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

Now available! Our new Provider Data Catalog makes it easier for you to search and download publicly reported data. We’ve also improved Medicare’s Compare sites.

Background

Section 3004(a) of the Affordable Care Act established the LTCH QRP. In addition, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the reporting of standardized patient assessment data on quality, resource use, and other measures by Post-Acute Care (PAC) providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and LTCHs.

Care Compare

Care Compare formats the reported data to be readily used by the public, which provides a snapshot of the quality of care for each Long-Term Care Hospital (LTCH). This tool helps families compare some key quality metrics, such as pressure ulcers and readmissions, for over 350 LTCHs across the nation.

LTCH Provider Preview Reports

Before Quality Measure (QM) data is publicly reported on Care Compare, Long-Term Care Hospital’s (LTCHs) have an opportunity to review and correct, as well as preview, their data. A Review and Correct Report is available for providers to access in the Centers for Medicare & Medicaid Services (CMS) reporting system, which will assist them in identifying whether there are any issues with the assessment data already collected and submitted before the applicable quarterly data submission deadlines. The data for the CDC/NHSN measures are not added to the Review and Correct Reports since they are stewarded by the CDC. In lieu of this, the CDC makes accessible to LTCH reports that are similar to the Review and Correct Reports that allow for real-time review of data submissions for all CDC NSHN measures. These are referred to as “CMS Reports” within the “Analysis Reports” page in the NHSN Application. Correction of any errors identified by the facility must be submitted by the final submission deadlines found in the Downloads section of the LTCH Quality Reporting Program (QRP) Data Submission Deadlines webpage.

Following the QRP data submission deadline, a quarterly Provider Preview Report issued by CMS displays the data that will be publicly reported. The purpose of these reports is to give LTCHs the opportunity to review their quality measure results on each quality measure prior to public display on Care Compare. Reports are available in the LTCH Internet Quality Improvement and Evaluation System (iQIES).

LTCHs will have 30 days to preview their quality measure results beginning on the date the reports are available. LTCHs reviewing their preview reports will not be able to correct any of the underlying data, as all data submission/correction deadlines for the targeted period will have passed.

An LTCH may request CMS review of the data contained within their Provider Preview Report, should they believe the quality measure results to be inaccurate (numerator, denominator, or quality metric). All such requests must be made during the 30-day preview period.

Procedures for Requesting CMS Review of an LTCH’s Measure Data:

The Centers for Medicare & Medicaid Services (CMS) encourages Long-Term Care Hospitals (LTCHs) to review their data as provided in the Preview Reports. If an LTCH disagrees with performance data (i.e., the numerator, denominator, or quality metric) contained within their Preview Report, they will have an opportunity to request review of that data by CMS. In order to make such a request, LTCH providers must adhere to the process outlined below:

• Requests for CMS review of data may be submitted to CMS beginning on the day the LTCH Provider Preview Reports are available in the LTCH Internet Quality Improvement and Evaluation System (iQIES) folders through 11:59:59 p.m. PST on day 30 of the preview period.
• CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
• LTCHs are required to submit their request to CMS via email with the subject line: “[Provider Name] LTCH Public Reporting Request for Review of Data” and include their LTCH CMS Certification Number (CCN) (e.g., ABC LTCH Public Reporting Request for Review of Data, XXXXXX). The request must be sent to the following email address: LTCHPRquestions@cms.hhs.gov.
• The email request must include the following information:
  1. LTCH CCN
  2. LTCH Business Name
  3. LTCH Business Address
  4. CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address, i.e. not a post office box
  5. Information supporting the LTCH’s belief that the data contained within the LTCH’s Provider Preview Report is erroneous including, but not limited to quality measures affected, and aspects of quality measures affected (i.e., the numerator, denominator, quality metric)
• After submitting a request, LTCHs will receive an email confirming receipt of their request and may be asked to provide additional information to allow CMS to fully evaluate the request. Such requests from CMS will be sent to the contact person named above.
• CMS will review all requests and provide a response outlining the decision via email. Please note that LTCH-identified errors in data resulting from inaccurate data submissions that an LTCH failed to correct prior to the applicable quarterly data submission deadline are not acceptable reasons for granting reconsideration. Also, CMS will not consider correcting quality measure calculations that providers find to be inaccurate due to missing data that was submitted beyond the applicable quarterly data submission deadline.
• Data that CMS decides/agrees to correct will be corrected and displayed during the subsequent quarterly release of LTCH quality data on Care Compare.
• The data used to generate the LTCH Provider Preview Reports are frozen for the upcoming Care Compare refresh, and corrections submitted after the generation of the LTCH Provider Preview Report will not be reflected until the next quarterly preview report is generated.

Please note: The only method for submitting a request to CMS for review of your preview report data is via email. Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) in the request being submitted to CMS for review.

Updates

March 28, 2024

Care Compare March Refresh of LTCH QRP Data – Now Available

The March 2024 refresh of the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

The data are based on quality assessment data submitted by LTCHs to Centers for Medicare & Medicaid Services (CMS) from Quarter 3, 2022 through Quarter 2, 2023, and for the LTCH Change in Mobility measure, Quarter 3, 2021 through Quarter 2, 2023. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 2, 2022 through Quarter 1, 2023 for the Clostridium Difficile Infection (CDI), Catheter-Associated Urinary Tract Infections (CAUTI), and Central Line-Associated Bloodstream Infections (CLABSI) measures, Quarter 4, 2022 through Quarter 1, 2023 for the Healthcare Personnel (HCP) Influenza measure, and Quarter 2, 2023 for the HCP COVID-19 Vaccine measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022.

In summary, the following LTCH QRP measures will be displayed on Care Compare and PDC during the March 2024 refresh:

• Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support
  • Q3 2021 – Q2 2023 (7/1/2021 – 6/30/2023)
• Drug Regimen Review Conducted with Follow-Up for Identified Issues – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• Compliance with Spontaneous Breathing Trial (SBT) by Day 2 of the LTCH Stay
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• Ventilator Liberation Rate
  • Q3 2022 – Q2 2023 (7/1/2022 – 6/30/2023)
• National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Influenza Vaccination Coverage Among Healthcare Personnel
  • Q4 2022 – Q1 2023 (10/1/2022 – 3/31/2023)
• COVID-19 Vaccination Coverage among Healthcare Personnel
  • Q2 2023 (4/1/2023 – 6/30/2023)
• Discharge to Community – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
• Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
• Potentially Preventable 30-Days Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)

Please visit Care Compare and PDC to view the updated quality data. For questions about LTCH QRP Public Reporting, please email LTCHPRquestions@cms.hhs.gov.

March 15, 2024

LTCH Provider Preview Reports – Now Available

The Long-Term Care Hospital (LTCH) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the June 2024 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by LTCHs from Quarter 4, 2022 through Quarter 3, 2023, and for the LTCH Change in Mobility measure, Quarter 4, 2021 through Quarter 3, 2023. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 3, 2022 through Quarter 2, 2023 for the Clostridium Difficile Infection (CDI), Catheter-Associated Urinary Tract Infections (CAUTI), and Central Line-Associated Bloodstream Infections (CLABSI) measures, Quarter 4, 2022 through Quarter 1, 2023 for the Healthcare Personnel (HCP) Influenza measure, and Quarter 3, 2023 for the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022 for this refresh.

Providers have until April 15, 2024 to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Care Compare. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website. However, providers can request Centers for Medicare & Medicaid Services (CMS) review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

For more information, please visit the CMS LTCH QRP Public Reporting website.

December 20, 2023

Care Compare December Refresh of LTCH QRP Data – Now Available

The December 2023 Refresh of the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

The data are based on quality assessment data submitted by LTCHs to Centers for Medicare & Medicaid Services (CMS) from Quarter 2, 2022 through Quarter 1, 2023, and for the LTCH Change in Mobility measure, Quarter 2, 2021 through Quarter 1, 2023. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 1, 2022 through Quarter 4, 2022 for the Clostridium Difficile Infection (CDI), Catheter-Associated Urinary Tract Infections (CAUTI), and Central Line-Associated Bloodstream Infections (CLABSI) measures, Quarter 4, 2022 through Quarter 1, 2023 for the Healthcare Personnel (HCP) Influenza measure, and Quarter 1, 2023 for the HCP COVID-19 Vaccine measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022.

In summary, the following LTCH QRP measures will be displayed on Care Compare and PDC during the December 2023 Refresh:

• Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital Patients Requiring Ventilator Support
  • Q2 2021 – Q1 2023 (4/1/2021 – 3/31/2023)
• Drug Regimen Review Conducted with Follow-Up for Identified Issues – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Compliance with Spontaneous Breathing Trial (SBT) by Day 2 of the LTCH Stay
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• Ventilator Liberation Rate
  • Q2 2022 – Q1 2023 (4/1/2022 – 3/31/2023)
• National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
  • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
• National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
  • Q1 2022 - Q4 2022 (1/1/2022 – 12/31/2022)
• National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure
  • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
• Influenza Vaccination Coverage Among Healthcare Personnel
  • Q4 2022 – Q1 2023 (10/1/2022 – 3/31/2023)
• COVID-19 Vaccination Coverage among Healthcare Personnel
  • Q1 2023 (1/1/2023 – 3/31/2023)
• Discharge to Community – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
• Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
• Potentially Preventable 30-Days Post-Discharge Readmission Measure for Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)
  • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)

Please visit Care Compare and PDC to view the updated quality data. For questions about LTCH QRP Public Reporting, please email LTCHPRquestions@cms.hhs.gov.

December 15, 2023

LTCH Provider Preview Reports – Now Available

The Long-Term Care Hospital (LTCH) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the March 2024 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by LTCHs from Quarter 3, 2022 through Quarter 2, 2023, and for the LTCH Change in Mobility measure, Quarter 3, 2021 through Quarter 2, 2023. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 2, 2022 through Quarter 1, 2023 for the Clostridium Difficile Infection (CDI), Catheter-Associated Urinary Tract Infections (CAUTI), and Central Line-Associated Bloodstream Infections (CLABSI) measures, Quarter 4, 2022 through Quarter 1, 2023 for the Healthcare Personnel (HCP) Influenza measure, and Quarter 2, 2023 for the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022 for this refresh.

Providers have until January 16, 2024 to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Care Compare. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website. However, providers can request Centers for Medicare & Medicaid Services (CMS) review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

 CMS LTCH QRP Public Reporting website.

LTCH Quality Reporting Program Archives