The Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder measure evaluates the percentage of discharges from inpatient or residential treatment for diagnoses of substance use disorders (SUD) among Medicaid or Medicare-Medicaid beneficiaries, aged 18 years and older, which were followed by a treatment service for SUD.
This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.
Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter.
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All visits occurring during the 12-month performance period.
None
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While this clinical quality measure (CQM) has not undergone consensus-based entity (CBE) endorsement, the electronic clinical quality measure (eCQM) collection type for this measure has gone through the CBE process and is outlined below.
Link to endorsement measure record: Documentation of Current Medications in the Medical Record
Impact Summary: This measure supports the Merit-based Incentive Payment System (MIPS) goals of improving the quality and safety of care for patients and promoting higher-value care by ensuring clinicians document a current and complete medication list at each visit, which supports accurate clinical decision-making and helps reduce preventable medication errors and adverse drug events.
Clinician performance has consistently increased from 2021 to 2024, but highlighted improvement is needed among lower-performing clinicians. The analysis showed that a medication documentation rate of 100% is achievable. Based on the PY 2024 data, only 7.7% of the assessed visits lacked documentation of medications. While performance for this measure in MIPS continues to be high, there continues to be instances of poor performance as seen by Decile 1: 3.65 - 78.37.
For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:
Battelle analyzed benchmark values for “Measure_ID”=130 and “CMS eCQM ID”=N/A to generate CQM benchmark data.
About Figure 1: Figure 1 is a boxplot that shows how rates have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of rates. The dots represent the minimum and maximum rates, and the line connecting them shows the range of the rates. The box itself covers the middle 60% of the rates, from the 20th to the 80th percentile. A “+” sign shows the average rate. This type of graph makes overall trends in rates over time as well as the consistency and spread of the results easier to visualize.
Figure 1. Boxplot of Performance Rate by Year
Figure 1 Interpretation: Although each year there are some clinicians with very low performance, the 20th percentile has consistently increased from 87.26% in 2021 to 96.34% in 2024. For this measure, a higher rate indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of rates across deciles for the most recent year with data available.
Table 1. Importance (Decile by Performance Rate, 2024)
| Mean | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Performance Rate | 92.3 | 3.7-78.4 | 78.4-96.3 | 96.3-99.5 | 99.5-100 | 100 | 100 | 100 | 100 | 100 | 100 |
Table 1 Interpretation: More than 80% of clinicians have a performance rate greater than 95%, and more than 60% of clinicians have a rate of 100%. If Decile 8 performance (100%) is used as a plausible, achievable benchmark, and clinicians in Deciles 1 through 4 improved to that level, the estimated percentage of visits with current medications documented in the medical record would increase by about 7.7% (from 92.3% to 100%), potentially leading to better health outcomes for patients.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Link to Endorsement Measure Record: HBIPS-2 Hours of physical restraint use
The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.
The total number of hours that all psychiatric inpatients were maintained in physical restraint.
Numerator Basis: The numerator evaluates the number of hours of physical restraint; however, the algorithm calculates the number of minutes to ensure a more accurate calculation of the measure. Convert the minutes to hours when analyzing and reporting this measure.
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Number of psychiatric inpatient days. Denominator basis per 1,000 hours.
Total leave days
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Link to Endorsement Measure Record: HBIPS-2 Hours of physical restraint use
Impact Summary: This measure supports the Inpatient Psychiatric Facility Quality Reporting Program’s goal of improving patient safety and patient experience by measuring the total number of hours that patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.
Performance has stayed very steady from 2020 to 2024, showing consistent performance among inpatient psychiatric facilities. The mean performance is driven by very high scores in the top two deciles. If the average performance of Decile 3 in 2024 (0.009) is considered a plausible, achievable score, and the facilities in Deciles 4 through 10 improved to reach that score, the estimated rate per 1,000 hours of physical restraint use could decrease, preventing harm that may result from excess restraint use.
For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:
Battelle analyzed all values for “HBIPS-2” not marked as “Not Available” from the corresponding IPFQR_QualityMeasures_Facility.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: This figure shows that performance has been very consistent across the last 5 years, with no discernible improvement or decrease in overall performance. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the number of patient-hours represented within each group for the most recent year with available data. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patient-hours than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller group size may be associated with better performance.
Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 0.340 (1.335) | 0 | 0.001 | 0.009 | 0.021 | 0.040 | 0.073 | 0.118 | 0.212 | 0.436 | 2.465 |
| Facilities | 1,353 | 136 | 135 | 135 | 136 | 135 | 135 | 136 | 135 | 135 | 135 |
| Patient- Hours (1000s) | 28,391 | 709 | 1,796 | 3,047 | 3,770 | 3,771 | 3,086 | 3,180 | 3,046 | 3,218 | 2,768 |
Table 1 Interpretation: The facilities with scores in the lowest 20% (the first two deciles) represent less than 10% of the total patient-hours. This suggests that smaller facilities may tend to perform better. The mean performance is driven by very high scores in the top two deciles. If the average performance of Decile 3 (0.009) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated rate per 1,000 hours of physical restraint use could decrease, preventing harm that may result from excess restraint use.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Measure active in the Inpatient Psychiatric Facility Quality Reporting Program since 2013.
The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.
The total number of hours that all psychiatric inpatients were held in seclusion.
Numerator Basis: The numerator evaluates the number of hours of seclusion; however, the algorithm calculates the number of minutes to ensure a more accurate calculation of the measure. Convert the minutes to hours when analyzing and reporting this measure.
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Number of psychiatric inpatient days Denominator basis per 1,000 hours.
Total leave days
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Link to Endorsement Measure Record: HBIPS-3 Hours of seclusion use
Impact Summary: This measure supports the Inpatient Psychiatric Facility Quality Reporting Program’s goal of improving patient safety and patient experience by measuring the total number of hours that patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.
Performance has stayed very steady from 2020 to 2024, showing consistent performance among inpatient psychiatric facilities. Table 1 shows data from 2024. The 2024 mean score is largely influenced by higher scores in the top two deciles. If the 407 facilities in decile 3, with an average score of 0, represent a plausible and achievable benchmark, then improvement among facilities in Deciles 4 through 10 toward that benchmark could reduce the estimated rate of seclusion use per 1,000 patient hours and help reduce preventable patient harm associated with excess seclusion in the remaining facilities.
For this measure, Battelle reviewed the following publicly available datasets available at Hospitals data archive | Provider Data Catalog:
Battelle analyzed all values for “HBIPS-3” not marked as “Not Available” from the corresponding IPFQR_QualityMeasures_Facility.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: This figure shows that performance has been very consistent across the last 5 years, with no discernible improvement or decrease in overall performance. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the number of patient-hours represented within each group in the most recent year with available data. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller group size may be associated with better performance scores.
Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 0.360 (2.006) | 0 | 0 | 0 | 0.002 | 0.017 | 0.047 | 0.102 | 0.188 | 0.386 | 2.871 |
| Facilities | 1355 | 136 | 135 | 136 | 135 | 136 | 135 | 136 | 135 | 136 | 135 |
| Patient-Hours (1,000s) | 28,401 | 1,650 | 1,940 | 1,920 | 3,945 | 3,403 | 3,196 | 3,166 | 3,696 | 2,815 | 2,669 |
Table 1 Interpretation: The facilities with scores in the lowest 30% (the first three deciles) represent less than 20% of the total patient-hours. This suggests that smaller facilities may tend to perform better. The mean performance is driven by very high scores in the top two deciles. If the average performance of Decile 3 (0) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, the estimated rate per 1,000 hours of seclusion use could decrease, reducing preventable harm to patients that may result from excess seclusion.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Percentage of healthcare personnel (HCP) who receive the influenza vaccination.
The numerator for this measure consists of HCP in the denominator population, who fall into one of the categories below. HCP should be counted as vaccinated if they receive influenza vaccine any time from when it first became available, such as August or September, through March 31 of the following year.
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The denominator for this measure consists of healthcare personnel (HCP) who are physically present in the healthcare facility for at least 1 working day between October 1 through March 31 of the following year. Denominators are to be calculated separately for three required categories of HCP and can also be calculated for a fourth optional category:
None
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Link to Endorsement Measure Record: Influenza Vaccination Coverage Among Healthcare Personnel
Impact Summary: This measure supports the Long‑Term Care Hospital (LTCH) Quality Reporting Program goal of measuring and improving the quality of care provided in long‑term care hospitals by assessing whether LTCHs implement a core patient‑safety and infection‑prevention practice, health care personnel influenza vaccination, to support safer care environments and improve the quality of care for patients with complex, prolonged hospital stays.
Facility performance decreased between 2020 and 2021, then had little discernable change from 2021 to 2024, showing an opportunity for improvement in vaccination of HCP. Improving performance among lower-scoring facilities could help ensure 17,500 additional HCP, or about 58 HCP per entity, receive influenza vaccinations.
For this measure, Battelle reviewed the following publicly available datasets available at Long-Term Care Hospital - Provider Data | Provider Data Catalog (cms.gov):
Battelle analyzed all values for “L_015_01” not marked as “Not Available” from the corresponding Long-term_Care_Hospital-Provider_Data.csv file.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 5 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Figure 1 shows a drop from a median value of nearly 83% in 2020 to a median value of 70.3% in 2021. There has been little discernible change since 2021. For this measure, a higher score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the population represented within each group. It is important to note that the groups (referred to as deciles, each comprising 10% of the organizations) with the lowest or highest scores may contain larger or smaller populations than other groups. For example, if the lowest-scoring decile includes only 5% of the total population, then smaller group size may be associated with lower performance scores.
Table 1. Importance in the most recent year of data available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 69.1 (19.5) | 30.3 | 49.0 | 56.6 | 63.0 | 68.5 | 73.4 | 79.2 | 84.6 | 90.7 | 96.5 |
| Entities | 304 | 31 | 30 | 31 | 30 | 30 | 31 | 30 | 31 | 30 | 30 |
| Population | 100,241 | 10,029 | 9,606 | 11,159 | 10,642 | 8,631 | 11,951 | 8,950 | 7,587 | 8,052 | 13,634 |
Table 1 Interpretation: To estimate the number of positive outcomes (influenza vaccinations for health care personnel), the population is multiplied by the average score for each decile. Right now, the total estimated number of positive outcomes across all deciles is about 70,000. If the average performance of Decile 8 (84.6%) is considered a plausible, achievable score, and the entities in Deciles 1 through 7 improved to reach that score, about 17,500 additional positive outcomes could occur. This translates to about 58 health care personnel per entity and means that improving performance on this measure could help ensure that several thousand more health care workers receive influenza vaccinations, potentially leading to better health outcomes.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
The IPF Readmission measure is a facility-level measure that estimates an unplanned, 30-day, risk-standardized readmission rate for adult Medicare fee-for-service (FFS) patients discharged from an inpatient psychiatric facility with a principal discharge diagnosis of a psychiatric disorder or dementia/Alzheimer's disease. The performance period used to identify cases in the denominator is 24 months. Data from 12 months prior to the start of the performance period through the performance period are used to identify risk factors.
The Use of Pharmacotherapy for Opioid Use Disorder measure evaluates the percentage of Medicaid or Medicare-Medicaid participants, aged 18 years and older, who have been diagnosed with an opioid use disorder (OUD) who filled a prescription for, were administered, or dispensed, a Food and Drug Administration (FDA)-approved medication to treat or manage OUD during the measurement year.