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Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Update Jeffrey A. Buck, PhD Senior Advisor for Behavioral Health, Program Lead IPFQR
Centers for Medicare & Medicaid Services (CMS)
Vinitha Meyyur, PhD Task Order Contracting Officer’s Representative (COR)
IPF Outcome and Process Measure Development and Maintenance, CMS
Evette Robinson, MPH Project Lead, IPFQR Program
Value, Incentives, and Quality Reporting (VIQR)
Education and Outreach Support Contractor (SC) Follow us on Twitter: @QIOProgram
December 2015 Tweet with our conference hashtag: #CMSQualCon15
Agenda
• Overview of the IPFQR Program
• Program Changes and Lessons Learned
• IPFQR Key Informant Survey: Preliminary Results
• New Measure Development
2
3
IPFQR Program Update
Overview of the IPFQR Program
IPFQR Program Background
• The IPFQR program was implemented October 1, 2012. As part of CMS’ pay-for-reporting program, eligible facilities are
subject to payment reduction for non-participation. This is intended to encourage IPFs and clinicians to improve the quality
of inpatient care.
This requires collection and reporting of aggregate, annual, and facility-
level data, not patient-level data.
The Inpatient Psychiatric Facility (IPF) Prospective Payment
System (PPS) FY 2016 Final Rule was published on August 5,
2015, in the Federal Register found at
http://www.gpo.gov/fdsys/pkg/FR-2015-08-05/pdf/2015-18903.pdf.
The IPFQR Program (42 CFR Part 412) begins on page one of the
PDF or page 46651 of the Federal Register.
4
What is an IPF?
5
• IPFs are either psychiatric units
within acute care or critical
access hospitals, or
freestanding psychiatric
hospitals.
• CMS uses the quarterly IPF
Provider-Specific File (PSF) to
determine program eligibility.
• IPF PPS billing is designated by
the facility’s CCN.
Freestanding: XX4000 – XX4499
Acute Care Hospital: S replaces
0 as the third digit
Critical Access Hospital: M
replaces 1 as the third digit
Acute Care 64%
Critical Access
4%
Freestanding 32%
IPFs by Type Providers appear as indicated by the October IPF PSF
Total number of facilities: 1,670
6
IPFQR Program Update
Program Changes and Lessons Learned
IPFQR Program Measures
7
Measure FY
2014
FY
2015
FY
2016
FY
2017
FY
2018
Measure
Type
Sampling
Allowed
HBIPS-2: Hours of Physical Restraint Use X X X X X Chart-
Abstracted No
HBIPS-3: Hours of Seclusion Use X X X X X Chart-
Abstracted No
HBIPS-4: Patients Discharged on Multiple Antipsychotic
Medications X X X blank blank
Chart-
Abstracted Yes
HBIPS-5: Patients Discharged on Multiple Antipsychotic
Medications with Appropriate Justification X X X X X
Chart-
Abstracted Yes
HBIPS-6: Post-Discharge Continuing Care Plan Created X X X X blank Chart-
Abstracted Yes
HBIPS-7: Post-Discharge Continuing Care Plan
Transmitted to Next Level of Care at Discharge X X X X blank
Chart-
Abstracted Yes
Transition Record with Specified Elements Received by
Discharged Patients blank blank blank blank X
Chart-
Abstracted Yes
Timely Transmission of Transition Record blank blank blank blank X Chart-
Abstracted N/A
Screening for Metabolic Disorders blank blank blank blank X Chart-
Abstracted N/A
IPFQR Program Measures
8
Measure FY
2016
FY
2017
FY
2018 Measure Type
Sampling
Allowed
SUB-1: Alcohol Use Screening X X X Chart-Abstracted Yes
SUB-2: Alcohol Use Brief Intervention Provided or Offered and
SUB-2a: Alcohol Use Brief Intervention blank blank X Chart-Abstracted Yes
TOB-1: Tobacco Use Screening blank X X Chart-Abstracted Yes
TOB-2: Tobacco Use Treatment Provided or Offered and TOB-2a:
Tobacco Use Treatment bland X X Chart-Abstracted Yes
TOB-3: Tobacco Use Treatment Provided or Offered at Discharge
and
TOB-3a: Tobacco Use Treatment at Discharge
blank blank X Chart-Abstracted Yes
IMM-2: Influenza Immunization blank X X Chart-Abstracted No
Influenza Vaccination Coverage among Healthcare Personnel blank X X Web-Based reported
on NHSN website No
Use of Electronic Health Record X X X Structural Web-
Based N/A
Assessment of Patient Experience of Care X X X Structural Web-
Based N/A
FUH: Follow-Up After Hospitalization for Mental Illness X X X Claims-Based N/A
IPFQR Program Measure Results
9
Notes:
• Lower values for HBIPS-2 and HBIPS-3 indicate better performance.
• FY 2016 measure results are preliminary.
IPFQR Program Measure Results
Quality Measures
10
Notes:
• HBIPS-4 and HBIPS-5 measure data were blinded for FY 2014.
• Lower values for HBIPS-4 indicate better performance.
• FUH Measure data will be suppressed for FY 2016 due to calculation challenges.
• FY 2016 measure results are preliminary.
9.3% 9.4%
29.7% 36.7%
73.5% 76.9%
84.8%
62.7% 69.6%
77.5% 71.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
FY15 FY16 FY15 FY16 FY14 FY15 FY16 FY14 FY15 FY16 FY16
HBIPS-4Patients Discharged
on MultipleAntipsychoticMedications
HBIPS-5Patients Discharged
on MultipleAntipsychoticMedications
with AppropriateJustification
HBIPS-6Post DischargeContinuing Care
Plan Created
HBIPS-7Post DischargeContinuing CarePlan Transmittedto Next Level ofCare Provider
SUB-1Alcohol
UseScreening
Perc
en
tag
e (
%)
IPFQR Program Measure Results
11
Structural Measures
Ce
rt. E
HR
3
3.2
%
No
n-C
ert
. E
HR
6
4.1
%
Paper 2.7%
0%
50%
100%
FY16
Pe
rce
nt
Mo
st
Co
mm
on
ly U
se
d M
eth
od
Use of EHR by Type
Ye
s
29
.2%
N
o
70
.8%
0%
50%
100%
FY16
Pe
rce
nt
Us
ed
HIS
P
Use of EHR HISP
Ye
s
72
.3%
N
o
27
.7%
0%
50%
100%
FY16
Pe
rce
nt
Off
ere
d E
oC
As
se
ss
me
nt
Experience of Care
Assessment Notes:
• Lower values for HBIPS-2 and HBIPS-3 indicate better performance.
• FY 2016 measure results are preliminary.
Changes to the IPFQR Program
12
Program
Year Measures Participating IPFs
Year 1 (FY 2014) 6 1,815
Year 2 (FY 2015) 6 1,725
Year 3 (FY 2016) 10 1,670
Year 4 (FY 2017) 13 blank
Year 5 (FY 2018) 16 blank
• To reduce burden, IPFs no longer submit measure data by age
strata and quarter.
• Starting with the 2016 data submission period, IPFs will submit
non-measure data, including total annual discharges overall,
by age strata, payer, and diagnostic categories.
Changes to the IPFQR Program
• Starting with the 2017 data submission period, IPFs will have the
option to use the existing sampling guidelines or the global
sampling option outlined in the FY 2016 IPF PPS Final Rule.
• A list of the measures for which sampling is allowed includes: HBIPS-5
SUB-1/-2/-2a
TOB-1/-2/-2a/-3/-3a
IMM-2
Transition Record with Specified Elements Received by Discharged
Patients
Timely Transmission of Transition Record
Screening for Metabolic Disorders
13
Implicit Values
A high quality/performing IPF:
• Maximizes use of best/evidence-based practices
• Treats the whole patient, not just the admitting diagnosis
• Continues to engage with the patient after discharge with
respect to issues such as follow through with referrals,
treatment adherence, and health status
• Promotes recovery-oriented care and patient and
family/caregiver participation in treatment and planning
14
Misperceptions about Measures
•
• Performance is related to payment.
• Best performance results in a “0 or 100” score.
15
A measure is a program requirement.
Frequent Concerns About Measure Requirements
16
• Additional burden from collection or reporting
• Some measures not endorsed by either the National
Quality Forum (NQF) and/or the Measure
Applications Partnership (MAP)
• Some IPFs feel there are measure specifications
beyond the scope of psychiatric hospitals’
responsibility
• Variation
What happens to patients post-discharge is not an IPF role
17
IPFQR Program Update
IPFQR Key Informant Survey Preliminary Results
Overview
• CMS’ IPFQR program staff conducted interviews
with advocates, professional associations, and
government agencies concerned with inpatient
psychiatric care
• Results from the interviews will be used to:
Better understand the impacts of the program
Improve IPF policy and quality measurement
18
External • National Association of Psychiatric
Health Systems (NAPHS)
• National Association of State Mental
Health Program Directors
(NASMHPD) Research Institute
• National Council for Behavioral Health
• National Association of State Alcohol
and Drug Abuse Directors
(NASADAD)
• Mental Health America (MHA)
• American Hospital Association (AHA)
• American Psychiatric Association
(APA)
• National Alliance on Mental Illness
(NAMI)
• Dr. Harold Pincus
Key Informants
Internal • Veterans Health Administration
(VHA)
• Health Resources and Services
Administration (HRSA)
• Substance Abuse and Mental
Health Services Administration
(SAMHSA)
• Assistant Secretary for Planning and
Evaluation (ASPE)
• Agency for Healthcare Research
and Quality (AHRQ)
• The National Institute of Mental
Health (NIMH)
19
Quantitative Results
20
Interviewees were asked to rate each area from
1 (least important) to 5 (most important)
Measure Area Total Average External Average Internal Average
Discharge 4.83 (1) 4.94 (1) 4.67 (1)
Patient Safety 4.64 (2) 4.63 (2) 4.67 (1)
Psychotropic prescribing 4.50 (3) 4.56 (3) 4.42 (5)
Recovery-oriented clinical care 4.20 (4) 4.11 (5) 4.33 (6)
Admission/intake 4.13 (5) 4.17 (4) 4.08 (8)
Counseling/psychotherapy 4.13 (5) 3.89 (7) 4.50 (4)
Non-psychiatric comorbidities 4.04 (7) 3.89 (7) 4.30 (7)
Preadmission 3.93 (8) 4.11 (5) 3.60 (9)
Post-discharge 3.73 (9) 3.17 (9) 4.58 (3)
Affordable care 3.13 (10) 3.00 (10) 3.33 (10)
Numbers in parentheses indicate rank.
Qualitative Results: Themes
The following themes were identified in stakeholders’
qualitative comments: • Quality should be measured across the continuum of care, with IPFs
focusing on warm hand-offs between providers.
“Increasing IPF accountability for what happens to patients after discharge
could be improved. Since hospital stays are relatively short, greater emphasis is
needed on managing transitions to outpatient care and what can be done to
prevent patients from falling through cracks and ending-up back in the hospital.”
– Patient Advocacy Organization
“The program should focus upon coordinated care and connection with
providers upon discharge . . . Continuity of care and active care coordination is
a huge issue.” – Provider Advocacy Organization
“There should be more measures around transition to and from IPFs, ensuring
continuity of care, post-discharge monitoring, and follow-up.” – HHS Agency
21
Qualitative Results: Themes cont.
• Opportunity exists to better integrate CMS/HHS behavioral health
programs.
“CMS and others (like SAMHSA) should support a common language and
common format for quality reporting. Defining a common understanding and
measurement strategy is key and takes time.” – Advocacy Organization
“We’d like to see improved communications with the field, specifically
regarding long-range planning about where we want to get to [regarding
quality].” – Provider Advocacy Organization
“It would be great to have measures that go across [government] programs.”
– HHS Agency
• Medical and psychiatric conditions should be treated together.
“Measures should look at a patients' whole-health (thorough physical
examination) and not just psychiatric issues . . . Underlying issues can
manifest with psychiatric symptoms. “ – Patient Advocacy Organization
22
Qualitative Results: Measures
Stakeholders also identified future measures and
measure concepts in the following main areas: • Patient safety/assaults
“A patient’s number one concern is safety.” – Provider Advocacy Organization
“There are concerns about the number of violent incidences in IPFs . . . we
support a measure of assaults.” – Provider Advocacy Organization
“We recommend measuring assaults by other patients and staff.” – Patient
Advocacy Organization
• Patient experience
“We are the most concerned about patient experience and whether the patient
was treated respectfully. The program needs a uniform measure of patient
experience.” – Patient Advocacy Organization
“We are interested in the development of a patient perception measure.”
– Provider Advocacy Organization
“Patient experience is a gap.” – HHS Agency
23
Qualitative Results: Measures cont.
• Access to care “The program should include measures of access to inpatient care, such
as measuring the time between referral to inpatient treatment and actual
admission.” – HHS Agency
“Our biggest concern is with the access to treatment by the seriously
mentally ill.” – HHS Agency
• Outcome measures, in general “Members would like to see more incentives/accountability for outcomes.”
– Patient Advocacy Organization
“Discharge measures should be clearly tied to outcomes.” – Provider
Advocacy Organization
“We should be shifting the paradigm of quality measurement to focus on
outcomes rather than processes.” – Agency
24
25
IPFQR Program Update
New Measure Development
Contract Purpose and Scope
Development, maintenance, reevaluation, and
implementation of quality measures for the IPFQR
Program, including:
• Development of up to eight measures and e-specification of up
to four measures over the project period of performance
(FY 2015–FY2018)
• Maintenance and reevaluation of measures in the IPFQRP
• Support of the rulemaking process, dry runs, and other
measure implementation activities
• Coordination of measure development, maintenance, and
implementation activities with other measure stewards
26
Overview of the Measure Development Process
27
Environmental Scan/Gap Analysis
TEP assessment of measure topics
Patient/caregiver focus groups and
interviews
Targeted literature review on
prioritized topics
Measure concept business case development
TEP evaluation of measure concepts
Federal partner input on measure
concepts
CMS selection of measure concepts for development
Measure Testing Public Comment Final
Specifications
New Measure Development for FY2016: Medication Reconciliation at Admission
28
Measure Type: Process
Measure Description: Percent of IPF admissions for which
mediation reconciliation was completed on admission for each
prescription/non-prescription product, including medication
name, dose, route, frequency, and purpose
Importance of Measure: Evidence suggests that accurate
medication history/reconciliation reduces medication errors
and ADEs
Patient/Caregiver Perspective: Encourage patient/caregiver
engagement in the medication reconciliation process which
allows them to express concerns and preferences regarding
medication use
New Measure Development for FY2016: Medication Continuation within 30 Days of Inpatient Discharge
29
Measure Type: Process
Measure Description: Percent of IPF discharges for which
patients were dispensed pharmacotherapy treatment within
30 days of discharge for three specific conditions: major
depressive disorder, schizophrenia, and bipolar disorder
Importance of Measure: Continuation of evidence-based
medications has been shown to reduce relapse and improve
rehospitalization rates
Patient/Caregiver Perspective: Consistently noted the
desire for better discharge planning and care continuity
including medication management and regular follow-up
New Measure Development for FY2016: Opioid- or Psychotropic-Related Adverse Drug Events
Measure Type: Outcome
Measure Description: Percent of IPF discharges for which
patients had at least one adverse drug event (ADEs) related
to opioid OR psychotropic use during the hospitalization
Importance of Measure: Reducing ADEs is a national
priority
Patient/Caregiver Perspective: Monitoring side effects
related to medication use is important, providers should listen
to patient’s concerns and preferences about medication use
30
Contact Information
• Jeffrey A. Buck, PhD
• Rebecca Kliman, MPH
• Vinitha Meyyur, PhD
• Evette Robinson, MPH
31
