Percentage of Inpatient Rehabilitation Facility Patients Whose Functional Abilities Were Assessed and Functional Goals Were Included in Their Treatment Plan
Identifying Attributes
Care Settings
Country
Publishing Organisation
Type of Quality Indicator
IOM Quality Dimension
Domain
Defining Attributes
Definition
Percentage of inpatient rehabilitation facility (IRF) patients whose functional abilities were assessed and functional goals were included in their treatment plan.
Numerator
Total number of IRF stay-level records in the denominator meeting the following criteria on the selected functional assessment data: For patients with a complete stay, the record is counted in the numerator if: a. a valid score indicating functional status (01 to 06) or a valid code indicating the activity was not attempted (07, 09, 10, 88) or a "^" indicating items affected by the skip pattern for each of the admission functional assessment items, and1 b. a valid score indicating functional status (01 to 06) or a valid code indicating the activity was not attempted (07, 09, 10, 88) for a discharge goal indicating the patient's expected level of independence, for at least one self-care or mobility item, and c. a valid score indicating functional status (01 to 06) or a valid code indicating the activity was not attempted (07, 09, 10, 88) or a "^" indicating items affected by the skip pattern for each of the discharge functional assessment items. For patients with an incomplete stay, the stay is counted in the numerator if:2 a. a valid score indicating functional status (01 to 06) or a valid code indicating the activity was not attempted (07, 09, 10, 88) or a "^" indicating items affected by the skip pattern for each of the admission functional assessment items, and b. a valid score indicating functional status (01 to 06) or a valid code indicating the activity was not attempted (07, 09, 10, 88) for a discharge goal indicating the patient's expected level of independence, for at least one self-care or mobility item.
1 Admission and discharge functional assessment items included in this measure are three self-care items (GG0130A1/A3, GG0130B1/B3, and GG0130C1/C3) and twelve mobility items (GG0170B1/B3, GG0170C1/C3, GG0170D1/D3, GG0170E1/E3, GG0170F1/F3, GG0170I1/I3, GG0170J1/J3, GG0170K1/K3, GG0170R1/R3, GG0170RR1/RR3, GG0170S1/S3, GG0170SS1/SS3). All functional assessment items are included when selecting a patient's discharge goal (GG0130A2, GG0130B2, GG0130C2, GG0130E2, GG0130F2, GG0130G2, GG0130H2, GG0170A2, GG0170B2, GG0170C2, GG0170D2, GG0170E2, GG0170F2, GG0170G2, GG0170I2, GG0170J2, GG0170K2, GG0170L2, GG0170M2, GG0170N2, GG0170O2, GG0170P2, GG0170R2, GG0170S2). 2 Incomplete stays are defined as those patients (1) discharged to acute care that results in the patient's absence from the IRF for longer than 3 calendar days, (2) who die while in the IRF, (3) who leave the IRF against medical advice, or (4) who had a stay of less than 3 days. All IRF stays that are not classified as incomplete stays are classified as complete stays.
Denominator
The total number of IRF stays with a discharge date during the targeted 12 months (i.e., 4 quarters) time period.
Exclusions
There are no denominator exclusions for this measure.
Use of Risk Adjustment
Risk Adjustments
None
Stratifications
None
Data Attributes
Type of Data Collection
Data Collection Methods
Effective on October 1, 2022, the IRF-PAI Version 4.0 is used to collect and submit assessment data for the IRF QRP. The LTCH QRP creates LTCH quality reporting requirements, as mandated by Section 3004(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. Every year, by October 1, we publish the quality measures LTCHs must report.
Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Internet Quality Improvement and Evaluation System (iQIES).
Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
Source and Reference Attributes
Evidence Source
Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual. Accessed August 3, 2023. Available from: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf.
Centers for Medicare & Medicaid Services (CMS), United States. Inpatient rehabilitation facilities - The Measures. Accessed August 3, 2023. Available from: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures.
Technical Specifications
Technical specifications: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf
Summary of Measures: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures
Inpatient Rehabilitation Facility - Quality Reporting Program measures: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/irf-quality-reporting/irf-quality-reporting-program-measures-information-
Link to Measurement Tools
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)