CMS-10432 Substance Use Measure Collection

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

Online Data Entry Tool Content for Substance Use Measure Collection

Fiscal Year (FY) 2019 and Subsequent Years

IPFs should complete this form using the fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Substance Use - SUB-1: Alcohol Use Screening

NUMERATOR CY 2017

T he number of patients who were screened for alcohol use

using a validated screening questionnaire for unhealthy

drinking within the first three days of admission

D ENOMINATOR CY 2017

The number of hospitalized inpatients 18 years of age and older

IPFs should complete this form using the fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Substance Use - SUB-2: Alcohol Use Brief Intervention Provided or Offered

N UMERATOR CY 2017

The number of patients who received or refused a brief intervention

DENOMINATOR CY 2017

T he number of hospitalized inpatients 18 years of age and older

who screen positive for unhealthy alcohol use or an alcohol use disorder

(alcohol abuse or alcohol dependence)

IPFs should complete this form using the fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Substance Use - SUB-2a: Alcohol Use Brief Intervention

NUMERATOR CY 2017

The number of patients who received a brief intervention

DENOMINATOR CY 2017

T he number of hospitalized inpatients 18 years of age and older

who screen positive for unhealthy alcohol use or an alcohol use disorder

(alcohol abuse or alcohol dependence)

IPFs should complete this form using the fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Substance Use - SUB-3: Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge

NUMERATOR CY 2017

T he number of patients who received or refused at discharge

a prescription for medication for treatment of alcohol or drug use disorder OR

received or refused a referral for addictions treatment

D ENOMINATOR CY 2017

The number of hospitalized inpatients 18 years of age and older identified

with an alcohol or drug use disorder

IPFs should complete the form in a fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Substance Use - SUB-3a: Alcohol and Other Drug Use Disorder Treatment at Discharge

NUMERATOR CY 2017

T he number of patients who received a prescription at discharge

for medication for treatment of alcohol or drug use disorder OR a referral for

addictions treatment

DENOMINATOR CY 2017

T he number of hospitalized inpatients 18 years of age and older identified

with an alcohol or drug use disorder

PRA Disclosure Statement

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 0938-1171.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 estimates(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, MD 21244-1650. Expiration Date: xx/xx/xxxx

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