Percentage of Inpatient Rehabilitation Facility Patients Whose Functional Abilities Were Assessed and Functional Goals Were Included in Their Treatment Plan

Identifying Attributes

Care Settings
Rehabilitation Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)
Type of Quality Indicator
Process
IOM Quality Dimension
Person-Centredness
Domain
Person-Centred Care

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
No
Risk Adjustments

None

Stratifications

None

Data Attributes

Type of Data Collection
Standardised clinical data
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
Quarterly
Frequency of Data Collection in Days
91
Reporting Methods

Internet Quality Improvement and Evaluation System (iQIES).

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
Indicator Has Recommended Targets
Yes

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.

Link to Measurement Tools

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)

Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025