Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
The Improving Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the Secretary to specify resource use measures and other measures, on which post-acute care (PAC) providers are required to submit necessary data specified by the Secretary. The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen, LLC to develop the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure for the Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) settings. Acumen, LLC operates under the Quality Measure & Assessment Instrument Development & Maintenance & QRP contract (75FCMC18D0015, Task Order 75FCMC19F0003).
This document presents the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) draft measure specifications. Section 2 provides an overview of the measure and a high-level summary of its key features. Section 3 describes the methodology used to calculate the draft Patient/Resident COVID-19 Vaccine measure including its data sources, study population, draft items, and steps for calculating the final measure score.
This cross-setting process measure reports the percentage of stays in which patients in an IRF/LTCH and residents in a SNF are up to date with their COVID-19 vaccinations per the CDC’s latest guidance. The definition of “up to date” may change based on the CDC’s latest guidance.
Data collection and measure calculation would be conducted separately for each setting. The measure would require the collection of COVID-19 vaccination data from the discharge assessments on the IRF-PAI for IRF patients, LCDS for LTCH patients, and MDS for SNF residents. Data would be collected using a standardized item harmonized across the assessment instruments. The measure would be reported using one quarter of data, and updated quarterly based on data obtained through the assessment instruments.
This COVID-19 vaccination item does not currently exist on the IRF-PAI, LTCH nor SNF item sets but would be added to each item set – the discharge assessment – to capture this information. Below is the vaccine data currently collected:
CMS posted the DRAFT MDS 3.0 v1.18.11 Item Sets on December 23, 2022 with the statement of plans to release the FINAL Item Sets in “early 2023.”
We’ll be watching for those FINAL Item Sets as well as the presence of the COVID-19 vaccine item.