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

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

What are the LTCH quality reporting measures?

Data for the LTCH QRP measures are collected and submitted through three methods:

  • LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS)
  • Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
  • Medicare Fee-For-Service Claims

Measures adopted for and removed from the LTCH QRP are listed below.


LCDS Measures

Data collected using the LCDS and submitted to the Centers for Medicare & Medicaid Services (CMS) via the Internet Quality Improvement and Evaluation System (iQIES):

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

This measure was finalized in the FY 2014 Inpatient Prospective Payment System (IPPS)/LTCH Prospective Payment System (PPS) Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50853). This measure was finalized as an Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) measure in the FY 2016 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2015 (80 FR 49723). Data collection for this measure began on April 1, 2016.

2. 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 2015 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2014 (79 FR 50286). Data collection for this measure began on April 1, 2016.

3. 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 as an IMPACT Act measure in the FY 2016 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2015 (80 FR 49723). Data collection for this measure began on April 1, 2016.

4. Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support (NQF #2632)

This measure was finalized in the FY 2015 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2014 (79 FR 50286). Data collection for this measure began on April 1, 2016.

5. Drug Regimen Review Conducted with Follow-Up for Identified Issues – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57193). Data collection for this measure began on July 1, 2018. 

6. Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

This measure was finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published on August 14, 2017 (82 FR 38425). Data collection for this measure began on July 1, 2018, using data elements that already exist on the LTCH CARE Data Set. This measure replaces Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678).

7. Compliance with Spontaneous Breathing Trial (SBT) by Day 2 of the LTCH Stay

This measure was finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38425). Data collection for this measure began on July 1, 2018.

8. Ventilator Liberation Rate

This measure was finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38425). Data collection for this measure began on July 1, 2018.

9. Transfer of Health Information to the Provider Post-Acute Care

This measure was finalized in the FY 2020 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 16, 2019 (84 FR 42526). Data collection for this measure is to be determined.

10. Transfer of Health Information to the Patient Post-Acute Care

This measure was finalized in the FY 2020 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 16, 2019 (84 FR 42526). Data collection for this measure is to be determined.

CDC NHSN Measures

Data for the NHSN measures are submitted to the CDC:

1. National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection Outcome Measure (NQF #0138)

An application of the measure was finalized in the FY 2012 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 18, 2011 (76 FR 51743). The National Quality Forum (NQF) version of the measure was finalized in the FY 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53614). Data collection for this measure began on October 01, 2012.

2. National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection Outcome Measure (NQF #0139)

An application of the measure was finalized in the FY 2012 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 18, 2011 (76 FR 51743). The NQF version of the measure was finalized in the FY 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53614). Data collection for this measure began on October 01, 2012.

3. National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Clostridium difficile Infection Outcome Measure (NQF #1717)

This measure was finalized in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50853). Data collection for this measure began on January 1, 2015.

4. Influenza Vaccination Coverage Among Healthcare Personnel (NQF #0431)

This measure was finalized in the FY 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53614). The data collection time frame was revised in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50853). Data collection for this measure began on October 1, 2014.

Medicare Fee-For-Service Claims-Based Measures

The following are Medicare Fee-For-Service Claims-based measures. There is no additional LTCH QRP data collection or submission associated with these measures.

1. Discharge to Community – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) (NQF #3480)

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57193).

2. Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57193).

3. Potentially Preventable 30-Days Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57193).

For more detailed information on data collection and submission deadlines, please refer to the LTCH Quality Reporting Data Submission Deadlines webpage. For more information on the LCDS, please reference the LTCH CARE Data Set and the LTCH CARE Data Set Manual webpage.

Measures Removed from LTCH QRP

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

An application of the measure was finalized in the FY 2012 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 18, 2011 (76 FR 51743). The NQF-endorsed, risk-adjusted version of the measure was adopted in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50853). This measure was finalized as an IMPACT Act measure in the FY 2016 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2015 (80 FR 49723). Data collection for this measure began on October 1, 2012. As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38425), this measure was replaced by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning on July 1, 2018.

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 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53614). The data collection time frame was revised in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57193). Data collection for this measure began on October 1, 2014. This measure was finalized for removal in the FY 2019 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2018 (83 FR 41633). Beginning on October 1, 2018, LTCHs should enter a dash (–) or any valid code for O0250A, O0250B, and O0250C until the next LTCH CARE Data Set is released.

3. National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus Bacteremia Outcome Measure (NQF #1716)

This measure was finalized in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50853). Data collection for this measure began on January 1, 2015. The data for this measure was submitted via CDC/NHSN. Data collection for this measure ended on October 1, 2018. 

4. National Healthcare Safety Network (NHSN) Ventilator-Associated Event (VAE) Outcome Measure

This measure was finalized in the FY 2015 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2014 (79 FR 50286). Data collection for this measure began on January 1, 2016. Data collection for this measure began on January 1, 2016. The data for this measure were submitted via CDC/NHSN. This measure was finalized for removal in the FY 2019 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2018 (83 FR 41631 through 41632). Data collection for this measure ended on October 1, 2018.

5. All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Long-Term Care Hospitals (NQF #2512)

This measure was finalized in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50853). This is a claims-based measure and no additional data need to be submitted by the LTCH. As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38425), this measure was removed from the LTCH QRP beginning with the FY 2019 LTCH QRP.

Updates

November 3, 2020

LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.2

The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Measure Calculations and Reporting User’s Manual Version 3.1.2 addendum and associated risk adjustment appendix are now available in the Downloads section below.

The manual serves as an addendum that communicates quality measure updates to the LTCH QRP Measure Calculations and Reporting User’s Manual Version 3.1 and replaces the LTCH QRP Measure Calculations and Reporting User’s Manual Version 3.1.1. The LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.2 is effective on October 1, 2020 and provides information on measure-related changes in a change table format in lieu of a complete update to the overall manual. Additionally, the updated Risk Adjustment Appendix file for the LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.2 is included and replaces the Risk Adjustment Appendix file for the LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.1.

Additional updates to the quality measure specifications in the manual V3.1.2, which are not included in the manual V3.1.1, are corrections to the LTCH Ventilator Liberation Rate (VLR) measure’s calculation formulae. The predicted score formula and expected score formula were corrected, and existing formulae and variable definitions originally defined in the LTCH QRP Measure Calculations and Reporting User’s Manual V3.1 were revised to reflect the corrected formulae. The only changes to the Risk Adjustment Appendix for manual V3.1.2 are updated language referencing the VLR measure and the LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.2 addendum. No coefficient values were changed between the Risk Adjustment Appendices for manual V3.1.2 and manual V3.1.1.

September 8, 2020

LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.1

The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Measure Calculations and Reporting User’s Manual Version 3.1.1 and associated risk adjustment appendix are now available in the Downloads section below.

This document serves as an addendum that communicates quality measure updates to the LTCH QRP Measure Calculations and Reporting User’s Manual Version 3.1. The LTCH QRP Measure Calculations and Reporting User’s Manual V3.1.1 is effective on October 1, 2020 and provides information on measure-related changes in a change table format in lieu of a complete update to the overall manual. Additionally, we have included the updated Risk Adjustment Appendix File for the LTCH Quality Reporting Program Measures Calculations and Reporting User’s Manual V3.1.1, which contains the risk-adjustment values used to calculate the risk-adjusted quality measures.

We would like to describe several changes to the quality measure specifications, including removal of the Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened measure and updates to the exclusion criteria for the LTCH Functional Outcome and Discharge to Community measures.

Specification update to the LTCH Functional Outcome Measure: Change in Mobility Among Patients Requiring Ventilator Support:

  1. Exclusion criteria: The age exclusion criterion for this measure has been updated from 21 years to 18 years, such that any patient younger than 18 years of age will be excluded from measure calculations.

Specification update for the LTCH Discharge to Community Measure:

  1. Exclusion criteria: This measure has been updated to exclude patients who had a long-term nursing facility (NF) stay in the 180 days preceding their hospitalization and LTCH stay, with no intervening community discharge between the long-term NF stay and qualifying hospitalization.

June 17, 2020

Revised: FY 2022 LTCH QRP APU Table for Reporting Assessment-Based Measures and SPADES

The Centers for Medicare & Medicaid Services (CMS) is delaying the release of the Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) V5.0. This delay is due to the COVID-19 Public Health Emergency (PHE). As a result, the implementation of the FY 2022 LTCH Quality Reporting Program (QRP) Annual Payment Update (APU) Table for Reporting Assessment-Based measures and Standardized Patient Assessment Data Elements (SPADES) is revised. This document is found in the Downloads section below.

The items indicated in the column for Data Collection Periods Q1, Q2, and Q3 of 2020 using the LTCH Continuity Assessment Record and Evaluation Data Set (LCDS) V4.0 will continue to be required for FY 2022 APU calculation in Q4 2020. This will continue until October 1st of the year that is at least one fiscal year after the end of the PHE.

LTCH Quality Reporting Program Archives

Page Last Modified:
12/31/2020 02:07 PM