Frequently Asked Questions for the IPFQR Program
Existing Measures
HBIPS-2:
1. Question: Does the term “transitional hold” count as a restraint?
Answer: A physical restraint is any manual method, physical or mechanical device, material, or equipment that is used as a restriction to manage a patient’s behavior or restrict freedom of movement, and is not a standard treatment for the patient’s condition. A transitional hold would be considered a form of restraint.
HBIPS-4 through -7:
1. Question: The chart notes the patient is not a resident of the United States, has no benefits, and is not entitled to follow up mental health services. Even though a next level of care provider referral was made, there is no place to transmit the care plan. Should “refusal of next care provider” be selected for the first care plan data element? Or should it be documented “referral made” but “care plan not transmitted?” Neither one of these options seem accurate.
Answer: Beginning with 1/1/15 discharges, for the data element Patient Referral to Next Level of Care Provider, allowable value 3 (the medical record contains documentation that the patient’s residence is not in the USA, and they are returning to another country after discharge) is the appropriate response and will exclude the case from the discharge measures. For 2014 discharges, allowable value 4 (documentation that the patient was not referred to the next level of care provider) is the correct response.
2. Question: Two separate patients were admitted to the behavioral health unit and both patients left against medical advice (AMA) before seeing a physician. There is not a discharge summary regarding either of these visits since the physician never saw them. Could these cases be considered as elopement since they left without treatment?
Answer: It is up to the facility to determine, per their policy, whether a patient is considered to have left against medical advice (AMA) or whether it is considered an elopement. However, ALL patients leaving AMA should be offered a referral to a next level of care provider. If the patient refuses, the abstractor should answer accordingly (allowable value 2 for Patient Referral to Next Level of Care Provider).
HBIPS-6 through -7
1. Question: For patients being readmitted within five days, is the exclusion for readmission to the psych facility or to anywhere in the facility as a whole?
Answer: It is readmission to the facility as a whole (both inpatient and IPF patients). Since facilities have up to five days to send the Continuing Care Plan (CCP) after discharge, those patients readmitted within 5 days after discharge are excluded. This new denominator exclusion was added to HBIPS-6 and -7 beginning with January 2015 discharges.
2. Question: A hospital has two campuses - the main hospital and the Inpatient Psychiatric Hospital. If a psychiatric inpatient is transferred to the main campus ER and gets admitted to inpatient status at the main campus with a new diagnosis, is value 1 the correct response for the Continuing Care Plan (CCP) data elements? The Notes for Abstraction state, “If the hospital has an electronic medical record (EMR) and the next level of care provider has access to the complete hospital EMR, select allowable value 1.”
Answer: If the hospital has an electronic medical record (EMR) and the next level of care provider has access to the complete hospital EMR, select allowable value 1 for the Continuing Care Plan (CCP) data elements if the medical record contains documentation that the next level of care provider has access to the EMR.
SUB-1
1. Question: Patient was seen in the ER where she was noted to be "intoxicated, but no blood alcohol level was drawn until the next day.” Results were negative and she was admitted to the psychiatric unit. Per the notes for abstraction for data element Alcohol Use Status, “If patient has a blood alcohol test indicative of acute intoxication, select value 2." Should value 2 be selected based on the physician’s assessment of intoxication or does there have to be a blood test? The patient was not later screened for alcohol use after sober.
Answer: There does not have to be a blood alcohol level drawn for this measure. The physician documentation did not reference the blood alcohol level and acute intoxication, so it cannot be used to select allowable value 2. An alcohol use screen should have been performed within the first three days of admission. If a screen was not performed, select allowable value 6.
SUB-1 (continued)
2. Question: Is the blood alcohol test considered a validated screening tool?
Answer: No. The blood alcohol test does not take the place of a validated screening tool. However, the result of the test can indicate acute intoxication, which allows the abstractor to select allowable value 2.
3. Question: If the patient is asked “Do you drink alcohol?” and they answer “No,” can we use this as our validated tool?
Answer: This would be an example of a prescreening question, which may be used in order to identify a non-drinker and thus eliminate the patient from further administration of a validation tool. Choose allowable value 1 for the data element Alcohol Use Status when provided with a negative response to the prescreening question. Further screening with a validated screening tool should be done on those patients who do drink to determine if there is a need for intervention.
4. Question: If the patient arrives in the ER and is screened with an appropriate tool and then gets admitted to a Behavioral Health Unit (BHU), does the patient need to be re-screened?
Answer: No, the patient does not need to be re-screened. To meet the intent of the Alcohol Use Screening measure (SUB-1), the patient needs to be screened with a validated tool within the first three days of admission.
Assessment of Patient Experience of Care Measure
1. Question: How will this question be asked?
Answer: This is an attestation measure. It assesses whether IPFs administer a detailed assessment of patient experience of care using a standardized collection protocol and a structured instrument. If the facility answers “yes,” the name of the survey administered is to be entered.
2. Question: What is considered a standardized collection protocol to assess patient experience?
Answer: It means that the administration of the instrument occurs under rules or guidelines that ensure or promote comparability of individual responses.
Use of Electronic Health Record
1. Question: How will this measure be collected?
Answer: The facility will attest to one of three statements that best describes the facility’s typical use of an EHR system (excluding the billing system) during the reporting period, and whether the use includes the exchange of interoperable health information with a health information service provider. The three statements are as follows:
a. The facility most commonly used paper documents or other forms of information exchange (for example, email) not involving the transfer of health information using EHR technology at times of transitions in care.
b. The facility most commonly exchanged health information using non-certified EHR technology (that is, not certified under the ONC HIT Certification Program) at times of transitions in care.
c. The facility most commonly exchanged health information using certified EHR technology (certified under the ONC HIT Certification Program) at times of transitions in care.
The attestation should be based on the hospital’s activities as of December 31 of the reporting year.
2. Question: What does the attestation ask?
Answer: It asks which of the three statements best describes the facility’s typical use of an EHR system (excluding the billing system) during the reporting period, and whether the use includes the exchange of interoperable health information with a health information service provider.
3. Question: What timeframe is used?
Answer: The attestation should be based on the hospital’s activities as of December 31 of the reporting year.
New Measures for CY 2015
IMM-2
1. Question: When is the reporting period for IMM-2?
Answer: Since this measure covers vaccination during the influenza season, data collection (data reporting) will occur only during that time, October 1, 2015 through March 31, 2016. Data submission will occur July 1- August 15, 2016.
2. Question: How do we collect the data for IMM-2?
Answer: For the purposes of the IPF Quality Reporting Program, IMM-2 is a chart abstracted measure and includes only those patients admitted to the IPF. Facilities will submit data via the QualityNet Portal July 1 – August 15, 2016.
3. Question: How is IMM-2 going to be reported for the IPFs?
Answer: Data collection will start with the 2015 to 2016 influenza season (October 1, 2015 to March 31, 2016) with submission July 1- August 15, 2016. Reporting on Hospital Compare will occur in April 2017.
Influenza Vaccination Coverage Among Healthcare Personnel
1. Question: How is this measure reported?
Answer: IPFs will use the CDC National Healthcare Safety Network (NHSN) infrastructure and protocol to report the measure for the IPFQR program. It will be necessary to perform set up prior to reporting. Step-by-step instructions are available at http://www.cdc.gov/nhsn/acute-care-hospital/setup.html . An operational guidance document to assist with reporting this measure is posted on the CDC website at http://www.cdc.gov/nhsn/acute-care-hospital/hcp-vaccination/index.html.
Follow-Up After Hospitalization for Mental Illness (FUH)
1. Question: How will this measure be calculated?
Answer: CMS will calculate this measure by linking Medicare Fee-For-Service (FFS) Parts A & B claims data. Details concerning the calculation of the measure are available in the program manual.
Follow-Up After Hospitalization for Mental Illness (FUH) (continued)
2. Question: How is the FUH measure abstracted?
Answer: The FUH measure does not require data abstraction or reporting by the IPF. CMS will calculate this measure by linking Medicare Fee-For-Service (FFS) Parts A & B claims data.
TOB-1
1. Question: Where can the TOB specifications be found, since they are not on the Joint Commission website?
Answer: The TOB specifications are found in the Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15) located at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228773989482 .
2. Question: Will documentation of "smoker" or "smokeless" tobacco use suffice for type of tobacco product used?
Answer: Yes. The use of "smoker" would equate to cigarette use and "smokeless tobacco" to the use of smokeless tobacco.
3. Question: Is a specific screening tool recommended or required for the TOB measures for FY2017 IPFQR?
Answer: There is no recommended or required screening tool for the TOB measures.
4. Question: Which healthcare providers can complete the screening for tobacco use and who can provide the initial counseling within the three day window?
Answer: Any healthcare provider can complete the screening for tobacco use and provide the initial counseling.
TOB-2 and -2a
1. Question: What constitutes practical counseling?
Answer: The components of practical counseling require interaction with the patient to address the following: recognizing dangerous situations, developing coping skills, and providing basic information about quitting. More information can be found in the Public Health Service Guideline entitled Counseling Patients to Quit: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/counsel.pdf.
2. Question: Will Nicotine gum or patch prescribed as a PRN medication during the admission qualify as FDA-approved cessation medications offered during admission?
Answer: Those medications are listed in Table 9.1 FDA-Approved Tobacco Cessation Medications, so they qualify as appropriate medications. Per the Notes for Abstraction for data element Tobacco Use Treatment FDA-Approved Cessation Medication, if the nicotine replacement therapy is ordered PRN and the patient does not receive any doses during the hospital stay, select allowable value 2 (the patient refused the FDA-approved tobacco cessation medications during the hospital stay).
3. Question: Does the patient have to sign the counseling/education/referral forms to indicate that they received them or can a nurse document in the chart that this information was provided?
Answer: No. The patient does not need to sign the form as long as the nurse documents it was provided and interaction occurred.
Cognitive Impairment – Applies to SUB-1 and all TOB measures
1. Question: Must the chart specifically state the words "cognitive impairment,” “altered mental status,” or “confused” to select "YES"? Can terms such as “delusional” or “loose associations” be used to determine cognitive impairment?
Answer: There is not an all-inclusive list of terms that can be used to determine cognitive impairment; however, examples of terms that equate to cognitive impairment in the data elements can be found on pages 1-27 (SUB-1) and 1-390 (TOB) of the Alphabetical Data Dictionary of the National Hospital Inpatient Quality Reporting Measures Specifications Manual Release Notes v4.4.
2. Question: Effective January 2015, the data element Cognitive Impairment is no longer in the alphabetical data dictionary. Cognitive impairment is, however, still listed as a denominator exclusion for SUB-1. Please explain how we can exclude
Cognitive Impairment (continued) – Applies to SUB-1 and all TOB measures
cases for cognitive impairment without a data element question and allowable values to guide abstraction?
Answer: Beginning with January 1, 2015 discharges, a new allowable value has been added to the Alcohol Use Status data element. The new allowable value is “7: The patient was not screened for alcohol use during the first three days of admission because of cognitive impairment.” In 2015, cognitive impairment must be present the first three days of admission only, not the entire hospitalization. For the data element Tobacco Use Status, the new allowable value is “6: The patient was not screened for tobacco use during the first three days of admission because of cognitive impairment.”
Sampling
1. Question: Does the initial population for the SUB-1, TOB-1, TOB-2, and TOB-2a measures in the IPFQR program include only inpatient psychiatric patients or all inpatient discharges?
Answer: The initial population includes only the IPF’s population.
Facility/State/National (FSN) Report
1. Question: How do I get my FSN report?
Answer: The Facility/State/National (FSN) report is located in the QualityNet Secure Portal under My Reports. Log in to the QualityNet Secure Portal. Choose Inpatient Psychiatric Quality Reporting Program. Log in to Quality Net using your User ID, Password and Security Code. To run a Hospital Reporting – Inpatient Psychiatric Facility, State, and National Report: