Inpatient Psychiatric Hospital Facility Quality Measures by Facility

$179 / year

This dataset includes Psychiatric facilities that are eligible for the Inpatient Psychiatric Facility Quality Reporting (IPFQR) program are required to meet all program requirements, otherwise their Medicare payments may be reduced. It contains facility-wise data for the hospitals in United States for several inpatient psychiatric facility quality measures.

Complexity

The Inpatient Psychiatric Hospital Facility Quality Reporting (IPFQR) program is being developed as mandated by section 1886(s)(4) of the Social Security Act (SSA), as added and amended by Sections 3401(f) and 10322(a) of the Affordable Care Act (Pub.L. 111-148).
The IPFQR program is a pay-for-reporting program intended to equip consumers with quality of care information to make more informed decisions about healthcare options. It is also intended to encourage hospitals and clinicians to improve the quality of inpatient care provided to beneficiaries by, first, ensuring that providers are aware of and reporting on best practices for their respective facilities and type of care. Because this is a pay-for-reporting program, facilities will be subject to payment reduction for non-participation. Eligible Psychiatric hospitals that do not participate in the IPFQR program in a fiscal year will receive a 2.0 percentage point reduction to their annual update to their standard federal rate for that year. The reduction is noncumulative across payment years.

The IPFQR program requires facilities to submit data for specific inpatient psychiatric clinical process measures. These quality measures will be announced no later than October 1, 2012. To meet the IPFQR program requirement, Inpatient Psychiatric Facilities (IPFs) will be required to submit all quality measures in the form, manner, and time as specified by the Secretary, to the Centers for Medicare & Medicaid Services (CMS), beginning with Fiscal Year (FY) 2014 payment determination year and subsequent fiscal years. Participating IPFs must comply with the program requirements, which will be set forth through rule-making, including public reporting of the measure rates.

Date Created

2014-01-28

Last Modified

2020-07-31

Version

2020-07-31

Update Frequency

Quarterly

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare & Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Quality Reporting Programs, Quality Reporting Payments, Quality of Care Information, Eligible Psychiatric Hospitals, Psychiatric Hospital, Psychiatric Services, CMS Hospital Compare, Psychiatric Hospital Facilities

Other Titles

Psychiatric Hospital Compare Data by Facility, Inpatient Hospital Quality Measures, CMS Quality Measures Data, IPQRF Program Quality Measures, Inpatient Psychiatric Hospital Facility Quality Measures, Inpatient Psychiatric Hospital Facility Quality Reporting Program

NameDescriptionTypeConstraints
Provider_NumberCMS certification number (CCN). Identification number of the hospital within the CMS dataset.integerlevel : Nominal
Hospital_NameName of the hospital (also referred to as the provider)string-
AddressMain street address information of the hospitalstring-
CityMailing city. The city in the main street address of the hospital.string-
State_AbbreviationTwo-letter state abbreviation in the mailing address of the hospital. This includes information on hospitals in:string-
ZIP_Code5 digit postal zip code in the mailing address of the hospital.integerlevel : Nominal
CountyMailing county of the hospital.string-
HBIPS2_Measure_DescriptionDescription of Hospital Based Inpatient Psychiatric Services Core Measure Set. HBIPS2 is described as Hours of Physical Restraint Use. Total hours all patients spent in physical restraint as a proportion of total inpatient hours.string-
HBIPS2_Overall_Rate_Per_1000Indicates the overall rate per 1000 for Hospital Based Inpatient Psychiatric Services (HBIP2) Measure.numberlevel : Ratio
HBIPS2_Overall_NumeratorIndicates the overall Numerator value for Hospital Based Inpatient Psychiatric Services (HBIP2) Measure.numberlevel : Ratio
HBIPS2_Overall_DenominatorIndicates the overall Denominator value for Hospital Based Inpatient Psychiatric Services (HBIPS2) Measure.integerlevel : Ratio
HBIPS2_Overall_FootnoteFootnote Values for Overall Hospital Based Inpatient Psychiatric Services (HBIPS2) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
HBIPS3_Measure_DescriptionDescription of Hospital Based Inpatient Psychiatric Services Core Measure Set. HBIPS3 is described as Hours of Seclusion Use. Total hours all patients spent in seclusion as a proportion of total inpatient hours.string-
HBIPS3_Overall_Rate_Per_1000Indicates the overall rate per 1000 for Hospital Based Inpatient Psychiatric Services (HBIPS3) Measure.numberlevel : Ratio
HBIPS3_Overall_NumeratorIndicates the overall Numerator value for Hospital Based Inpatient Psychiatric Services (HBIPS3) Measure.numberlevel : Ratio
HBIPS3_Overall_DenominatorIndicates the overall Denominator value for Hospital Based Inpatient Psychiatric Services (HBIPS3) Measure.integerlevel : Ratio
HBIPS3_Overall_FootnoteFootnote Values for Overall Hospital Based Inpatient Psychiatric Services (HBIPS3) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
HBIPS5_Measure_DescriptionDescription of Hospital Based Inpatient Psychiatric Services Core Measure Set. HBIPS5 is described as Patients discharged on multiple antipsychotic medications with appropriate justification. Percent of patients discharged on multiple antipsychotic medications with appropriate justification as a proportion of patients discharged on two or more antipsychotic medications. Appropriate justifications are limited to augmentation of clozapine, tapering to monotherapy, and history of at least three failed trials of monotherapy.string-
HBIPS5_Overall_Percent_of_TotalIndicates the overall percentage for Hospital Based Inpatient Psychiatric Services (HBIPS5) Measure.numberlevel : Ratio
HBIPS5_Overall_DenominatorIndicates the overall Denominator value for Hospital Based Inpatient Psychiatric Services (HBIPS5) Measure.integerlevel : Ratio
HBIPS5_Overall_FootnoteFootnote Values for Overall Hospital Based Inpatient Psychiatric Services (HBIPS5) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
SMD_Measure_DescriptionDescription of Screening for Screening for Metabolic Disorders (SMD) Measure.string-
SMD_PercentIndicates the overall percentage for Screening for Metabolic Disorders (SMD) Measure.integerlevel : Ratio
SMD_DenominatorIndicates the overall Denominator value of Screening for Metabolic Disorders (SMD) Measure.integerlevel : Ratio
SMD_FootnoteIndicates the footnote value of Screening for Metabolic Disorders (SMD) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
SUB1_Measure_DescriptionDescription of Substance Use Treatment Measure. SUB1 is described as Alcohol Use Screening. Measures the percent of patients age 18 years or older who were screened for alcohol use, using a validated screening questionnaire for unhealthy alcohol use within three days of admission as a proportion of patients discharged.string-
SUB1_PercentIndicates the overall percentage for Substance1 Measure.numberlevel : Ratio
SUB1_DenominatorIndicates the overall Denominator value for Substance1 Measure.integerlevel : Ratio
SUB1_FootnoteFootnote Values for Substance1 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
SUB2_2a_Measure_DescriptionDescription of Substance Use Treatment Measure. Substance2 is described as Alcohol Use Brief Intervention Provided or Offered.string-
SUB2_PercentIndicates the overall percentage for Substance2 Measure.numberlevel : Ratio
SUB2_DenominatorIndicates the overall Denominator value for Substance2 Measure.integerlevel : Ratio
SUB2_FootnoteFootnote Values for Substance2 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
SUB2a_PercentIndicates the overall percentage for Substance2a Measure.numberlevel : Ratio
SUB2a_DenominatorIndicates the overall Denominator value for Substance2a Measure.integerlevel : Ratio
SUB2a_FootnoteFootnote Values for Substance2a Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
SUB3_3a_Measure_DescriptionDescription of National-wise Substance Use Treatment Measure. SUB3 3a is described as use of Alcohol and other Drug Use Disorder Treatment Provided or Offered at Discharge.string-
SUB3_PercentIndicates the overall percentage for SUB3 Measure.integerlevel : Ratio
SUB3_DenominatorIndicates the overall Denominator value for SUB3 Measure.integerlevel : Ratio
SUB3_FootnoteIndicates the footnote Values for Substance3 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
SUB3a_PercentIndicates the overall percentage for SUB3a Measure.integerlevel : Ratio
SUB3a_DenominatorIndicates the overall Denominator value for SUB3a Measure.integerlevel : Ratio
SUB3a_FootnoteIndicates the footnote Values for Substance3a Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TOB1_Measure_DescriptionDescription of Substance Use Treatment Measure. TOB1 is described as Tobacco Use Screening. Measures the percent of patients age 18 years or older who were screened for tobacco use, using a validated screening questionnaire for unhealthy tobacco use within three days of admission as a proportion of patients discharged.string-
TOB1_PercentIndicates the overall percentage for Tobacco1 Measure.numberlevel : Ratio
TOB1_DenominatorIndicates the overall Denominator value for Tobacco1 Measure.integerlevel : Ratio
TOB1_FootnoteFootnote Values for Tobacco1 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TOB2_2a_Measure_DescriptionDescription of Substance Use Treatment Measure. Tobacco2 is described as Tobacco Use Treatment during the hospital stay.string-
TOB2_PercentIndicates the overall percentage for Tobacco2 Measure.numberlevel : Ratio
TOB2_DenominatorIndicates the overall Denominator value for Tobacco2 Measure.integerlevel : Ratio
TOB2_FootnoteFootnote Values for Tobacco2 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TOB2a_PercentIndicates the overall percentage for Tobacco2a Measure.numberlevel : Ratio
TOB2a_DenominatorIndicates the overall Denominator value for Tobacco2a Measure.integerlevel : Ratio
TOB2a_FootnoteFootnote Values for Tobacco2a Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TOB3_3a_Measure_DescriptionDescription of Substance Use Treatment Measure. It is described as Tobacco Use Treatment Provided or Offered at Discharge.string-
TOB3_PercentIndicates the overall percentage for Tobacco3 Measure.numberlevel : Ratio
TOB3_DenominatorIndicates the overall Denominator value for Tobacco3 Measure.integerlevel : Ratio
TOB3_FootnoteFootnote Values for Tobacco3 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TOB3a_PercentIndicates the overall percentage for Tobacco3a Measure.numberlevel : Ratio
TOB3a_DenominatorIndicates the overall Denominator value for Tobacco3a Measure.integerlevel : Ratio
TOB3a_FootnoteFootnote Values for Tobacco3a Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
PEoC_Measure_DescriptionDescription of Patient Experience of Care Measure. PEOC is a structural measure. This is a mandatory attestation: does the facility routinely assess patient experience of care using a standardized collection protocol and a structured instrument, and if yes, which tool did they use.string-
Is_PEoC_Assessed_ResponseWhether the Response of the Patient Experience of Care Measure is assessed or not.boolean-
PEoC_Assessed_FootnoteFootnote Values for Patient Experience of Care Assessed Measure . Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
EHR_Use_Measure_DescriptionDescription of Electronic Health Record Measure. EHR is a structural measure. This is a mandatory attestation: identify the degree to which the facility employes EHR systems in their service program and use such systems to support health information exchange at times of transitions in care.string-
EHR_Use_ResponseAssessed Response of the Use of Electronic Health Record Measure.string-
EHR_Use_FootnoteFootnote Values for Electronic Health Record Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
EHR_HISP_Measure_DescriptionDescription of Facility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in care.string-
Is_EHR_HISP_ResponseWhether the Response of the Electronic Health Record (EHR) Health Information Service Provider (HISP) Measure is assessed or not.boolean-
EHR_HISP_FootnoteFootnote Values for Electronic Health Record (EHR) Health Information Service Provider (HISP) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TR1_Measure_DescriptionDescription of Transition record with specified elements received by discharged patients (TR1).string-
TR1_PercentIndicates the percentage of Transition Record with specified elements (TR1) Measure.integerlevel : Ratio
TR1_DenominatorIndicates the overall Denominator value for Transition Record with specified elements (TR1) Measure.integerlevel : Ratio
TR1_FootnoteFootnote Values for Transition Record with specified elements (TR1) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TR2_Measure_DescriptionDescription of Timely Transmission of transition record (TR2) Measure.string-
TR2_PercentIndicates the percentage of Timely Transmission of transition record (TR2) Measure.integerlevel : Ratio
TR2_DenominatorIndicates the overall Denominator value for Timely Transmission of transition record (TR2) Measure.integerlevel : Ratio
TR2_FootnoteFootnote Values for Timely Transmission of transition record (TR2) Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
TR2_Start_DateThe first day of TR2 data measures was collected. The date format is YYYY-MM-DD.date-
TR2_End_DateThe last day of TR2 data measures was collected. The date format is YYYY-MM-DD.date-
FUH_Measure_DescriptionDescription of Follow-Up after Hospitalization (FUH) Measure. FUH for Mental Illness measures the percentage of discharged patients age 6 years or older who had an outpatient visit, an intensive outpatient encounter, or a partial hospitalization with a mental health practitioner, within 7 days and 30 days of discharge. CMS will calculate these measures based on Medicare claims data.string-
FUH30_PercentIndicates the percent for Follow-up after Hospitalization (FUH) for Mental Illness of 30-Days.numberlevel : Ratio
FUH30_DenominatorIndicates the overall Denominator value for Follow-up after Hospitalization (FUH) Measure within 30 Days of discharge.integerlevel : Ratio
FUH30_FootnoteFootnote Values for Follow-Up After Hospitalization (FUH) Measure within 30 Days of discharge. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
FUH7_PercentIndicates the percent for Follow-up after Hospitalization (FUH) for Mental Illness of 7-Days.numberlevel : Ratio
FUH7_DenominatorIndicates the overall Denominator value for Follow-up after Hospitalization (FUH) Measure within 30 Days of discharge.integerlevel : Ratio
FUH7_FootnoteFootnote Values for Follow-Up After Hospitalization (FUH) Measure within 30 Days of discharge. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
FUH_Measure_Start_DateThe first day of FUH data measures was collected. The date format is YYYY-MM-DD.date-
FUH_Measure_End_DateThe last day of FUH data measures was collected. The date format is YYYY-MM-DD.date-
READM30_IPF_Measure_DescriptionDescription of patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF).string-
READM30_IPF_CategoryIndicates the category of patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF).string-
READM30_IPF_DenominatorIndicates the overall Denominator value for patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF).integerlevel : Ratio
READM30_IPF_RateIndicates the rate for patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF).numberlevel : Ratio
READM30_IPF_Lower_EstimateIndicates the lower estimate value for patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF).numberlevel : Ratio
READM30_IPF_Higher_EstimateIndicates the higher estimate value for patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF).numberlevel : Ratio
READM30_IPF_FootnoteFootnote Values for patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF). Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
READM30_IPF_Start_DateThe first day the data regarding READM30 IPF Measure was collected. The date format is YYYY-MM-DD.date-
READM30_IPF_End_DateThe last day the data regarding READM30 IPF Measure was collected. The date format is YYYY-MM-DD.date-
IMM2_Measure_DescriptionIndicates the description of Influenza Immunization2 Measure.string-
IMM2_PercentIndicates the overall percentage for Influenza Immunization2 Measure.numberlevel : Ratio
IMM2_DenominatorIndicates the overall Denominator value for Influenza Immunization2 Measure.integerlevel : Ratio
IMM2_FootnoteFootnote Values for Influenza Immunization2 Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
HCP_Measure_DescriptionIndicates the description of Healthcare Personnel Influenza Vaccination Measure.string-
HCP_PercentIndicates the overall percentage for Healthcare Personnel Measure.integerlevel : Ratio
HCP_DenominatorIndicates the overall Denominator value for Healthcare Personnel Measure.integerlevel : Ratio
HCP_FootnoteFootnote Values for Healthcare Personnel Measure. Footnote describes an additional piece of information given separately for the compiled data.integerlevel : Nominal
Flu_Season_Start_DateThe first day of the Flu Season data measures was collected. The date format is YYYY-MM-DD.date-
Flu_Season_End_DateThe last day of the Flu Season data measures was collected. The date format is YYYY-MM-DD.date-
LatitudeIdentifies the geographical location Latitude.number-
LongitudeIdentifies the geographical location Longitude.number-
Provider NumberHospital NameAddressCityState AbbreviationZIP CodeCountyHBIPS2 Measure DescriptionHBIPS2 Overall Rate Per 1000HBIPS2 Overall NumeratorHBIPS2 Overall DenominatorHBIPS2 Overall FootnoteHBIPS3 Measure DescriptionHBIPS3 Overall Rate Per 1000HBIPS3 Overall NumeratorHBIPS3 Overall DenominatorHBIPS3 Overall FootnoteHBIPS5 Measure DescriptionHBIPS5 Overall Percent of TotalHBIPS5 Overall DenominatorHBIPS5 Overall FootnoteSMD Measure DescriptionSMD PercentSMD DenominatorSMD FootnoteSUB1 Measure DescriptionSUB1 PercentSUB1 DenominatorSUB1 FootnoteSUB2 2a Measure DescriptionSUB2 PercentSUB2 DenominatorSUB2 FootnoteSUB2a PercentSUB2a DenominatorSUB2a FootnoteSUB3 3a Measure DescriptionSUB3 PercentSUB3 DenominatorSUB3 FootnoteSUB3a PercentSUB3a DenominatorSUB3a FootnoteTOB1 Measure DescriptionTOB1 PercentTOB1 DenominatorTOB1 FootnoteTOB2 2a Measure DescriptionTOB2 PercentTOB2 DenominatorTOB2 FootnoteTOB2a PercentTOB2a DenominatorTOB2a FootnoteTOB3 3a Measure DescriptionTOB3 PercentTOB3 DenominatorTOB3 FootnoteTOB3a PercentTOB3a DenominatorTOB3a FootnotePEoC Measure DescriptionIs PEoC Assessed ResponsePEoC Assessed FootnoteEHR Use Measure DescriptionEHR Use ResponseEHR Use FootnoteEHR HISP Measure DescriptionIs EHR HISP ResponseEHR HISP FootnoteTR1 Measure DescriptionTR1 PercentTR1 DenominatorTR1 FootnoteTR2 Measure DescriptionTR2 PercentTR2 DenominatorTR2 FootnoteTR2 Start DateTR2 End DateFUH Measure DescriptionFUH30 PercentFUH30 DenominatorFUH30 FootnoteFUH7 PercentFUH7 DenominatorFUH7 FootnoteFUH Measure Start DateFUH Measure End DateREADM30 IPF Measure DescriptionREADM30 IPF CategoryREADM30 IPF DenominatorREADM30 IPF RateREADM30 IPF Lower EstimateREADM30 IPF Higher EstimateREADM30 IPF FootnoteREADM30 IPF Start DateREADM30 IPF End DateIMM2 Measure DescriptionIMM2 PercentIMM2 DenominatorIMM2 FootnoteHCP Measure DescriptionHCP PercentHCP DenominatorHCP FootnoteFlu Season Start DateFlu Season End DateLatitudeLongitude
10007MIZELL MEMORIAL HOSPITAL702 N MAIN STOPPAL36467COVINGTONHours of physical-restraint use3753Hours of seclusion use3753Patients discharged on multiple antipsychotic medications with appropriate justification71.014.0Screening for metabolic disorders (SMD)100258Percent of patients screened for alcohol use using a validated screening questionnaire96259Alcohol use brief intervention provided or offered100.017.0100.017.0Alcohol and other drug use disorder treatment provided or offered at discharge100.017.0100.017.0Tobacco use screening29259Tobacco use treatment provided or offered100.074.0100.074.0Tobacco use treatment provided or offered at discharge100.074.00.074.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolTrueFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)100259Timely transmission of transition record (TR2)1002592017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness60.02528.0252016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)Worse than the National Rate31625.721.330.52015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)11123Influenza vaccination coverage among healthcare personnel (HCP)37272017-10-012018-03-3131.291971999999998-86.255415
10008CRENSHAW COMMUNITY HOSPITAL101 HOSPITAL CIRCLELUVERNEAL36049CRENSHAWHours of physical-restraint use5.05178Hours of seclusion use4.05178Patients discharged on multiple antipsychotic medications with appropriate justification100.0195.0Screening for metabolic disorders (SMD)100557Percent of patients screened for alcohol use using a validated screening questionnaire99643Alcohol use brief intervention provided or offered8.0119.02.0119.0Alcohol and other drug use disorder treatment provided or offered at discharge1.0582.01.0582.0Tobacco use screening97616Tobacco use treatment provided or offered97.0429.072.0429.0Tobacco use treatment provided or offered at discharge94.0375.07.0375.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolFalseFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)97665Timely transmission of transition record (TR2)986652017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness51.09817.3982016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate24017.313.821.42015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)95299Influenza vaccination coverage among healthcare personnel (HCP)77562017-10-012018-03-3131.692595-86.26615600000001
10011ST VINCENT'S EAST50 MEDICAL PARK EAST DRIVEBIRMINGHAMAL35235JEFFERSONHours of physical-restraint use2.0223.06217Hours of seclusion use6217Patients discharged on multiple antipsychotic medications with appropriate justification2.041.0Screening for metabolic disorders (SMD)36276Percent of patients screened for alcohol use using a validated screening questionnaire97351Alcohol use brief intervention provided or offered0.014.00.014.0Alcohol and other drug use disorder treatment provided or offered at discharge0.032.00.032.0Tobacco use screening98352Tobacco use treatment provided or offered43.065.011.065.0Tobacco use treatment provided or offered at discharge0.041.00.041.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolFalseFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)8381Timely transmission of transition record (TR2)83812017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness50.03212.5322016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate25917.914.122.72015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)66154Influenza vaccination coverage among healthcare personnel (HCP)75362017-10-012018-03-3133.595351-86.665182
10012DEKALB REGIONAL MEDICAL CENTER200 MED CENTER DRIVEFORT PAYNEAL35968DE KALBHours of physical-restraint use5266Hours of seclusion use5266Patients discharged on multiple antipsychotic medications with appropriate justification1.0Screening for metabolic disorders (SMD)88169Percent of patients screened for alcohol use using a validated screening questionnaire99208Alcohol use brief intervention provided or offered1.01.0Alcohol and other drug use disorder treatment provided or offered at discharge1.01.0Tobacco use screening100207Tobacco use treatment provided or offered100.026.0100.026.0Tobacco use treatment provided or offered at discharge25.012.00.012.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolFalseFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)100217Timely transmission of transition record (TR2)1002172017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness46.21315.4132016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate28323.218.928.22015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)9992Influenza vaccination coverage among healthcare personnel (HCP)95432017-10-012018-03-31
10016SHELBY BAPTIST MEDICAL CENTER1000 FIRST STREET NORTHALABASTERAL35007SHELBYHours of physical-restraint use10.017518Hours of seclusion use1.017518Patients discharged on multiple antipsychotic medications with appropriate justification96.023.0Screening for metabolic disorders (SMD)98452Percent of patients screened for alcohol use using a validated screening questionnaire100633Alcohol use brief intervention provided or offered99.0114.099.0114.0Alcohol and other drug use disorder treatment provided or offered at discharge94.0224.093.0224.0Tobacco use screening99633Tobacco use treatment provided or offered98.0346.096.0346.0Tobacco use treatment provided or offered at discharge98.0313.098.0313.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolTrueFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careTrueTransition record with specified elements received by discharged patients (TR1)99622Timely transmission of transition record (TR2)986222017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness50.09421.3942016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate51819.716.723.02015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)100305Influenza vaccination coverage among healthcare personnel (HCP)96722017-10-012018-03-3133.253679-86.814261
10021DALE MEDICAL CENTER126 HOSPITAL AVEOZARKAL36360DALEHours of physical-restraint use1290Hours of seclusion use1290Patients discharged on multiple antipsychotic medications with appropriate justification100.055.0Screening for metabolic disorders (SMD)0171Percent of patients screened for alcohol use using a validated screening questionnaire95165Alcohol use brief intervention provided or offered100.016.012.016.0Alcohol and other drug use disorder treatment provided or offered at discharge0.016.00.016.0Tobacco use screening97165Tobacco use treatment provided or offered75.068.012.068.0Tobacco use treatment provided or offered at discharge75.068.024.068.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolFalseFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)99165Timely transmission of transition record (TR2)1001652017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness39.54314.0432016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate25620.116.324.82015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)98100Influenza vaccination coverage among healthcare personnel (HCP)100252017-10-012018-03-3131.451345-85.630966
10023BAPTIST MEDICAL CENTER SOUTH2105 EAST SOUTH BOULEVARDMONTGOMERYAL36116MONTGOMERYHours of physical-restraint use39.013802Hours of seclusion use25.013802Patients discharged on multiple antipsychotic medications with appropriate justification8.040.0Screening for metabolic disorders (SMD)30573Percent of patients screened for alcohol use using a validated screening questionnaire76798Alcohol use brief intervention provided or offered61.0161.059.0161.0Alcohol and other drug use disorder treatment provided or offered at discharge43.0352.035.0352.0Tobacco use screening96794Tobacco use treatment provided or offered72.0443.062.0443.0Tobacco use treatment provided or offered at discharge37.0414.02.0414.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolFalseFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)31030Timely transmission of transition record (TR2)310302017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness17.41848.71842016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate51921.518.424.82015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)84314Influenza vaccination coverage among healthcare personnel (HCP)873762017-10-012018-03-3132.327144-86.276764
10033UNIVERSITY OF ALABAMA HOSPITAL619 SOUTH 19TH STREETBIRMINGHAMAL35233JEFFERSONHours of physical-restraint use239.030848Hours of seclusion use1.0617.030848Patients discharged on multiple antipsychotic medications with appropriate justification1.0Screening for metabolic disorders (SMD)96266Percent of patients screened for alcohol use using a validated screening questionnaire99472Alcohol use brief intervention provided or offered100.0116.0100.0116.0Alcohol and other drug use disorder treatment provided or offered at discharge100.0252.059.0252.0Tobacco use screening99472Tobacco use treatment provided or offered88.0301.013.0301.0Tobacco use treatment provided or offered at discharge64.0258.01.0258.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolTrueFacility's highest level typical use of an electronic health records system (EHR)Paper or Other FormFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careTrueTransition record with specified elements received by discharged patients (TR1)96576Timely transmission of transition record (TR2)755762017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness45.910919.31092016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate45918.915.922.32015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)97280Influenza vaccination coverage among healthcare personnel (HCP)973492017-10-012018-03-3133.506129-86.80192199999999
10034COMMUNITY HOSPITAL INC805 FRIENDSHIP ROADTALLASSEEAL36078ELMOREHours of physical-restraint use2125Hours of seclusion use2125Patients discharged on multiple antipsychotic medications with appropriate justification1.0Screening for metabolic disorders (SMD)12161Percent of patients screened for alcohol use using a validated screening questionnaire87183Alcohol use brief intervention provided or offered1.01.0Alcohol and other drug use disorder treatment provided or offered at discharge1.01.0Tobacco use screening85183Tobacco use treatment provided or offered1.01.0Tobacco use treatment provided or offered at discharge1.01.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolTrueFacility's highest level typical use of an electronic health records system (EHR)Certified EHR TechnologyFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careFalseTransition record with specified elements received by discharged patients (TR1)0161Timely transmission of transition record (TR2)01612017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness53.31526.7152016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate20319.915.625.32015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)7383Influenza vaccination coverage among healthcare personnel (HCP)26342017-10-012018-03-3132.535292999999996-85.911996
10039HUNTSVILLE HOSPITAL101 SIVLEY RDHUNTSVILLEAL35801MADISONHours of physical-restraint use7450Hours of seclusion use7450Patients discharged on multiple antipsychotic medications with appropriate justification83.029.0Screening for metabolic disorders (SMD)50264Percent of patients screened for alcohol use using a validated screening questionnaire100575Alcohol use brief intervention provided or offered100.0107.0100.0107.0Alcohol and other drug use disorder treatment provided or offered at discharge6.0149.06.0149.0Tobacco use screening100576Tobacco use treatment provided or offered90.0283.081.0283.0Tobacco use treatment provided or offered at discharge0.0257.00.0257.0Patient experience of care (PEoC) routinely assessed using standardized collection protocolFalseFacility's highest level typical use of an electronic health records system (EHR)Certified EHR TechnologyFacility exchanged interoperable health information with a health information service provider (HISP) at times of transitions in careTrueTransition record with specified elements received by discharged patients (TR1)88583Timely transmission of transition record (TR2)875832017-01-012017-12-31Percent of patients receiving follow-up care within 30 days (FUH-30) or within 7 days (FUH-7) after hospitalization for mental illness47.714926.21492016-07-012017-06-30Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility (READM-30-IPF)No Different than the National Rate53619.516.622.92015-07-012017-06-30Influenza immunization (IPFQR-IMM-2)100284Influenza vaccination coverage among healthcare personnel (HCP)78632017-10-012018-03-3134.721226-86.581547