Updated 12/2013 Hospital-Based Inpatient Psychiatric Services (HBIPS) Paper Tool for Discharge

Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7

01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)

This paper abstraction tool is provided as an optional, informal mechanism to aid psychiatric facilities and hospital psychiatric units in the collection of the measures for the CMS Inpatient Psychiatric Facility Quality Reporting Program. The tool is designed to collect patient specific data; however, once abstracted, the data will need to be compiled and reported to CMS in aggregate. It should be noted that skip logic is not contained within the paper abstraction tool. If there are any questions or concerns regarding use of this paper abstraction tool, please contact the IPFQR Program Support Contractor .

Birthdate:______/______/______

UTD is not an allowable entry.

Patient Identifier: ______

Admission Date: ______/______/______

UTD is not an allowable entry.

Discharge Date: ______/______/______

UTD is not an allowable entry.

Individual Medical Record Data Collection Tool

Select the applicable Strata based on the Patient Age at Discharge (in years) (Discharge Date – Birth Date) for this record:

_____Age 1 year through 12 years
(Patient Age at Discharge ≥1 year and < 13 years)

_____Age 13 years through 17 years
(Patient Age at Discharge ≥ 13 years and < 18 years)

_____Age 18 years through 64 years
(Patient Age at Discharge ≥ 18 years and < 65 years)

_____Age greater than or equal to 65 years
(Patient Age at Discharge ≥65 years)

During review of the record, the abstractor will be prompted to enter a 0 or a 1 for both the numerator and denominator for the measures below.

Patient Level

HBIPS-4

______Numerator

______Denominator

HBIPS-5

______Numerator

______Denominator

HBIPS-6

______Numerator

______Denominator

HBIPS-7

______Numerator

______Denominator

The information from each medical record will be used to determine the numerator and denominator,which will be aggregated for submission to QualityNet.

HBIPS-4

What was the patient’s discharge disposition? (Discharge Disposition)

_____ 1Home

_____ 2Hospice – Home

_____ 3Hospice – Health Care Facility

_____ 4Acute Care Facility

_____ 5Other Health Care Facility

_____ 6Expired

_____ 7Left Against Medical Advice (AMA)

_____ 8Not Documented or Unable to Determine (UTD)

If Discharge Disposition equals 6,then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-4. Add 0 to the numerator and denominator for HBIPS-4.
If Discharge Dispositionequals1, 2, 3, 4, 5, 7, or 8,then continue and proceed to Psychiatric Care Setting for HBIPS-4.

Did the patient receive care in an inpatient psychiatric setting? (Psychiatric Care Setting)

_____(Yes)The patient received care in an inpatient psychiatric setting.

_____(No)The patient did not receive care in an inpatient psychiatric setting.

If Psychiatric Care Setting equals Yes, then continue and proceed to Patient Referral to Next Level of Care Provider.
If Psychiatric Care Setting equals No, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-4.Add 0 to the numerator and denominator for HBIPS-4.

Is there documentation in the medical record that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting? (Patient Referral to Next Level of Care Provider)

_____ 1The medical record contains documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting.

_____ 2The medical record contains documentation that the patient or guardian refused the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting OR refused to authorize release of information OR readmission within 5 days of discharge.

_____ 3The medical record contains documentation that the patient eloped OR failed to return from leave and was discharged OR that the patient has not yet been discharged from the hospital OR discharged from the hospital to another level of care outside of the hospital system from a setting other than a Psychiatric Care Setting. Residence outside U.S. after discharge.

_____ 4The medical record contains documentation that the patient was not referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting for a reason other than above.

_____ 5The medical record does not contain documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting OR unable to determine from medical record documentation.

If Patient Referral to Next Level of Care Provider equals 3, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-4. Add 0 to the numerator and denominator for HBIPS-4.

If Patient Referral to Next Level of Care Provider equals 1, 2, 4, or 5, then continue and proceed to Number of Antipsychotic Medications Prescribed at Discharge.

What is the documented number of antipsychotic medications prescribed for the patient at discharge? (Number of Antipsychotic Medications Prescribed at Discharge)

_____ (0-99)

_____ UTD

If Number of Antipsychotic Medications Prescribed at Discharge equals 0, the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-4. Add 0 to the numerator and denominator for HBIPS-4.

If Number of Antipsychotic Medications Prescribed at Discharge equals 1,then the case will be included(Measure Category Assignment of “D”). Stop abstracting. Add 1 to the denominator for HBIPS-4. Add 0 to the numerator for HBIPS-4.
If Number of Antipsychotic Medications Prescribed at Discharge is greater than or equal to 2or equals UTD, the case will be included (Measure Category Assignment of “E”). Stop abstracting. Add 1to BOTH the numerator and denominator for HBIPS-4.

HBIPS-5

What is the Length of Stay? Length of Stay (in days) equalsDischarge Date minus Admission Date.

If Length of Stay is less than or equal to 3days, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-5. Add 0 to the numerator and denominator for HBIPS-5.

If Length of Stay is greater than 3days, then continue and proceed to Discharge Disposition.

What was the patient’s discharge disposition? (Discharge Disposition)

_____ 1Home

_____ 2Hospice – Home

_____ 3Hospice – Health Care Facility

_____ 4Acute Care Facility

_____ 5Other Health Care Facility

_____ 6Expired

_____ 7Left Against Medical Advice (AMA)

_____ 8Not Documented or Unable to Determine (UTD)

If Discharge Disposition equals 6,then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-5. Add 0 to the numerator and denominator for HBIPS-5.

If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8,then continue and proceed to Psychiatric Care Setting for HBIPS-5.

Did the patient receive care in an inpatient psychiatric setting? (Psychiatric Care Setting)

_____ (Yes)The patient received care in an inpatient psychiatric setting.

_____ (No)The patient did not receive care in an inpatient psychiatric setting.

If Psychiatric Care Setting equals Yes, then continue and proceed to Patient Referral to Next Level of Care Provider.

If Psychiatric Care Setting equals No, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-5. Add 0 to the numerator and denominator for HBIPS-5.

Is there documentation in the medical record that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting? (Patient Referral to Next Level of Care Provider)

_____ 1The medical record contains documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting.

If Patient Referral to Next Level of Care Provider equals 3, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-5. Add 0 to the numerator and denominator for HBIPS-5.

If Patient Referral to Next Level of Care Provider equals 1, 2, 4, or 5, then continue and proceed to Number of Antipsychotic Medications Prescribed at Discharge.

What is the documented number of antipsychotic medications prescribed for the patient at discharge? (Number of Antipsychotic Medications Prescribed at Discharge)

_____ (0-99)

_____ UTD

If Number of Antipsychotic Medications Prescribed at Discharge is less than or equal to1, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-5. Add 0 to the numerator and denominator for HBIPS-5.

If Number of Antipsychotic Medications Prescribed at Discharge equals UTD, then the case will be included (Measure Category Assignment of “D”). Stop abstracting. Add 1to the denominator for HBIPS-5. Add 0 to the numerator for HBIPS-5.
If Number of Antipsychotic Medications Prescribed at Dischargeis greater than or equal to2,then continue and proceed to Appropriate Justification for Multiple Antipsychotic Medications.

Is there documentation in the medical record of appropriate justification for the patient being discharged on 2or more antipsychotic medications? (Appropriate Justification for Multiple Antipsychotic Medications)

_____1The medical record contains documentation of a history of a minimum of 3failed multiple trials of monotherapy.

_____2The medical record contains documentation of a recommended plan to taper to monotherapy due to previous use of multiple antipsychotic medications OR documentation of a cross-taper in progress at the time of discharge.

_____3The medical record contains documentation of augmentation of Clozapine.

_____4The medical record contains documentation of a justification other than those listed in Allowable Values 1-3.

_____5The medical record does not contain documentation supporting the reason for being discharged on2 or more antipsychotic medications OR unable to determine from medical record documentation.

If Appropriate Justification for Multiple Antipsychotic Medications equals 1, 2, or 3,then the case will be included (Measure Category Assignment of “E”). Stop abstracting. Add 1to BOTH the numerator and denominator for HBIPS-5.

If Appropriate Justification for Multiple Antipsychotic Medications equals 4 or 5,then the case will be included (Measure Category Assignment of “D”). Stop abstracting. Add 1to the denominator for HBIPS-5. Add 0 to the numerator for HBIPS-5.

HBIPS-6

What was the patient’s discharge disposition? (Discharge Disposition)

_____ 1Home

_____ 2Hospice – Home

_____ 3Hospice – Health Care Facility

_____ 4Acute Care Facility

_____ 5Other Health Care Facility

_____ 6Expired

_____ 7Left Against Medical Advice (AMA)

_____ 8Not Documented or Unable to Determine (UTD)

If Discharge Disposition equals 6,then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-6. Add 0 to the numerator and denominator for HBIPS-6.

If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8,then continue and proceed to Psychiatric Care Setting for HBIPS-6.

Did the patient receive care in an inpatient psychiatric setting? (Psychiatric Care Setting)

_____ (Yes)The patient received care in an inpatient psychiatric setting.

_____ (No) The patient did not receive care in an inpatient psychiatric setting.

If Psychiatric Care Setting equals Yes, then continue and proceed to Patient Referral to Next Level of Care Provider.

If Psychiatric Care Setting equals No, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-6. Add 0 to the numerator and denominator for HBIPS-6.

Is there documentation in the medical record that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting? (Patient Referral to Next Level of Care Provider)

_____ 1The medical record contains documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatientpsychiatric setting.

_____ 3The medical record contains documentation that the patient eloped OR failed to return from leave and was discharged OR that the patient has not yet beendischarged from the hospital OR discharged from the hospital to another level of care outside of the hospital system from a setting other than a Psychiatric Care Setting. Residence outside U.S. after discharge.

If Patient Referral to Next Level of Care Provider equals 1,4, or 5,then continue and proceed to Continuing Care Plan-Principal Discharge Diagnosis.

If Patient Referral to Next Level of Care Provider equals 2 or 3,then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for HBIPS-6. Add 0 to the numerator and denominator for HBIPS-6.

Is there documentation in the medical record of a continuing care plan which includes the principal discharge diagnosis AND was the continuing care plan, including the principal discharge diagnosis, transmitted to the next level of care provider no later than the fifth post-discharge day? (Continuing Care Plan-Principal Discharge Diagnosis)

_____1The medical record contains a continuing care plan which includes the principal discharge diagnosis AND was transmitted to the next level of care provider no later than the fifth post-discharge day.

_____2The medical record contains a continuing care plan which includes the principal discharge diagnosis but was not transmitted to the next level of care provider by the fifth post-discharge day.

_____3The medical record does not contain a continuing care plan which includes the principal discharge diagnosis OR unable to determine from medical record documentation.

If Continuing Care Plan-Principal Discharge Diagnosis equals 3, then the case is included (Measure Category Assignment of “D”). Stop abstracting. Add 1to the denominator for HBIPS-6. Add 0 to the numerator for HBIPS-6. (Note: The case will be included in the denominator at this point;however, for quality and internal review purposes, it is recommended that you abstract and evaluate all of the Continuing Care Plan elements.)

If Continuing Care Plan-Principal Discharge Diagnosis equals 1 or 2,then continue and proceed to Continuing Care Plan-Reason for Hospitalization.

Is there documentation in the medical record of a continuing care plan which includes the reason for hospitalization AND was the continuing care plan, including the reason for hospitalization, transmitted to the next level of care provider no later than the fifth post-discharge day? (Continuing Care Plan-Reason for Hospitalization)

_____1The medical record contains a continuing care plan which includes the reason for hospitalization AND was transmitted to the next level of care provider no later than the fifth post-discharge day.

_____2The medical record contains a continuing care plan which includes the reason for hospitalization but was not transmitted to the next level of care provider by the fifth post-discharge day.

_____3The medical record does not contain a continuing care plan which includes thereason for hospitalization OR unable to determine from medical recorddocumentation.

If Continuing Care Plan-Reason for Hospitalization equals 3,then the case is included (Measure Category Assignment of “D”). Stop abstracting. Add 1to the denominator for HBIPS-6. Add 0 to the numerator for HBIPS-6. (Note: The case will be included in the denominator at this point;however, for quality and internal review purposes, it is recommended that you abstract and evaluate all of the Continuing Care Plan elements.)

If Continuing Care Plan-Reason for Hospitalization equals 1 or 2,then continue and proceed to Continuing Care Plan-Discharge Medications.

Is there documentation in the medical record of a continuing care plan which includes the discharge medications, dosage, and indication for use or states no medications were orderedat discharge AND was the continuing care plan, including discharge medications, transmitted to the next level of care provider no later than the fifth post-discharge day? (Continuing Care Plan-Discharge Medications)

_____1The medical record contains a continuing care plan which includes the discharge medications, dosage, and indication for use or that no medications were ordered at discharge and was transmitted to the next level of care provider no later than the fifth post-discharge day.

_____2The medical record contains a continuing care plan which includes the discharge medications, dosage, and indication for use or that no medications were ordered at discharge but was not transmitted to the next level of care provider by the fifth post-discharge day.

_____3The medical record does not contain a continuing care plan which includes the discharge medications, dosage, and indication for use or that no medications were ordered at discharge OR unable to determine from medical record documentation OR if more than one list exists in the continuing care plan and do not match.