Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Measures Information

The purpose of this webpage is to provide information on the measures reported by LTCHs in accordance with the LTCH QRP. On this page, you will find descriptions of each measure, links to measure specifications, and other measure-related information. This page is revised as measure updates become available.

What are the LTCH QRP measures?

Measures adopted for and removed from the LTCH QRP are listed below. Several are endorsed by the consensus-based entity (CBE) contracted by the Secretary to guide the selection of performance measures for federal health programs. Data for the LTCH QRP measures are collected and submitted through three methods:

• LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS)
• Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
• Medicare Fee-For-Service Claims

LCDS Assessment-Based Measures

Data collected using the LCDS and submitted to the Centers for Medicare & Medicaid Services (CMS) via the Internet Quality Improvement and Evaluation System (iQIES):

LTCH QRP Measure #1. Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) [CMIT Measure ID #00520 (CBE-endorsed)]

This measure was initially finalized in the FY 2014 Inpatient Prospective Payment System (IPPS)/LTCH Prospective Payment System (PPS) Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50874 through 50877). The measure was adopted as an Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) measure in the FY 2016 IPPS/LTCH PPS Final Rule (80 FR 49736 through 49739). Data collection for this measure began on April 1, 2016.

LTCH QRP Measure #2. Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support [CMIT Measure ID #00275 (CBE-endorsed)]

This measure was finalized in the FY 2015 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2014 (79 FR 50298 through 50301). Data collection for this measure began on April 1, 2016.

LTCH QRP Measure #3. Drug Regimen Review Conducted with Follow-Up for Identified Issues – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) [CMIT Measure ID #00225 (not endorsed)]

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57219 through 57223). Data collection for this measure began on July 1, 2018.

LTCH QRP Measure #4. Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury [CMIT Measure ID #000121 (not endorsed)]

This measure was finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published on August 14, 2017 (82 FR 38433 through 38439). Data collection for this measure began on July 1, 2018. This measure replaced Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (CBE #0678).

LTCH QRP Measure #5. Compliance with Spontaneous Breathing Trial (SBT) by Day 2 of the LTCH Stay [CMIT Measure ID #00143 (not endorsed)]

This measure was finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38439 through 38433). Data collection for this measure began on July 1, 2018.

LTCH QRP Measure #6. Ventilator Liberation Rate [CMIT Measure ID #00759 (not endorsed)]

This measure was finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38433 through 38446). Data collection for this measure began on July 1, 2018.

LTCH QRP Measure #7. Transfer of Health (TOH) Information to the Provider Post-Acute Care (PAC) [CMIT Measure ID #00728 (not endorsed)]

This measure was finalized in the FY 2020 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 16, 2019 (84 FR 42527 through 42532). Data collection for this measure began on October 1, 2022.

LTCH QRP Measure #8. Transfer of Health (TOH) Information to the Patient Post-Acute Care (PAC) [CMIT Measure ID #00727 (not endorsed)]

This measure was finalized in the FY 2020 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 16, 2019 (84 FR 42532 through 42535). Data collection for this measure began on October 1, 2022.

LTCH QRP Measure #9. Discharge Function Score [CMIT Measure ID #01698 (not endorsed)]

This measure was finalized in the FY 2024 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 28, 2023. Data collection for this measure began on October 1, 2023.

LTCH QRP Measure #10. COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date [CMIT Measure ID #01699 (not endorsed)]

This measure was finalized in the FY 2024 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 28, 2023. Data collection for this measure will begin on October 1, 2024.

For more detailed information on data collection and submission deadlines, please refer to the LTCH Quality Reporting Data Submission Deadlines webpage. For more information on the data sets and guidance related to the collection and reporting of assessment data, please refer to the LCDS assessment instrument and specifically Chapter 3 of the LCDS Manual located on the LTCH CARE Data Set (LCDS) & LCDS Manual webpage.

CDC NHSN Measures

Data for these measures are submitted via the CDC’s NHSN:

LTCH QRP Measure #11. National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure [CMIT Measure ID #00459 (CBE-endorsed)]

This measure was finalized in the FY 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53616 through 53619). Data submission for this measure began on October 1, 2012.

LTCH QRP Measure #12. National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure [CMIT Measure ID #00460 (CBE-endorsed)]

This measure was finalized in the FY 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53616 through 53619). Data submission for this measure began on October 1, 2012.

LTCH QRP Measure #13. National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure [CMIT Measure ID #00462 (CBE-endorsed)]

This measure was finalized in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50865 through 50868). Data submission for this measure began on January 1, 2015.

LTCH QRP Measure #14. Influenza Vaccination Coverage Among Healthcare Personnel [CMIT Measure ID #00390 (CBE-endorsed)]

This measure was finalized in the FY 2013 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 31, 2012 (77 FR 53630 through 53631). The data submission time frame was revised in the FY 2014 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 19, 2013 (78 FR 50878 through 50881). Data submission for this measure began on October 1, 2014.

LTCH QRP Measure #15: COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) [CMIT Measure ID #00180 (not endorsed)]

This measure was finalized in the FY 2022 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 13, 2021 (86 FR.45438 through 45446). Data submission for this measure began October 1, 2021. This measure was modified in the FY 2024 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 28, 2023. Data collection for the modified measure began on October 1, 2023.

Medicare Fee-For-Service Claims-Based Measures

The following are Medicare Fee-For-Service Claims-based measures. Because claims-based measures can be calculated using data that have already been submitted to the Medicare program for payment purposes, no additional information collection is required from LTCHs.

LTCH QRP Measure #16. Discharge to Community – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) [CMIT Measure ID #00210 (CBE-endorsed)]

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57207 through 57215). Data for this measure began with CY 2016 claims data.

LTCH QRP Measure #17. Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) [CMIT Measure ID #00434 (CBE-endorsed)]

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which, which was published in the Federal Register on August 22, 2016 (81 FR 57199 through 57207). Data for this measure began with CY 2016 claims data.

LTCH QRP Measure #18. Potentially Preventable 30-Days Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) [CMIT Measure ID #00575 (not endorsed)]

This measure was finalized in the FY 2017 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 22, 2016 (81 FR 57215 through 57219). Data for this measure began with CY 2016 claims data.

Measures Removed from LTCH QRP

1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened

As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38433 through 38439), this measure was replaced by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning on July 1, 2018.

2. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay)

This measure was finalized for removal in the FY 2019 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2018 (83 FR 41632 through 41633).

3. National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus Bacteremia Outcome Measure

This measure was finalized for removal in the FY 2019 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2018 (83 FR 41628 through 41630).

4. National Healthcare Safety Network (NHSN) Ventilator-Associated Event (VAE) Outcome Measure

This measure was finalized for removal in the FY 2019 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 17, 2018 (83 FR 41630 through 41632).

5. All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Long-Term Care Hospitals

As finalized in the FY 2018 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 14, 2017 (82 FR 38446 through 38447), this measure was removed from the LTCH QRP beginning with the FY 2019 LTCH QRP.

6. Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function

This measure was finalized for removal in the FY 2024 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 28, 2023. Data collection for this measure ended on October 1, 2023.

7. Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function

This measure was finalized for removal in the FY 2024 IPPS/LTCH PPS Final Rule, which was published in the Federal Register on August 28, 2023. Data collection for this measure ended on October 1, 2023.

Updates

December 1, 2023

LTCH QRP Claims-Based Measures Manual and Accompanying Files – Now Available

The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Claims-Based Measures Manual is now available. The manual serves as a resource used to calculate claims-based measures that are included in the LTCH QRP. The Discharge to Community (DTC)–Post Acute Care (PAC) LTCH QRP (DTC) and Potentially Preventable 30-Day Post-Discharge Readmission Measure for LTCH QRP (PPR) Supplemental Codes file provides both a list of codes used to identify readmission and diagnoses and a list of covariates used in risk adjustment across the DTC and PPR measures. The Medicare Spending Per Beneficiary (MSPB)–PAC LTCH QRP (MSPB LTCH) Covariates file provides a list of covariates used in risk-adjustment for the MSPB LTCH measure. Lastly, the MSPB LTCH Clinically Unrelated Services Exclusion document and MSPB LTCH First Day Service Exclusions files are available. These documents provide a list of services that are excluded from MSPB LTCH measure calculation.

These files can be accessed in the Downloads section of this webpage.

September 19, 2023

Revised LTCH QRP APU Table for FY 2025 and LTCH QRP APU Table for FY 2026

The Fiscal Year (FY) 2024 Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Final Rule (88 FR 58640) revised data collection and submission requirements for the LTCH Quality Reporting Program (QRP) affecting the FY 2025 and FY 2026 QRPs. A revised table providing the data elements that will be required to meet the Annual Payment Update (APU) minimum data completion threshold for the FY 2025 LTCH QRP and the LTCH QRP APU Table for reporting assessment-based Quality Measures (QMs) and standardized patient assessment data elements to CMS affecting FY 2026 APU determination are now available in the Downloads section of this webpage. We also note that the FY 2024 LTCH PPS final rule (88 FR 58640) finalized the requirement for LTCHs to report 100 percent of the required quality measures data and standardized patient assessment data collected using the LCDS on at least 85 percent of all assessments submitted beginning with the FY 2026 QRP (1/1/2024 through 12/31/2024).

September 6, 2023

LTCH QRP Quality Measure Calculations and Reporting User’s Manual V5.0, Change Table, Risk Adjustment Appendix File, and Imputation Appendix File – Now Available

The Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User’s Manual Version 5.0 is now available. This document serves as an update to the specifications used to calculate quality measures that are included in the LTCH QRP. Additionally, the LTCH QRP Measure Calculations and Reporting User’s Manual Change Table Version 5.0 is now available. This document provides a summary of measure-related changes between Version 5.0 of the LTCH QRP Measure Calculations and Reporting User’s Manual and Version 4.0 of the LTCH QRP Measure Calculations and Reporting User’s Manual specified in change table format. Furthermore, the Risk Adjustment Appendix File for the LTCH QRP Measure’s Calculations and Reporting User’s Manual Version 5.0, which contains risk-adjustment values used to calculate the risk-adjusted quality measures are available. Lastly, the Imputation Appendix File for the LTCH QRP Measure’s Calculations and Reporting User’s Manual Version 5.0 is available. This file contains imputed coefficients used to calculate the new Discharge Function Score measure.

These files are effective October 1, 2023 and can be accessed in the Downloads section of this webpage.

Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Archives