Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program of the Centers for Medicare and Medicaid Services (CMS)

 

Data submission to the CMS IPFQR is part of the service package received by Behavioral Healthcare Performance Measurement System members, saving valuable staff time at the facility.

 

In August 2016, NRI submitted quality data on behalf of the 152 psychiatric facilities that requested NRI services (with 100% compliance among participants).

 

CMS released the IPFQR final rule that updates the FY2019 Medicare payment determination requirements and identifies new measures for the program.  Beginning with the January 1, 2017 reporting period, the requirements are as follows:

 

HBIPS 2 - Hours of Physical Restraint Use. Total hours all patients spent in physical restraint as a proportion of total inpatient hours.

 

HBIPS 3 - Hours of Seclusion Use. Total hours all patients spent in seclusion as a proportion of total inpatient hours.

 

HBIPS 5 - Discharge on Multiple Antipsychotic Medications with Appropriate Justification. Percent of patients discharged on multiple antipsychotic medications with appropriate justification as a proportion of patients discharged on two or more antipsychotic medications. Appropriate justifications are limited to augmentation of clozapine, tapering to monotherapy, and history of at least three failed trials of monotherapy. 

 

Follow-Up After Hospitalization (FUH) for Mental Illness measures the percentage of discharged patients age 6 years or older who had an outpatient visit, an intensive outpatient encounter, or a partial hospitalization with a mental health practitioner, within 7 days and 30 days of discharge. CMS will calculate these measures based on Medicare claims data.

 

SUB 1- Alcohol Use Screening.  Measures the percent of patients age 18 years or older who were screened for alcohol use using a validated screening questionnaire for unhealthy alcohol use within three days of admission as a proportion of patients discharged.

 

SUB-2/2a -Alcohol Use Brief Intervention.  SUB 2 -Measures the percent of patients age 18 or older who screened positive for unhealthy alcohol use that were offered or refused Alcohol Use Brief Intervention.  SUB2a measures patients who screened positive for unhealthy alcohol use who received a brief intervention during the hospital stay.

NEW!  SUB 3/3a - Measures the percent of patients age 18 and older identified with an alcohol or drug use disorder who receive or refuse a prescription for alcohol or drug use disorder AND who received or refused a referral for addictions treatment.

Influenza Immunization (IMM-2) – Inpatients, age 6 months and older, discharged during Oct – March who are screened for influenza vaccination status and vaccinated prior to discharge.

 

Influenza Vaccination Coverage Among Healthcare Personnel – Facilities will use the CDC National Healthcare Safety Network (NHSN) to report on healthcare personnel who receive the influenza vaccination Oct- March.

 

TOB-1 – Tobacco Use Screening – Inpatients age 18 and older who were screened within three days of admission for tobacco use (cigarettes, smokeless tobacco, pipe, and cigars) within the past 30 days.

 

TOB-2 & TOB-2a – Tobacco Use Treatment Provided or Offered & Tobacco Use Treatment Received - TOB-2 - Inpatients identified as tobacco product users within the past 30 days who receive or refuse practical counseling to quit AND receive or refuse FDA-approved cessation medications during the first three days after admission.

 

TOB-2a - Inpatients who received counseling AND medication as well as those who received counseling and had reason for not receiving the medication during the first three days after admission.

 

TOB-3/3a - Tobacco Use Treatment at Discharge – TOB3 - Patients identified as tobacco product users within the past 30 days who were referred to or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication upon discharge. TOB 3a - Patients who were referred to evidence-based outpatient counseling AND received a prescription for FDA-approved cessation medication upon discharge as well as those who were referred to outpatient counseling and had reason for not receiving a prescription for medication.

 

NEW! Transition Record with Specified Elements Received by Discharged Patients  - Percentage of patients, regardless of age, discharged from an inpatient facility who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements. 

NEW!  Timely Transmission of Transition Record - Patients for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.

 

NEW!  Screening for Metabolic Disorders - The percentage of discharges for which a structured metabolic screening for 4 elements was completed in the past year. The four included tests are body mass Index, blood pressure, glucose or HbA1c, and a lipid panel.

 

Assessment of Patient Experience of Care is a structural measure. This is a mandatory attestation: does the facility routinely assess patient experience of care using a standardized collection protocol and a structured instrument, and if yes, which tool did they use.

 

Uses of an EHR is a structural measure. This is a mandatory attestation: identify the degree to which the facility employs EHR systems in their service program and use such systems to support health information exchange at times of transitions in care.

 

FY2019 payment determination final rule requirements can be found in the Federal Register of August 2, 2016 and on the web at: https://federalregister.gov/a/2016-18476.  Measure data will represent January – December discharges and events, unless otherwise noted.

 

To keep abreast of reporting requirements, facilities are encouraged to review postings under Inpatient Psychiatric Facilities on the Quality Net website (http://www.qualitynet.org).

 

 

Lucille Schacht, NRI's Senior Director for Performance and Quality Improvement, has been formally appointed to the technical advisory panel for the Federal Centers for Medicare and Medicaid Services (CMS) for the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program, and to the technical advisory panel for The Joint commission for HBIPS.