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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 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: 

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 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


June 10, 2019

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 – 2017 and Quarter 3 – 2018 and reflects what will be published on LTCH Compare during
the September 2019 refresh of the website. Providers have until July 10, 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.

Beginning with the September 2019 refresh, CMS will publicly display measure results on the LTCH
Compare website for the Potentially Preventable 30-Day Post-Discharge Readmissions measure adopted
for the LTCH Quality Reporting Program (QRP). CMS decided not to publish this measure in late 2018
to allow more testing to ensure it provides a reliable, accurate picture of provider performance on
quality, in line with CMS’s Meaningful Measures Initiative to address high-priority areas for
quality measurement with measures that will help improve outcomes while minimizing provider burden.
We have since completed this additional testing and have refined the method for assigning providers
to performance categories, in which their performance level is compared to the national rate. LTCH
performance data for these measures will be included for the first time on this preview report.

CMS is additionally previewing the Discharge to Community (DTC) measure for the first time, using
updated methodology for assigning categorical ratings to each provider based on their performance
on this measure (better than, same as, or worse than the national average).

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:

• The LTCH data referenced in the above messaging, we invite you to view the LTCH Quality Public
Reporting webpage, LTCH Compare and/or Preview Report Access Instructions
• Potentially Preventable Readmissions measures, we invite you to view our related Fact Sheet and Q
& A documents on the LTCH QRP Public Reporting webpage, under the Downloads section.
• The newly updated methodology used to assign categorical ratings to providers with respect to
their performance on the DTC measure, as referenced above, we invite you to view our related Fact
Sheet and Q & A documents on the LTCH QRP Public Reporting webpage, under the Downloads section.

June 05, 2019

LTCH Compare Quarterly Refresh

The June 2019 quarterly Long-term Care Hospital (LTCH) Compare refresh, including updated quality measure results based on data submitted to CMS between Quarter 3 2017 – Quarter 2 2018, is now available.

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

May 31, 2019

Update of the Discharge to Community Measure for the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)

The LTCH DTC measure was first displayed on the LTCH Compare website in fall 2018 and will be refreshed in fall 2019. CMS has refined the statistical methodology for assigning providers to performance categories for public display to align with the Potentially Preventable Readmissions measures in the PAC QRPs and the Hospital-Wide Readmission measure in the Inpatient QRP. This refinement results in greater variation in provider performance categories, allowing better discernment of providers that underperform or overperform considerably compared with the national rate. The refinement will be reflected for the first time in the fall 2019 Quarterly Refresh for the Long-Term Care Hospital (LTCH) Compare website, and the related August 2019 LTCH Provider Preview Reports.

Background

  • The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) directed the Secretary to specify and publicly report measures reflecting successful discharge to community for use in the LTCH QRP.
  • The LTCH QRP DTC measure was finalized in the Fiscal Year 2017 IRF PPS Final Rule. Confidential feedback reports were distributed to LTCH providers in fall 2017 and the measures were first displayed on the LTCH Compare website in fall 2018.
  • For the fall 2019 public display refresh of the DTC measure, and in future years, CMS has refined the method by which we assign providers to performance categories to align with the claims-based Potentially Preventable Readmissions measures in the LTCH QRP and the Hospital-Wide Readmission measure in the Inpatient QRP.
  •  Our revised methodology results in greater variation in performance categories, allowing better discernment of provider performance, including those that underperform or overperform considerably compared with the national rate. This refinement will be reflected in the fall 2019 Quarterly Refresh of the LTCH Compare website, as well as the August 2019 LTCH Provider Preview Reports.

May 30, 2019

Publication of Potentially Preventable Readmission Measures for the Post-Acute Care Quality Reporting Programs (QRPs)

Beginning fall 2019, CMS will publicly display measure results on the Long-Term Care Hospital Compare website for the Potentially Preventable 30-Day Post-Discharge Readmissions measure adopted for the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP). We postponed publishing this measure in late 2018 to allow more testing to ensure it provides a reliable, accurate picture of provider performance on quality, in line with CMS’s Meaningful Measures Initiative to address high-priority areas for quality measurement with measures that will help improve outcomes while minimizing provider burden. We have since completed this additional testing and have refined the method for assigning providers to performance categories, in which their performance level is compared to the national rate.

Background

  • The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 directs the Secretary to specify a measure that reflects all-condition risk-adjusted potentially preventable hospital readmission rates for use in the LTCH QRP. The IMPACT Act also requires the Secretary to publicly report provider performance on resource use and other measures, including measures to reflect all-condition risk-adjusted potentially preventable hospital readmission measures. 
  • CMS developed a potentially preventable 30-day readmission measure for the LTCH QRP to meet the resource use and other measures domain as mandated by the IMPACT Act.
  •  Since potentially preventable readmission rates are relatively low, we conducted additional testing to ensure that this measure reliably assesses a provider’s performance on quality. We postponed publishing this measure while we were conducting this additional testing.
  • We have since completed our additional testing and will publish this measure on the LTCH Compare website for the September 2019 LTCH Compare Quarterly Refresh.
  • As a result of the additional testing, we have refined our method for assigning providers to performance categories, which indicate their level of performance compared to the national rate. This refinement will also be reflected in both the September 2019 LTCH Compare Quarterly Refresh and the June 2019 Provider Preview Reports.

March 6, 2019

LTCH Compare Quarterly Refresh

The March 2019 quarterly Long-term Care Hospital (LTCH) Compare refresh, including updated quality measure results based on data submitted to CMS between Quarter 2 2017 – Quarter 1 2018, is now available.

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

March 4, 2019

LTCH Provider Preview Reports- Now Available – March 4, 2019 

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 3 – 2017 and Quarter 2 – 2018, and reflects what will be published on LTCH Compare during the June 2019 refresh of the website. Providers have until April 3, 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:

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

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