SB3743 96TH GENERAL ASSEMBLY

LRB096 20325 KTG 36190 b

96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
SB3743

Introduced 2/11/2010, by Sen. Christine Radogno

SYNOPSIS AS INTRODUCED:

New Act

Creates the Long Term Care Hospital Quality Improvement Transfer Program Act. Provides that because it is vital for the State of Illinois to find methods to improve the health care outcomes of patients served by the healthcare programs operated by the Department of Healthcare and Family Services, the Department shall establish the Long Term Care Hospital Quality Improvement Transfer Program. Provides that the program is designed to better utilize the specialized services available in the State to improve the health outcomes of the most severely injured and ill patients and to enhance the continuity and coordination of care for these patients. Contains provisions concerning how a hospital may qualify to participate in the program; hospital outcome and measurement data; exemptions; hospital duties; supplemental per diem rates; and other matters. Requires the Department to satisfy certain reporting requirements; to implement, monitor, and evaluate the program; and other matters. Permits the Department to use up to $500,000 of funds contained in the Public Aid Recoveries Trust Fund per State fiscal year to operate the program and to expand existing contracts, issue new contracts, issue personal service contracts, or purchase other services, supplies, or equipment for the purposes the program. Effective immediately.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 1. Short title. This Act may be cited as the Long Term Care Hospital Quality Improvement Transfer Program Act.

Section 5. Purpose of Act. The General Assembly finds that it is vital for the State of Illinois to find methods to improve the health care outcomes of patients served by the healthcare programs operated by the Department of Healthcare and Family Services. Improving a patient's health not only benefits the patient's quality of life but also results in a more efficient use of the resources needed to provide care. Estimates show that the Long Term Care Hospital Quality Improvement Transfer Program established under this Act could save approximately $10,000,000 annually. The program focuses on some of the most severely injured and ill patients in the State of Illinois. It is designed to better utilize the specialized services available in the State to improve these patients' health outcomes and to enhance the continuity and coordination of care for these patients. This program serves as one of the many pieces needed to reform the State of Illinois' healthcare programs to better serve the people of the State of Illinois.

Section 10. Definitions. As used in this Act:

(a) "CARE tool" means the Continuity and Record Evaluation (CARE) tool. It is a patient assessment instrument that has been developed to document the medical, cognitive, functional, and discharge status of persons receiving health care services in acute and post-acute care settings. The data collected is able to document provider-level quality of care (patient outcomes) and characterize the clinical complexity of patients.

(b) "Department" means the Illinois Department of Healthcare and Family Services.

(c) "Discharge" means the release of a patient from hospital care for any discharge disposition other than a leave of absence, even if for Medicare payment purposes the discharge fits the definition of an interrupted stay.

(d) "FTE" means "full-time equivalent" or a person or persons employed in one full-time position.

(e) "Hospital" means an institution, place, building, or agency located in this State that is licensed as a general acute hospital by the Illinois Department of Public Health under the Hospital Licensing Act, whether public or private and whether organized for profit or not-for-profit.

(f) "ICU" means intensive care unit.

(g) "LTC hospital" means a hospital that is designated by Medicare as a long term care hospital as described in Section 1886(m)(d)(1)(B)(iv)(I) of the Social Security Act.

(h) "LTC hospital criteria" means nationally recognized evidence-based evaluation criteria that have been publicly tested and includes criteria specific to an LTC hospital for admission, continuing stay, and discharge. The criteria cannot include criteria derived or developed by or for a specific hospital or group of hospitals. Criteria and tools developed by hospitals or hospital associations or hospital-owned organizations are not acceptable and do not meet the requirements of this subsection.

(i) "Patient" means an individual who is admitted to a hospital for an inpatient stay.

(j) "Program" means the Long Term Care Hospital Quality Improvement Transfer Program established by this Act.

(k) "STAC hospital" means a hospital that is not designated by Medicare as a long term care hospital as described in Section 1886(m)(d)(1)(B)(iv)(I) of the Social Security Act or a psychiatric hospital or a rehabilitation hospital.

Section 15. Qualifying Hospitals.

(a) Beginning on the effective date of this Act, the Department shall establish the Long Term Care Hospital Quality Improvement Transfer Program. Any hospital may participate in the program if it meets the requirements of this Section as determined by the Department.

(b) To participate in the program a hospital must do the following:

(1) Operate as a LTC hospital.

(2) Employ one-half of an FTE (designated for case management) for every 15 patients admitted to the hospital.

(3) Maintain on-site physician coverage 24 hours a day, 7 days a week.

(4) Maintain on-site respiratory therapy coverage 24 hours a day, 7 days a week.

(c) A hospital must also execute a program participation agreement with the Department. The agreement must include:

(1) An attestation that the hospital complies with the criteria in subsection (b) of this Section.

(2) A process for the hospital to report its continuing compliance with subsection (b) of this Section. The hospital must submit a compliance report at least annually.

(3) A requirement that the hospital complete and submit the CARE tool (the most currently available version or an equivalent tool designated and approved for use by the Department) for each patient no later than 7 calendar days after discharge.

(4) A requirement that the hospital use a patient satisfaction survey specifically designed for LTC hospital settings. The hospital must submit survey results data to the Department at least annually.

(5) A requirement that the hospital accept all clinically-approved patients for admission or transfer from a STAC hospital. The patient must be evaluated using LTC hospital criteria approved by the Department for use in this program and meet the appropriate criteria.

(6) A requirement that the hospital report quality and outcome measurement data, as described in Section 20 of this Act, to the Department at least annually.

(7) A requirement that the hospital provide the Department full access to patient data and other data maintained by the hospital. Access must be in compliance with State and federal law.

(8) A requirement that the hospital use LTC hospital criteria to evaluate patients that are admitted to the hospital to determine that the patient is in the most appropriate setting.

Section 20. Quality and outcome measurement data.

(a) For proper evaluation and monitoring of the program, each LTC hospital must provide quality and outcome measurement data ("measures") as specified in subsections (c) through (h) of this Section to the Department for patients treated under this program. The Department may develop measures in addition to the minimum measures required under this Section.

(b) Two sets of measures must be calculated. The first set should only use data for medical assistance patients, and the second set should include all patients of the LTC hospital regardless of payer.

(c) Average LTC hospital length of stay for patients discharged during the reporting period. The quotient of:

(1) Numerator: all patient days for discharged patients during the reporting period.

(2) Denominator: number of patient discharges associated with the days included in the numerator.

(d) Adverse outcomes rates: Percent of patients who expired or whose condition worsens and requires treatment in a STAC hospital. The quotient of:

(1) Numerator: sum of expirations plus discharges to a STAC Hospital.

(2) Denominator: total discharges.

(e) Ventilator weaning rate: Percent of patients discharged during the reporting period who have been successfully weaned off invasive mechanical ventilation. The quotient of:

(1) Numerator:

(A) Includes all patients who were admitted on invasive mechanical ventilation (per endotracheal or tracheostomy tube) and were completely weaned from invasive mechanical ventilation at discharge from the LTC hospital, patients admitted receiving part-time or nocturnal invasive mechanical ventilation, patients admitted on invasive mechanical and transitioned to noninvasive ventilation at time of discharge.

(B) Excludes patients who have not yet been discharged, patients who were not completely weaned from invasive mechanical ventilation, patients that were weaned for a period of time but returned to ventilator support and were ventilator-dependent at time of discharge, and patients who expired.

(2) Denominator: includes all ventilator dependent patients.

(f) Central Line Infection Rate per 1000 central line days: Number of patients discharged from a LTC hospital during the reporting period that had a central line in place and developed a bloodstream infection 48 hours or more after admission to the LTC hospital. The quotient of:

(1) Numerator:

(A) Includes all discharged patients that had a central line and developed a bloodstream infection as defined by the Centers for Disease Control and Prevention. The definition of central line includes any device that is not peripheral, including Single, Double, and Triple Lumen vascular catheters, percutaneously inserted central catheter lines, and Tunneled catheters such as Mediports and Groshongs. Number of primary bloodstream infections in patients with a central line catheter, including patients whose primary blood stream infection was identified at least 48 hours after admission.

(B) Excludes patients that:

(i) Were admitted to the LTC hospital with a bloodstream infection;

(ii) Had a bloodstream infection identified by the LTC hospital within 48 hours of the LTCH admission;

(iii) Were not discharged; or

(iv) Did not have a central line.

(2) Denominator: Number of central line catheter days for the reporting period.

(A) Includes central line catheter patient days for all discharges from the LTC hospital.

(B) Excludes patients that did not have a central line and exclude patient days for patients that left the facility for a leave of absence and subsequently returned to the LTC hospital and therefore were not discharged.

(g) Acquired pressure ulcers per 1000 patient days. The quotient of:

(1) Numerator: Number of pressure ulcers that developed during the LTC hospital hospitalization in patients discharged from a LTC hospital during the reporting period.

(A) Includes total number of stage 2-4 ulcers identified more than 48 hours after admission to the LTC hospital.

(B) Excludes the following:

(i) Ulcers in patients that have not yet been discharged.

(ii) Pressure ulcers Stage 2 and greater present at admission to the LTC hospital.

(iii) Stage 1 pressure ulcers.

(iv) Pressure ulcers that were identified within the first 48 hours of admission to the LTC hospital.

(2) Denominator: total patient days for the reporting period.

(h) Falls with injury per 1000 patient days: Number of falls among discharged LTC hospital patients discharged during the reporting period, who fell during the LTC hospital stay, regardless of distance fallen, that required an ancillary or surgical procedure (i.e. x-ray, MRI, sutures, surgery, etc.) The quotient of:

(1) Numerator:

(A) Includes the following:

(i) Falls with injury levels of minor, moderate, major, and death in accordance with the guidelines for falls with injury Fall Prevention Protocol of the National Database of Nursing Quality Indicators (NDNQI).

(ii) Assisted falls among discharged LTC hospital patients (patient caught themselves, staff or witness assisted falls, falls caught to prevent further falling).

(B) Excludes the following:

(i) Assisted falls (patient caught themselves, staff or witness assisted falls, falls caught to prevent further falling) among discharged LTC hospital patients that required physician exam or bandage but no ancillary test or procedure.

(ii) Falls that required a physician exam or bandage or ancillary test that was negative such as x-ray.

(iii) Falls with no injury according to NDNQI definitions.

(iv) Falls among the patients who have not yet been discharged.

(2) Denominator: Number of discharged LTC hospital patient days for the reporting period, with patient days calculated once per 24 hour period (usually at midnight excluding patient days for the period of non-LTC hospital patients and LTC hospital patients who are not yet discharged).

Section 25. Quality improvement transfer program.

(a) The Department may exempt the following STAC hospitals from the requirements in this Section:

(1) A hospital operated by a county with a population of 3,000,000 or more.

(2) A hospital operated by a State agency or a State university.

(b) STAC hospitals may transfer patients who meet criteria in the LTC hospital criteria and are medically stable for discharge from the STAC hospital.

(c) A patient in a STAC hospital may be exempt from a transfer if:

(1) The patients physician does not issue an order for a transfer;

(2) The patient or the individual legally authorized to make medical decisions for the patient refuses the transfer; or

(3) The patient's care is primarily paid for by Medicare or another third party. The exemption in this paragraph (3) of subsection (c) does not apply to a patient who has exhausted his or her Medicare benefits resulting in the Department becoming the primary payer.

Section 30. LTC hospital duties.

(a) The LTC hospital must notify the Department within 5 calendar days if it no longer meets the requirements under subsection (b) of Section 15.

(b) The LTC hospital may terminate the agreement under subsection (c) of Section 15 with a notice to the Department within 15 calendar days if the State of Illinois fails to issue payment within 50 days of submission of an appropriately submitted claim.

(c) The LTC hospital must assist the Department in creating patient and family education material concerning the program.

(d) The LTC hospital must retain the patient's admission evaluation to document that the patient meets the LTC hospital criteria and is eligible to receive the LTC supplemental per diem rate described in Section 35 of this Act.

Section 35. LTC supplemental per diem rate.

(a) The Department must pay a LTC supplemental per diem rate calculated under this Section to LTC hospitals that meet the requirements of Section 15 of this Act for patients who upon admission to the LTC hospital meet LTC hospital criteria.

(b) The Department must not pay the LTC supplemental per diem rate calculated under this Section if the LTC hospital no longer meets the requirements under Section 15 or terminates the agreement specified under Section 15. The Department must not pay the LTC supplemental per diem rate calculated under this Section if the patient does not meet the LTC hospital criteria upon admission.

(c) After the first year of operation of the program established by this Act, the Department may reduce the LTC supplemental per diem rate calculated under this Section by no more than 5% for a LTC hospital that does not meet benchmarks or targets set by the Department. The Department may also increase the LTC supplemental per diem rate calculated under this Section by no more than 5% for a LTC hospital that exceeds the benchmarks or targets set by the Department.

(d) The LTC supplemental per diem rate shall be calculated using the LTC hospital's inflated cost per diem, defined in subsection (f) of this Section, and subtracting the following:

(1) The LTC hospital's Medicaid per diem inpatient rate as calculated under 89 Ill. Adm. Code 148.270(c)(4).

(2) The LTC hospital's disproportionate share (DSH) rate as calculated under 89 Ill. Adm. Code 148.120.

(3) The LTC hospital's Medicaid Percentage Adjustment (MPA) rate as calculated under 89 Ill. Adm. Code 148.122.

(4) The LTC hospital's Medicaid High Volume Adjustment (MHVA) rate as calculated under 89 Ill. Adm. Code 148.290(d).

(e) LTC supplemental per diem rates are effective for 12 months beginning on October 1 of each year and must be updated every 12 months.

(f) For the purposes of this Section, "inflated cost per diem" means the quotient resulting from dividing the hospital's inpatient Medicaid costs by the hospital's Medicaid inpatient days and inflating it to the most current period using methodologies consistent with the calculation of the rates described in paragraphs (2),(3), and (4) of subsection (d). The data is obtained from the LTC hospital's most recent cost report submitted to the Department as mandated under 89 Ill. Adm. Code 148.210.

Section 40. Duties of the Department.

(a) The Department is responsible for implementing, monitoring, and evaluating the program. This includes but is not limited to:

(1) Collecting data required under Section 15 and data necessary to calculate the measures under Section 20 of this Act.

(2) Setting annual benchmarks or targets for the measures in Section 20 of this Act or other measures beyond the minimum required under Section 20. The Department must consult participating LTC hospitals when setting these benchmarks and targets.

(3) Monitoring compliance with all requirements of this Act.

(4) Creating patient and family education material about the program for STAC hospitals to use.

(b) The Department must issue an annual report by posting it to the Department's website. The annual report must include at least the following information:

(1) Information on the LTC hospitals that are qualified and participating in the program.

(2) Quality and outcome measures, as described in Section 20 of this Act, for each LTC hospital.

(3) A calculation of the savings generated by the program.

(4) Observations on how the program is working and any suggestions to improve the program in the future.

(c) The Department must establish monitoring procedures that ensure the LTC supplemental payment is only paid for patients who upon admission meet the LTC hospital criteria. The Department must notify qualified LTC hospitals of the procedures and establish an appeals process as part of those procedures. The Department must recoup any LTC supplemental payments that are identified as being paid for patients who do not meet the LTC hospital criteria.

(d) The Department must implement the program by October 1, 2010.

(e) The Department must execute an agreement as required under subsection (c) of Section 15 no later than 45 days after the effective date of this Act.

(f) The Department must notify Illinois hospitals which LTC hospital criteria are approved for use under the program. The Department may limit LTC hospital criteria to the most strict criteria that meet the definitions of this Act.

(g) The Department must identify discharge tools that are considered equivalent to the CARE tool and approved for use under the program. The Department must notify LTC hospitals which tools are approved for use under the program.

(h) The Department must notify Illinois LTC hospitals of the program and inform them how to apply for qualification and what the qualification requirements are as described under Section 15 of this Act.

(i) The Department must notify Illinois STAC hospitals about the operation and implementation of the program established by this Act.

(j) The Department must work with the Comptroller to ensure a process to issue payments to LTC hospitals qualified and participating in the program within 50 days of submission of an appropriate claim.

(k) The Department may use up to $500,000 of funds contained in the Public Aid Recoveries Trust Fund per State fiscal year to operate the program under this Act. The Department may expand existing contracts, issue new contracts, issue personal service contracts, or purchase other services, supplies, or equipment.

Section 99. Effective date. This Act takes effect upon becoming law.