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P. 1028
b. Proposed New Quality Measures for the FY 2016 Payment Determination and
Subsequent Years
We are proposing three new measures for the FY 2016 payment determination
and subsequent years for the IPFQR Program. The measures are: (1) SUB-1: Alcohol
Use Screening (Submitted for NQF review); (2) SUB-4: Alcohol & Drug Use: Assessing
Status After Discharge (Submitted for NQF review); and (3) Follow-Up After
Hospitalization for Mental Illness (FUH) (NQF #0576).
The three proposed measures were included in a publicly available document
entitled “List of Measures under Consideration for December 1, 2012” in compliance
with section 1890A(a)(2) of the Act, and they were reviewed by the MAP in its “MAP
Pre-Rulemaking Report: 2013 Recommendations on Measures Under Consideration by
HHS,” which is available on the NQF Web site at
http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partn
ership.aspx. We considered the input and recommendations provided by the MAP in
selecting measures to propose for the IPFQR Program at this time. The MAP supported
the inclusion of the third proposed measure in the IPFQR Program, and supported the
direction of the first two measures, noting that their recommendation is contingent on
NQF endorsement. The first two measures were submitted to the NQF in 2012.
Currently, the dates for their review have not been established.
The first two of these measures have been developed by and are maintained by
The Joint Commission (TJC) (the measure steward) and the third measure has been
developed by and is maintained by the National Committee for Quality Assurance
(NCQA) (the measure steward). These measures are appropriate for the purposes of
assessing the quality of inpatient psychiatric services and align with National Quality
Strategy goals of promoting effective prevention and treatment practices (clinical quality
of care), and promoting effective communication and coordination of care. Technical
specifications for measures “SUB-1: Alcohol Use Screening” and “SUB-4: Alcohol &
Drug Use: Assessing Status After Discharge” can be found on the TJC Web site at:
https://manual.jointcommission.org/bin/view/Manual/WebHome. Technical
specifications for the measure “Follow-Up After Hospitalization for Mental Illness”
(FUH) (NQF #0576) can currently be found on the NCQA Web site at:
http://www.ncqa.org/portals/0/FollowUp%20After%20Hospitalization%20for%20Mental%20Illness.pdf.
The three proposed measures for FY 2016 and subsequent years are described in
more detail below.
(1) SUB-1: Alcohol Use Screening (NQF Review Pending)
Individuals with mental health conditions experience substance use disorders
(SUDs) at a much higher rate than the general population. Individuals with the most
serious mental illnesses have the highest rates of such disorders. Co-occurring SUDs
often go undiagnosed and, without treatment, contribute to a longer persistence of
disorders, poorer treatment outcomes, lower rates of medication adherence, and greater
impairments to functioning. Accordingly, this proposed measure, and the one
immediately following, are intended to assess efforts by IPFs to screen for the most
common type of such disorder, alcohol abuse, and to follow up after discharge with
individuals who screen positive for alcohol abuse or who received a diagnosis of alcohol
or drug disorder during the inpatient stay.
In late 2008, TJC received funding from the Partnership for Prevention and HHS’
Substance Abuse and Mental Health Services Administration (SAMHSA) to develop,
specify, and test standardized performance measures addressing alcohol screening and
cessation counseling. Four alcohol/substance use performance measures were pilot tested
in the spring/summer of 2010. The four alcohol/substance use measures (SUB measure
set) were approved as a core measure set for use in TJC’s accreditation programs
(http://www.jointcommission.org/core_measure_sets.aspx). The SUB measures can be
found in the TJC’s Specification Manual for National Hospital Inpatient Quality
Measures at: https://manual.jointcommission.org/bin/view/Manual/WebHome.
The SUB-1: Alcohol Use Screening proposed measure assesses the number of
patients 18 years of age and older who were screened for alcohol use using a validated
screening questionnaire for unhealthy drinking during their inpatient stay, and is reported
as a percentage. The numerator includes the number of patients who were screened for
alcohol use using a validated screening questionnaire for unhealthy drinking. The
denominator includes the number of hospitalized inpatients 18 years of age or older.
Higher rates on the measure are indicative of better performance. The measure excludes
the following populations: patients younger than 18, cognitively impaired patients, and
patients admitted for less than 1 day or greater than 120 days.
This measure is specified for collection through chart abstraction. We are
proposing the form, manner, and timing of collection in section IX.D.9. of the preamble
of this proposed rule. Full specifications for this measure are available at:
https://manual.jointcommission.org/bin/view/Manual/WebHome.
The SUB-1: Alcohol Use Screening proposed measure meets the measure
selection exception requirements for the IPFQR Program under 1886(s)(4)(D)(ii) of the
Act as previously discussed in Section 4 (Considerations in Selecting Quality Measures)
of this rule. Although the proposed measure is not currently NQF-endorsed, we
considered available measures that have been endorsed or adopted by a consensus
organization and found no other feasible and practical measures on the topic of substance
use disorder screening for the inpatient population.
We invite public comment on this proposed measure.
(2) SUB-4: Alcohol and Drug Use: Assessing Status After Discharge (NQF Review
Pending)
The SUB-4: Alcohol and Drug Use proposed measure assesses whether
discharged patients are contacted between 7 and 30 days after hospital discharge in order
to collect post-discharge follow-up information regarding their alcohol or drug use status.
The measure applies to patients 18 years of age or older who screened positive for
alcohol abuse, or who received a diagnosis of alcohol or drug disorder during their
inpatient stay. The numerator includes the number of discharged patients that are
contacted between 7 and 30 days after hospital discharge and follow-up information
regarding alcohol or drug use status is collected. The denominator includes the number
of discharged patients 18 years of age and older who screened positive for alcohol abuse
or who received a diagnosis of alcohol or drug use disorder during their hospital stay.
Higher rates on the measure are indicative of better performance.
The following patients are excluded from the measure:
● Patients less than 18 years of age;
● Patients who are cognitively impaired;
● Patients who were not screened or refused to be screened for alcohol use;
● Patients who expired;
● Patients who have a duration of stay less than or equal to 1 day or greater than
120 days;
● Patients who do not screen positive for alcohol abuse;
● Patients discharged to another hospital;
● Patients who left against medical advice;
● Patients discharged to another health care facility;
● Patients discharged to home or other health care facility for hospice care;
● Patients who do not reside in the United States;
● Patients who do not have a phone or cannot provide any contact information;
● Patients discharged to a detention facility, jail, or prison; and
● Patients who are readmitted within the follow-up time frame.
This measure is specified for collection through chart abstraction. We are
proposing the form, manner, and timing of collection in section IX.D.9. of the preamble
of this proposed rule. Full specifications for this measure are available at:
https://manual.jointcommission.org/bin/view/Manual/WebHome
The SUB-4: Alcohol and Drug Use: Assessing Status After Discharge proposed
measure meets the measure selection exception requirements for the IPFQR Program
under section 1886(s)(4)(D)(ii) of the Act as previously discussed in section IX.D.4. of
the preamble of this proposed rule. Because this measure is not currently NQF-endorsed,
we considered other available measures that have been endorsed or adopted by a
consensus organization. We found no other feasible and practical measures on the topic
of post-discharge alcohol and drug assessment for inpatients who screened positive for
substance abuse.
We invite public comment on this proposed measure.
(3) Follow-Up After Hospitalization for Mental Illness (FUH) (NQF #0576)
In summary, we are retaining all six of the chart-abstracted measures previously
adopted for the FY 2014 payment determination and subsequent years. Also, for the
FY 2016 payment determinations and subsequent years, we are proposing the addition of
three new chart-abstracted measures for the IPFQR Program: (1) SUB-1: Alcohol Use
Screening (NQF review pending); (2) SUB-4: Alcohol & Drug Use: Assessing Status
After Discharge (NQF review pending); and (3) Follow-Up After Hospitalization for
Mental Illness (FUH) (NQF #0576).
We are proposing the collection requirements for these measures in the “form,
manner, and timing” section (section IX.D.9.) of the preamble of this proposed rule. The
table below lists the previously adopted measures for the FY 2014 payment determination
and subsequent years and the proposed additional measures for the FY 2016 payment
determination and subsequent years.