CMS-10432 Data Collection

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

Web-based Measure

Online Data Entry Tool Content

HBIPS-2 Hours of Physical Restraint Use

N UMERATOR Q4 2012 Q1 2013

P lease enter the total number of hours that all psychiatric 1-12 years old

p atients were in physical restraints for each age group. 13-17 years old

18-64 years old

65 and over

D ENOMINATOR Q4 2012 Q1 2013

P lease enter the number of inpatient psychiatric days 1-12 years old

f or each age group. 13-17 years old

( convert days to hours) 18-64 years old

65 and over

NOTE: Denominator basis is per 1,000 hours.

Q4 2012 Q1 2013

Measure rates of physical restraint use per inpatient 1-12 years old

p sychiatric day for each age group. 13-17 years old

18-64 years old

65 and over

Overall

NOTE: Measure rates will be auto calculated from above entries.

HBIPS-3 Hours of Seclusion Use

N UMERATOR Q4 2012 Q1 2013

P lease enter the total number of hours that all psychiatric 1-12 years old

p atients were in seclusion for each age group. 13-17 years old

18-64 years old

65 and over

D ENOMINATOR Q4 2012 Q1 2013

P lease enter the number of inpatient psychiatric days 1-12 years old

f or each age group. 13-17 years old

18-64 years old

65 and over

Q4 2012 Q1 2013

M easure rates of seclusion use per inpatient psychiatric day 1-12 years old

f or each age group. 13-17 years old

18-64 years old

65 and over

Overall

NOTE: Measure rates will be auto calculated from above entries.

HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications

N UMERATOR Q4 2012 Q1 2013

P lease enter the number of psychiatric patients discharged 1-12 years old

o n multiple antipsychotic medications for each age group. 13-17 years old

18-64 years old

65 and over

D ENOMINATOR Q4 2012 Q1 2013

P lease enter the total number of psychiatric patients 1-12 years old

d ischarged for each age group. 13-17 years old

18-64 years old

65 and over

Q4 2012 Q1 2013

M easure rates of psychiatric patients who were discharged 1-12 years old

o n multiple antipsychotic medications for each age group. 13-17 years old

18-64 years old

65 and over

Overall

NOTE: Measure rates will be auto calculated from above entries.

HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

N UMERATOR Q4 2012 Q1 2013

P lease enter the number of psychiatric patients discharged 1-12 years old

o n two or more multiple antipsychotic medications 13-17 years old

for each age group. 18-64 years old

65 and over

D ENOMINATOR Q4 2012 Q1 2013

P lease enter the total number of psychiatric patients 1-12 years old

d ischarged for each age group. 13-17 years old

18-64 years old

65 and over

Q4 2012 Q1 2013

M easure rates of psychiatric patients who were discharged 1-12 years old

o n multiple antipsychotic medications with appropriate 13-17 years old

j ustification for each age group. 18-64 years old

65 and over

Overall

NOTE: Measure rates will be auto calculated from above entries.

HBIPS-6 Patients Discharged from a Hospital-based Inpatient Psychiatric Setting with a Continuing Care Plan Created

N UMERATOR Q4 2012 Q1 2013

P lease enter the number of psychiatric patients for whom 1-12 years old

t he post discharge continuing care plan is created and contains 13-17 years old

a ll of the following: reason for hospitalization, principal 18-64 years old

discharge diagnosis, discharge medications, and next level of 65 and over

care.

D ENOMINATOR Q4 2012 Q1 2013

P lease enter the total number of psychiatric patients 1-12 years old

d ischarged for each age group. 13-17 years old

18-64 years old

65 and over

Q4 2012 Q1 2013

Measure rates of psychiatric patients who were discharged 1-12 years old

from a hospital-based inpatient psychiatric setting 13-17 years old

with a Continuing Care Plan Created for each age group. 18-64 years old

65 and over

Overall

NOTE: Measure rates will be auto calculated from above entries.

HBIPS-7 Patients Discharged from a Hospital-based Inpatient Psychiatric Setting with a Continuing Care Plan Provided to the Next Level of Care Clinician or Entity.

N UMERATOR Q4 2012 Q1 2013

P lease enter the number of psychiatric patients for whom 1-12 years old

t he post discharge continuing care plan was transmitted 13-17 years old

t o the next level of care. 18-64 years old

65 and over

D ENOMINATOR Q4 2012 Q1 2013

P lease enter the total number of psychiatric patients 1-12 years old

d ischarged for each age group. 13-17 years old

18-64 years old

65 and over

Q4 2012 Q1 2013

Measure rate of psychiatric patients who were discharged 1-12 years old

from a hospital-based inpatient psychiatric setting 13-17 years old

with a continuing care plan provided to the next level of care 18-64 years old

f or each age group. 65 and over

Overall

NOTE: Measure rates will be auto calculated from above entries.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX . The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.