions@cms.hhs.gov.

     

    January 04, 2018

    New Guidance on How to Update LTCH Demographic Data

    The demographic data displayed on the Provider Preview Reports and on Long-Term Care Hospital Compare is generated from information stored in the Automated Survey Processing Environment (ASPEN) system.

    If inaccurate demographic data is included on the Preview Report or on LTCH Compare, facilities need to contact their Medicare Administrative Contractor (MAC) for assistance. When requesting updates to your demographic data, it is important to specify that you want your data within the ASPEN system updated, instead of referring to your data on the Compare site.

    View the How to Update LTCH Demographic Data 1-4-18 PDF in the downloads section.

    Please note- updates to LTCH Provider demographic information do not happen in real time and can take up to 6-months to appear on LTCH Compare.

    LTCH Quality Reporting Archives

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