1. Dexanne B. Clohan, MD SVP & Chief Medical Officer HealthSouth November 14, 2014 IRF Quality Measurement: A Physiatrist’s View

2. CMS IRF Quality Reporting Program (QRP) QRP Initiated: (1) new or worsened pressure ulcers and (2) catheter- associated urinary tract infections New QRP Measures: (3) Flu vaccines for healthcare personnel and (4) patients, (5) 30-day, all-cause unplanned readmission Future QRP Measures: (6) MRSA infections (7) CDI infections What Will Get Measured Next? Function Fall rates Skin Integrity Reimbursement Effects  All quality data submitted to CMS must meet accuracy and completeness thresholds in order to avoid penalty:  Penalty is theoretically “all or nothing” – failing to submit one of the seven QRP measures accurately and completely will result in payment reduction  Penalty is a reduction to a hospital’s Medicare reimbursement update by 2% for the next fiscal year October 1, 2012October 1, 2014January 1, 2015 2

3. New Thresholds Imposed IRF PPS FY 2015 Final Rule Catheter-Related Infections – 100% Completion – CMS must receive 12 months of data from the NHSN system. Pressure Ulcers – 95% Completion – IRF-PAIs must include required QRP data. – 75% Accuracy – CMS will randomly select 5 patient records from 260 IRF providers. IRF-PAIs completed January 1, 2014-September 30, 2014* will be audited for accuracy for FY2016. *Abbreviated 9 month period a result of CY to FY transition 3

4. CMS still adjusting their own documentation requirements Requires accurate, complete, and consistent documentation by clinicians CMS QRP rules go beyond standard clinical practice Documentation CMS revised existing measures CMS is adding new measures at fast pace Continued Changes Patchwork system created by CMS for reporting is not efficient Multiple reporting methods have different timelines and definitions Reportable events are rare Complexity Increased proportion of clinicians’ time spent on paperwork More clinical time being spent on low incidence measures Effect on Staff Why is QRP challenging? 4

5. Reported through IRF-PAI (Inpatient Rehabilitation Facility – Patient Assessment Instrument) Based on CMS Fiscal Year (Oct-Sept) – Pressure Ulcers – Patient Influenza Vaccination Rates Reported through the NHSN (Managed by the CDC) Based on Calendar Year (Jan-Dec) – Catheter-related infections – Personnel Influenza Vaccination Rates – Antibiotic-Resistant Infections MRSA infections CDI Collected via Claims Data – 30-Day Acute Readmission Rates Multiple Reporting Methods 5

6. 6 Reportable Events Clinical Care Only reportable events should be reported Physician diagnosis Clinical treatment Billing codes Meet all criteria and timelines

7. The QRP Guide : Everything You Need to Know to be CMS Compliant A comprehensive and user-friendly document to help manage the task of understanding and complying with this rule contains information regarding the prevention, identification, and reporting of QRP measures. Compiles guidelines, rules and best practices from all sources involved in the inpatient rehab QRP, including: 7 HealthSouth’s Approach  IRF PPS Rule  CMS training  CDC guidelines  NHSN guidelines  IRF-PAI manual  IRF-PAI transmission

8. Training Clinical & Reporting – On-site meetings – Online HealthStream courses – Training webinars (recorded and posted) – QRP Guide – QRP@HealthSouth.com email address QRP@HealthSouth.com

9. Who is Involved? Chief Nursing Officer and Quality Director ultimately responsible for documentation and reporting Infection Control/Wound Care, Employee Health, Human Resources have role in gathering and reporting QRP data HIMS staff enter data into IRF-PAI Medical staff have oversight for clinical care and medical documentation 9

10. Data Analysis CMS has released limited QRP reports through QIESnet, but data can be monitored via IRF-PAI submissions and NHSN reports Strive to improve QRP compliance and clinical quality. Eventually, QRP will shift to pay-for-performance Look for ---or create--- benchmarks 10

11. Patient Safety Impact Engage staff in prevention of pressure ulcers, CAUTIs, and increase in flu vaccinations with a focus on the patient Share the data regarding events, vaccination rates, or the lack thereof! Stabilize processes for assessments and documentation in the medical record to allow staff to enhance clinical practice- not just documentation.

12. Regulatory Burden Patient Benefit