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LTCH Quality Reporting 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.

Updates

What are the Long-Term Care Hospital (LTCH) quality reporting measures?

Measures adopted for and removed from the LTCH QRP are listed below. Data for the LTCH QRP measures are collected and submitted through three methods:

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

LTCH Continuity Assessment Record and Evaluation (CARE) Data Set Measures

Data collected using the LTCH CARE Data Set submitted to 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 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 04/01/2016.

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 04/01/2016.

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 04/01/2016.

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 04/01/2016.

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 07/01/2018.

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 07/01/2018 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) as noted above.

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 07/01/2018.

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 07/01/2018.

Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) Measures

Data for the National Healthcare Safety Network (NHSN) measures submitted to the Centers for Disease Control (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 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 10/01/2012. The data for this measure is submitted via CDC/NHSN.

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 10/01/2012. The data for this measure is submitted via CDC/NHSN.

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 01/01/2015. The data for this measure is submitted via CDC/NHSN.

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 10/01/2014. The data for this measure is submitted via CDC/NHSN.

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)

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). This is a claims-based measure and no additional data need to be submitted by the LTCH.

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). This is a claims-based measure and no additional data need to be submitted by the LTCH.

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). This is a claims-based measure and no additional data need to be submitted by the LTCH.

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 data sets, please reference the LTCH CARE Data Set and the LTCH QRP Manual, located on the LTCH CARE Data Set and LTCH QRP 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 10/01/2012.  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 07/01/2018.

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 10/01/2014. 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 10/01/2018, 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 01/01/2015. The data for this measure is submitted via CDC/NHSN. Data collection for this measure ended 10/01/2018. 

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 01/01/2016. The data for this measure is 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 10/01/2018.

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. 

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