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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
TABLE 6: IPFQR Program Measure Set for the FY 2024 Payment Determination an dS ubsequentYears Measure ID
HBIPS-2
HBIPS-3
HBIPS-5

Measure Hours of Phvsical Restraint Use Hours of Seclusion Use Patients Discharged on Multiple Antipsychotic Medications with Annropriate Justification NIA
FAPH
Follow-Up After Psychiatric Hospitalization IMM-2
1659
Influenza Immunization SUB-2 and SUB-2a Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol NIA
Use Brief Intervention SUB-3 and SUB-3a Alcohol and Other Drug Use Disorder Treatment Provided or Offered at NIA
Discharge and SUB-3a Alcohol and Other Drug Use Disorder Treatment at Discharge TOB-2 and TOB-2a Tobacco Use Treatment Provided or Offered and TOB-2a Tobacco Use NIA
Treatment TOB-3 and TOB-3a Tobacco Use Treatment Provided or Offered at Discharge and TOB-3a NIA
Tobacco Use Treatment at Discharge NIA
Transition Record with Specified Elements Received by Discharged NIA
Patients Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care NIA
NIA
Screening for Metabolic Disorders 2860
NIA
Thirty-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient Psychiatric Facility Medication Continuation Following Inpatient Psvchiatric Discharge 3205
Med Cont COVID-19 Healthcare Personnel HCP Vaccination Measure COVIDHCP
TBD
Measure is no longer endorsed by the NQF but was endorsed at time of adoption. Section 1886s4Dii of the Act authorizes the Secretary to specify a measure that is not endorsed by the NQF as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. We attempted to find available measures for each of these clinical topics that have been endorsed or adopted by a consensus organization and found no other feasible and practical measures on the topics for the IPF setting.
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H. Considerations for Future Measure Topics As we have previously indicated, we seek to develop a comprehensive set of quality measures to be available for widespread use for informed decisionmaking and quality improvement in the IPF setting 79 FR 45974 through 45975. Therefore, through future rulemaking, we intend to propose new measures for development or adoption that will help further our goals of achieving better healthcare and improved health for individuals who obtain inpatient psychiatric services through the widespread dissemination and use of quality information. In 2017, we introduced the Meaningful Measures Framework as a tool to foster operational efficiencies and reduce costs including collection and reporting burden while producing quality measurement that is more focused on meaningful outcomes 83 FR 38591. As we continue to evolve the Meaningful Measures Framework, we have stated that we intend to better address health care priorities and gaps, emphasize
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digital quality measurement, and promote patient perspectives.164 As we work to align the IPFQR Programs measure set with these priorities, we have identified the following areas that we believe are important to stakeholders, but which are not covered in the current IPFQR Program measure set: Patient Experience of Care, Functional Outcomes Measurement, and digital measures. As described in the following subsections, we sought public comment on each of these topics and other future measure considerations which stakeholders believe are important.
We received the following public comment on measure considerations which stakeholders believe are important.
Comments: Many commenters suggested measure areas that they believe are important for IPFs. These areas were: 1 Suicide evaluation and reduction; 2 patient experience; 3
patient improvement; 4 clinical processes that impact significant 164 https www.cms.gov/meaningful-measures20-moving-measure-reduction-modernization.

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numbers of patients in important clinical domains; 5 patient and workforce safety; 6 caregiver engagement; 7 safety culture; 8
workforce engagement, 9
immunization status; 10 measures that more rigorously capture data on tobacco and substance use interventions; and 11 discharge planning measures. Some commenters recommended developing improved discharge planning measures.
One commenter recommended that CMS ensure that the role of nurse practitioners is included in measures.
One commenter recommend that CMS
engage with patients and their caregivers to identify topics they find important. Another commenter recommended that CMS seek industry input on measure considerations.
Response: We thank these commenters for this input. We will consider these recommendations as we seek to develop a more comprehensive measure set for the IPFQR Program.
1. Patient Experience of Care Data Collection Instrument When we finalized removal of the Assessment of Patient Experience of
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