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  2. CQM-1381

Decreased performance rate for CMS102 rehab assessment

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      Thank you for your question. The omission of rehabilitation assessment/therapy from the numerator logic is meaningful and designed to align with the intent of the chart-abstracted measure. Since rehabilitation is intended to address the patient's residual deficits, it strikes us as unusual that an assessment would occur prior to admission, where the focus is acute intervention and management of the stroke. In addition, while the chart-abstracted measure does not explicitly disallow that a rehabilitation assessment occurs prior to admission, it does constrain the performance of such an assessment to the rehabilitation team, who are most likely not present/available in the ED.

      We hope this clarifies the rationale behind the numerator logic for this measure. Nevertheless, we would certainly be interested in learning how you are incorporating rehabilitation assessments/treatment in your workflow prior to inpatient admission.
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      Thank you for your question. The omission of rehabilitation assessment/therapy from the numerator logic is meaningful and designed to align with the intent of the chart-abstracted measure. Since rehabilitation is intended to address the patient's residual deficits, it strikes us as unusual that an assessment would occur prior to admission, where the focus is acute intervention and management of the stroke. In addition, while the chart-abstracted measure does not explicitly disallow that a rehabilitation assessment occurs prior to admission, it does constrain the performance of such an assessment to the rehabilitation team, who are most likely not present/available in the ED. We hope this clarifies the rationale behind the numerator logic for this measure. Nevertheless, we would certainly be interested in learning how you are incorporating rehabilitation assessments/treatment in your workflow prior to inpatient admission.

      There is a gap in eMeasure 102: Ischemic or Hemorrhagic Stroke - Assessed for Rehabilitation. As the measure is currently written (V3), the rehabilitation assessment or treatments are included in the numerator statement, if these services were performed during the Non-Elective Inpatient Encounter. However, many times the rehabilitation assessments or treatments may occur while the patient is in the Emergency Department (ED) or in observation status, prior to the inpatient encounter. While the appropriate care is being provided, the facilities are not receiving credit for providing evidence based care, based on the measure specification.

      • Numerator =
      o AND:
       OR:
       OR: "Procedure, Performed: Rehabilitation Assessment"
       OR: "Procedure, Performed: Rehabilitation Therapy"
       OR: "Procedure, Performed not done: Patient Refusal" for "Rehabilitation Assessment "
      during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
       OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharged to Rehabilitation Facility')"

      The parallel Core Measure allows for the inclusion of the rehabilitation assessment or treatment that may occur prior to the inpatient admission. i.e. While the patient is in observation status or in the ED, prior to inpatient admission. As a result, the current version of the CQM will produce lower numerator populations.

      1.) Will the next update of the measure expand the timeframe to include the ED and Observation encounters to align the measures?

            JLeflore Joelencia Leflore
            bodinekm Kimberly M. Bodine (Inactive)
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