Long-Term Care Hospital Quality Reporting Program

We are advocates for our patients, their families, and the overall purpose/need for long- term care hospital services for a vulnerable patient population. We believe that the ongoing support of these services that are provided in our communities has filled and will continue to fill a vital need going forward and that there is inherent value in the work that we do.

Dubuis Health System, Inc. is embracing a process by which its individual hospitals will report clinical quality metrics to the public. The Long-Term Care Hospital Quality Reporting Program (LTCH QRP) is a process applicable to all Long-Term Care Hospitals and is mandated through the Affordable Care Act, Section 3004. The LTCH QRP begins on October 1, 2012 and is enforced by the Centers for Medicare and Medicaid Services (CMS). The data that is submitted to CMS via the LTCH QRP is patient specific and predominantly concurrent information that CMS intends to analyze and determine the overall quality of care/value of the care delivered to beneficiaries. All patients who are admitted to an LTCH regardless of payer source are included in the program.

There is a total of three quality metrics that must be reported accurately and timely to CMS in order to retain up to 2%
of the next applicable federal fiscal year reimbursement.  These measures include a Central-Line Associated Blood Stream Infection (CLABSI) Outcome Measure, a Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure, and a Percent of New or Worsening Pressure Wound Outcome Measure. The CLABSI and CAUTI are reported through the National Health Safety Network (NHSN) that serves to package and submit this data to the Centers for Disease Control (CDC) who in turn submits the data to CMS. The Percent of New or Worsening Pressure Ulcer Outcome Measure is reported to CMS via the QIES ASAP system and is included as part of the Continuity Assessment Record & Evaluation (CARE) Data Sets. There is a CARE Data Set completion requirement for all admitted, discharged, or expired patients on or after October 1, 2012. The LTCH QRP Manual which contains the CARE Data Sets and serves as the reference for organizations can be found on the CMS website at This manual will be updated periodically by CMS as the program evolves over time. In addition to the current manual this CMS website contains other vital pieces of information about the program which you may use as a reference to gain a complete understanding.

The LTCH QRP has number of positive affects. One affect is that the program will increasingly drive the quality of care delivered to patients to new heights. In addition the program will result in organizations embracing evidence-based guidelines such that the best possible outcomes may be achieved for the population of patients served, and finally the overall cost of care delivery should be reduced as a result. Dubuis Health System, Inc. understands the great urgency
today to deliver excellent care to the patients and families that we serve such that the patient can return to a greatly
improved level of functioning and such that funding for these services may be justified. Dubuis Health System, Inc. is well positioned to not only meet these CMS quality reporting requirements in the near term but we are also well positioned to surpass the other providers in our pursuit of excellence in patient care and focus upon overall population health in the communities that we serve.