PRMR Final MUC Recommendation Spreadsheet

RE: Feedback on Release of Measures Under Consideration List for 2023-2024 Review Cycle

We commend CMS’ recognition of the significant impact malnutrition has on all adult patient outcomes, as well as its consideration of the benefits of the expansion of the Global Malnutrition Composite Score (GMCS) (MUC2023-114) as an eCQM when extended to all adult ages 18 years or older. 

In its recent committee meeting, the Pre-Rulemaking Review (PRMR) committee identified areas for consideration with corresponding conditions for expansion of the GMCS to include all adults ages 18 and over. To best facilitate CMS’ decision making, each area of concern is outlined below along with supporting evidence.    

Increase involvement of more patient groups in further work in this measure, especially ensuring that certain measure components will not lead to limited patient autonomy. 

During the initial measure development, a National Dialogue Event was convened to identify barriers to malnutrition care, including representation from providers, payers, and patient advocacy groups. Patient representatives reported that, while the technical terminology of malnutrition may be challenging and emotionally charged, participation in shared decision making when assessing and treating malnutrition is key to preventing additional complications that may impact the patient’s quality of life.  Additionally, throughout the update process of the currently accepted GMCS, the Technical Expert Panel (TEP), which contains representation from patients and patient advocates, is consulted regularly to ensure any updates both reflect clinical practice and capture the patient voice.  Additional patient voices will be added to future TEPs to ensure adequate consideration of this unique perspective. 

This measure supports the interdisciplinary teams’ focus on the patient’s preferences regarding food choices, timing of meals, and/or self-feeding strategies within their individual, social and environmental circumstances.  The 2024 Scope and Standards of Practice for the RDN, a guidance document with standards to guide RDN practice, emphasize the provision of person-centered care with specific standards focused on collaboration with patients and their caregivers in the planning and provision of malnutrition care.

Finally, in designing measure logic and corresponding value sets, the measure steward and developer recognize the importance of patient autonomy in participating in nutrition assessment and/or care planning activities. Therefore, encounters can achieve high performance scores for each of these components even in a setting of a patient declining nutrition assessments and/or specific nutrition interventions with proper documentation.

The measure should include hospital-acquired malnutrition and high-risk nutritional practices in screening and assessment. 
A significant body of literature demonstrates that a patient’s nutritional status often declines during a hospitalization for a variety of reasons, including but not limited to restrictive diets, perceived poor meal quality, frequent use of fasting orders, mealtime interruptions, poor appetite, gastrointestinal symptoms, and low prioritization of nutrition by care providers.[3]  Therefore, identification of malnutrition risk and malnutrition developed during a hospitalization is essential to providing high-quality malnutrition care and improving patient outcomes. The current timing of the measure observations in the expanded GMCS does not preclude screening and assessments that occur later in the hospitalization from counting toward measure performance. Most hospital inpatient screening policies include rescreening if the initial screen is negative for malnutrition risk to capture those who may experience iatrogenic malnutrition. While the current logic does prioritize the absence of malnutrition risk and malnutrition, future updates will allow the measure steward to ensure changes in nutritional status and their associated care are accurately captured. 

Expansion of the GMCS to include all adults aged 18 and over will increase burden to both implementors and patients through increased staffing needs and increased rates of billing for services.

The GMCS is intended to capture facility performance in providing high-quality malnutrition care relative to a patient’s present or severity of malnutrition risk and/or malnutrition.  This optional eCQM is not expected to impact hospital staffing or clinical practices, as RDNs have long been established in providing cost-effective care and leading to cost savings through reductions in complications and both hospital and intensive care length of stay (LOS). The GMCS mirrors the well-established clinical workflows of RDNs in the provision of malnutrition care to adults in the acute care setting rather than proposing new workflows that may impact operational needs. 

Because this measure expansion is proposed for the IQR, billing for eligible patients will utilize the Medicare Severity Diagnosis Related Group (MS-DRG) system. Within this payment system, RDN assessments and interventions are not individually billed for; rather, they are considered a part of the bundled care provided to acute care patients.  

The GMCS too closely resembles the proposed Age Friendly Hospital Measure, which will result in duplicative reporting.

The Age Friendly Hospital Measure (MUC2023-196) evaluates a hospital’s commitment to improving care for adults aged 65 and older through five domains. One such domain, Frailty Screening and Intervention, requires hospitals to “screen for geriatric issues related to frailty including cognitive impairment/delirium, physical function/mobility, and malnutrition” at some point during the hospitalization with a recommendation to implement “nutrition plans where appropriate.” While elements of this measure may appear duplicative, there are several main differences. First, the Age Friendly Hospital measure includes only adults aged 65 and older, while the GMCS expansion will include all adults aged 18 and over. Additionally, the inclusion of nutrition screening represents only one of the four components of the GMCS; likewise, the Age Friendly Hospital measure requires only an attestation of completion of the steps, rather than true measurement and would therefore not capture malnutrition prevalence nor severity data critical to determining appropriate interventions. Therefore, while both proposed measures will allow hospitals to capture one similar element, duplicative reporting will not occur. 

In addition to aligning with several CMS goals, the proposed expansion (MUC2023-114) of the age range from 65 to 18 years of age or older is not expected to result in any additional reporting burden for reporting institutions because the data element of age is already being collected. 

Conclusion

The importance of identifying, diagnosing, and treating malnutrition continues to grow. Further, the relationship between malnutrition and food insecurity and its effects on health equity has been proven to be of importance and continues to be studied. Given the merit of the expansion of the measure age range to 18 years of age or older as described above, we strongly recommend that CMS consider adoption of the MUC 2023-114 into the Hospital IQR program.

The Academy of Nutrition and Dietetics and Avalere appreciate the continuous engagement of CMS pursuant to tackling malnutrition and improving quality care at the national level. We thank CMS for the continued engagement, and we look forward to working with you on future integration of these measures in the acute care setting and efforts to improve malnutrition quality of care across all care settings.

Please see attached letter for all appropriate references

The Age Friendly Hospital Measures proposed will have the greatest impact of any quality measure. The older adult population is responsible for so much of the cost of health care that even a small improvement will have enormous impact. This is also the right thing to do for patient autonomy and social vulnerability. These measures are simply good in every way.

Older adults are vulnerable patients and face inequities in healthcare due to their complex medical social needs and disabilities (functional, cognitive, hearing and vision etc).  Medical care that is often targeted at younger and less complex populations do not meet the needs of this large proportion of the medical community.  This leads to inequities in healthcare and does not maximize quality for a vulnerable population.  These measures are feasible and sensible, and elevate the care for the growing older population.  It is imperative for these to become measures, to ensure equity in healthcare.  

My name is Ariana Longley. I am submitting this public comment because I am a citizen concerned with patient safety. I experienced temporary minor harmed while seeking care but it could have been worse if I didn't speak up. I also work in the patient safety world and engage in activities like this that can positively impact patient safety. 

I applaud CMS for developing a Measures Under Consideration list that prioritizes patient safety and health equity.  Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect millions of patients. Recent data indicate that 1 out of 4 patients experience harm in hospitals, a quarter of which is preventable. An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis.

This year we’ll reach the 25^th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

MUC2023-048, MUC2023-049, and MUC2023-050: I strongly support the measures for Hospital Harm - Falls with Injury, Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure-to-Rescue), and Hospital Harm - Postoperative Respiratory Failure. The conditions detailed for all three measures are acceptable to me. 

MUC2023-146, 147, 148 and 149: I am pleased to see sub-measures for the Hospital Patient Experience of Care measures which elicit valuable insight from patients and their family/caregivers. I support all four measures around patient experience. 

MUC2023-188: I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag immensely. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices and hold them accountable.

MUC2023-219 and 2020: I strongly support the CLABSI And CAUTI measures as outlined, along with the considerations identified. 

Thank you for the opportunity to comment on these measures.

My name is John Laurence Adams.   I represent  _ (if commenting for an organization or network).  I am submitting this Public Comment because I lost my wife to medical error in 2017. My family and I were left with no support, so I know how valuable patient safety measures are. I was appalled to discover the immensity of the issue in this country and that information about medical errors is not shared or available to the public.  I support the CMS decision to approve the Patient Safety Structural Measure and urge that it be implemented as soon as possible to prevent additional death and suffering. 

I applaud CMS for developing a Measures Under Consideration list that prioritizes patient safety and health equity.  Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable. An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis.

This year we’ll reach the 25^th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

We also are grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. We are pleased to know our experience matters and that our input was heard.

Resources:
o   To Err is Human
o   One in four patients harmed:
§  Bates et al, New England Journal of Medicine
§  Office of the Inspector General
o   Diagnostic safety in the United States: 795,000 deaths or injuries annually, British Medical Journal

Specific PRMR Recommendations: We encourage patient safety and health equity advocates to especially pay attention to the following measures and address them in your Public Comment:

MUC2023-188: Patient Safety Structural Measure

n  Background:  This is a measure that asks hospital leaders to attest to whether their organization has established best practices in patient safety across 5 domains: 1) Leadership Commitment, 2) Strategy & Policy, 3) Culture of Safety & Learning, 4) Accountability & Transparency, and 5) Patient & Family Engagement. PFPS US strongly supports this recommendation. In the PRMR process, adoption was recommended with these conditions: “Publication of an implementation guide that documents how safety is to be measured and using data to narrow the scope before approving the measure for programs.”

n  Talking Point:  I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices.

Concerning the conditions articulated, we note: 1) The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work. 2) There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others.  While we welcome additional tools, there is no reason to wait on their development.

Resources:
o   Patient Safety Structural Measure: Full text
o   Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template
o   Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool
o   CANDOR (Communication and Optimal Resolution) Toolkit
o   World Health Organization’s Global Patient Safety Action Plan
o   Ascension Health Public Comment

My name is Rebeka Acosta and I am a Board Certified Patient Advocate with A+J Patient Advocacy in the Las Vegas, NV area. I applaud CMS for developing a MUC list that prioritizes patient safety and health equity.  I am also grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. It is a positive step forward knowing that patient experience matters and their input was heard.

Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable (https://www.nejm.org/doi/full/10.1056/NEJMsa2206117). An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis (https://qualitysafety.bmj.com/content/33/2/109).

This year we’ll reach the 25^th Anniversary of To Err is Human, the National Academy of Science's call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

MUC2023-188: Patient Safety Structural Measure: I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices.

The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work. There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others.  While we welcome additional tools, there is no reason to wait on their development.

My name is Rebeka Acosta and I am a Board Certified Patient Advocate with A+J Patient Advocacy in the Las Vegas, NV area. I applaud CMS for developing a MUC list that prioritizes patient safety and health equity.  I am also grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. It is a positive step forward knowing that patient experience matters and their input was heard.

Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable (https://www.nejm.org/doi/full/10.1056/NEJMsa2206117). An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis (https://qualitysafety.bmj.com/content/33/2/109).

This year we’ll reach the 25^th Anniversary of To Err is Human, the National Academy of Science's call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

MUC2023-196: Age-Friendly Hospital Measure: I am disappointed by the failure of the PRMR process to recommend the Age-Friendly Hospital Measure, especially given how much support there was articulated for its intent and evidence-based content. I agree with the comments expressed by the Hartford Foundation and the consortium of professional associations, led by the American College of Surgeons, who are the developers of this measure, that it has the potential to improve patient safety and outcomes for an increasingly vulnerable population of older Americans. Measures like this, which have a structural “attestation” component, are a useful complement to other outcome and process measures. They send a signal to organizational leadership and governance about what patients, policymakers, and medical professionals expect to see prioritized. Public reporting of the measure has the potential to be actionable information for older patients and their caregivers.

My name is Rebeka Acosta and I am a Board Certified Patient Advocate with A+J Patient Advocacy in the Las Vegas, NV area. I applaud CMS for developing a MUC list that prioritizes patient safety and health equity.  I am also grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. It is a positive step forward knowing that patient experience matters and their input was heard.

Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable (https://www.nejm.org/doi/full/10.1056/NEJMsa2206117). An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis (https://qualitysafety.bmj.com/content/33/2/109).

This year we’ll reach the 25^th Anniversary of To Err is Human, the National Academy of Science's call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

MUC2023-199: Connection to Community Service Provider

MUC2023-210: Resolution of At Least 1 Health-Related Social Need

I am disappointed by the failure to recommend the Connection to Community Service Provider measure and the Resolution of at least one Health-Related Social Need measure. I know that many hospitals are responsible for connecting patients in need to community resources and believe that organizations who are doing this should be acknowledged and given credit. I question whether hospitals will be viewed badly when a health-related social need is not resolved by a community-based service provider after a referral from the hospital. On the contrary, I see the value in shining a light on gaps in community resources when a hospital's demonstrated willingness to make referrals cannot be accomplished because needed safety net services are not available.

My name is Rebeka Acosta and I am a Board Certified Patient Advocate with A+J Patient Advocacy in the Las Vegas, NV area. I applaud CMS for developing a MUC list that prioritizes patient safety and health equity.  I am also grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. It is a positive step forward knowing that patient experience matters and their input was heard.

Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable (https://www.nejm.org/doi/full/10.1056/NEJMsa2206117). An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis (https://qualitysafety.bmj.com/content/33/2/109).

This year we’ll reach the 25^th Anniversary of To Err is Human, the National Academy of Science's call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

MUC2023-138: ESRD Dialysis Patient Life Goals Survey (PaLS): I believe it is important for dialysis treatment providers to prompt discussion with ESRD patients about life goals to ensure treatment aligns with individual preferences. While I share the concern that the tools needed to implement this measure are only available in English, I support the implementation of this measure and further work in expanding its availability in other languages.

The Age -Friendly  Hospital Measure is a first step towards providing high quality care for older adults and incentivizing providers to do the right thing for this vulnerable population.  Importantly, the measure was developed with input from multiple organizations that are working to improve care for older adults including  the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP). The measure incorporates essential elements of IHI’s Age-Friendly Health Systems program known as the 4Ms (What Matters, Medications, Mentation, Mobility), standards from ACEP’s Geriatric Emergency Department Accreditation (GEDA) framework, and ACS Geriatric Surgical Verification (GSV) standards.

I am asking CMS to move the Age Friendly Hospital measure forward into the hospital program as a participation measure. 

1. Age Friendly Measure is a New Type of Measure to Support Older Adults in the Hospital

The Age Friendly Hospital measure is a new type of measure, a “programmatic measure” that considers the full program of care needed for geriatric patients in the hospital. The American College of Surgeons (ACS) put forth the Age Friendly Hospital Measure as an initial strategic step to promote system thinking and cross-specialty actions that are essential for care coordination and collaboration between geriatricians and geriatric-based specialty care. It addresses high-priority areas for older patients using evidence-based process measures and the associated structural foundations necessary to support these clinical processes. The measure was developed through collaboration of the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP). It incorporates essential elements of IHI’s Age-Friendly Health Systems program known as the 4Ms (What Matters, Medications, Mentation, Mobility), standards from ACEP’s Geriatric Emergency Department Accreditation (GEDA) framework, and ACS Geriatric Surgical Verification (GSV) standards.

The programmatic approach is based on several decades of history implementing programs that demonstrably improve patient care provided by the clinical team, along with the facility. It is modeled after ACS quality programs, which have demonstrable improvements in patient outcomes.

2. Why is the measure important to put into the CMS IQR program?

Hospitals are increasingly faced with older patients who have complex medical, physiological, and psychosocial needs that are often inadequately addressed by the current healthcare infrastructure. The Age Friendly Hospital measure presents a quality program that addresses the current public health challenge facing the aging population—elements of responsibility, accountability, and data-driven improvement are programmatically applied for this population. Using this structure breaks down care siloes to create comprehensive care processes across the full spectrum of geriatric care.

The measure centers on the care of older adults in a facility, focusing on surgery, the emergency department (ED), and hospitalization (in general). These areas were targeted because this is where older adults are especially vulnerable. The measure incentivizes hospitals to take an integrated approach to the care of older adults by implementing multiple data-driven modifications to the entire clinical care pathway from the emergency department to the operating room to the inpatient units and beyond.

3. The Age Friendly Measure is Feasible

· Components of the Age Friendly Hospital Measure have been implemented nationally, demonstrating feasibility and usability of the measure. As of 2023, over 3400 sites of care participate in IHI’s Age-Friendly Health Systems

recognition in the movement, and GEDA verified programs are across 470 sites. ACS currently has thousands of delivery systems participating in programs with measures that follow the same framework as the Age Friendly Hospital Measure—over 60 hospitals participate in the ACS GSV program, and components of the GSV programs are in more than 500 ACS verified Trauma centers and 1500 CoC sites, to name a few. The GSV program has also been successfully implemented in multiple rural hospitals, demonstrating that it is feasible to meet these standards in various care settings.

4. History of Age Friendly Measure Revisions and Reviews

· The Age Friendly Hospital Measure (MUC 2023-196) is an updated measure that combines two measures previously reviewed by the National Quality Forum’s (NQF) Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC-2022-112) and the Geriatrics Surgical Measure (MUC-2022-032). The MAP Hospital Workgroups were very supportive of both measures, they conditionally supported the Geriatrics Surgical Measure with mitigating factors: 1) combining the two geriatric measures into a single measure that is less burdensome, or 2) focusing on only one measure.

· CMS has highlighted a need for a comprehensive measure that addresses the aging population during hospital stays. To support this effort, the Agency solicited comments on the measure concept in the 2024 Inpatient Prospective Payment System (IPPS) proposed rule.

5. Hospital-wide Age Friendly Hospital Measure Updated Based on Stakeholder Feedback

· Based on feedback received from the 2022 MUC process and FY 2024 IPPS proposed rule public comment, ACS developed the Age Friendly Hospital measure to streamline the previous measures and reduce burden. The measure now includes domains which target high-yield points of intervention for older adults—Eliciting Patient Healthcare Goals, Responsible Medication Management, Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition), Social Vulnerability (social isolation, economic insecurity, ageism, limited access to healthcare, caregiver stress, elder abuse), and Age-Friendly Care Leadership. The measure encourages hospital systems to rethink how they approach care for older patients with multiple medical, psychological, and social needs at highest risk for adverse events. It also emphasizes the importance of defining patient (and caregiver) goals.

· In January 2023, the Age Friendly Hospital Measure was included as part of the CMS/Battelle Pre-rulemaking Measure Review (PRMR), which reviews the upcoming measures under consideration for future inclusion of CMS quality programs. During the January 2023 PRMR Hospital Recommendation Meeting, 73.6% of the Recommendation Committee members voted in support of recommending the measure for inclusion in the Hospital IQR, but consensus is 75% which is why we are asking for additional support during this comment period. The measure concept has received broad support across organizations who care for older adults and was recently highlighted in Health Affairs (https://www.healthaffairs.org/content/forefront/need-geriatrics-measures). During the first round of PRMR comments, CMS received a total of 25 public comments on the Age Friendly Hospital Measure, with 20 comments in support of the measure and four in opposition. The ACS also submitted a sign-on letter that included signatures from 16 organizations that supported the implementation of the measure in the Hospital IQR.

There is an increasing influx of Baby Boomers (which is a large group of people with many healthcare needs) coming into the health care system which will only increase the burden on hospital systems and hospital staff. These Age Friendly Measures will support the work that needs to be done for these vulnerable patients to improve how we provide care and identify areas of need to improve patient outcomes. 

The Age Friendly Hospital Measure is a comprehensive plan of care for our older adults who need our support.  I am asking once again for CMS to move the Age Friendly Hospital measure forward into the hospital program as a participation measure.

Thank you in advance for your support.

1. Age Friendly Measure is a New Type of Measure to Support Older Adults in the Hospital.

The Age Friendly Hospital measure is a new type of measure, a “programmatic measure” that considers the full program of care needed for geriatric patients in the hospital. The American College of Surgeons (ACS) put forth the Age Friendly Hospital Measure as an initial strategic step to promote system thinking and cross-specialty actions that are essential for care coordination and collaboration between geriatricians and geriatric-based specialty care. It addresses high-priority areas for older patients using evidence-based process measures and the associated structural foundations necessary to support these clinical processes. The measure was developed through collaboration of the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI), and the American College of Emergency Physicians (ACEP). It incorporates essential elements of IHI’s Age-Friendly Health Systems program known as the 4Ms (What Matters, Medications, Mentation, Mobility), standards from ACEP’s Geriatric Emergency Department Accreditation (GEDA) framework, and ACS Geriatric Surgical Verification (GSV) standards.

· The programmatic approach is based on several decades of history implementing programs that demonstrably improve patient care provided by the clinical team, along with the facility. It is modeled after ACS quality programs, which have demonstrable improvements in patient outcomes.

2. Why is the measure important to put into the CMS IQR program?

· Hospitals are increasingly faced with older patients who have complex medical, physiological, and psychosocial needs that are often inadequately addressed by the current healthcare infrastructure. The Age Friendly Hospital measure presents a quality program that addresses the current public health challenge facing the aging population—elements of responsibility, accountability, and data-driven improvement are programmatically applied for this population. Using this structure breaks down care siloes to create comprehensive care processes across the full spectrum of geriatric care.

· The measure centers on the care of older adults in a facility, focusing on surgery, the emergency department (ED), and hospitalization (in general). These areas were targeted because this is where older adults are especially vulnerable. The measure incentivizes hospitals to take an integrated approach to the care of older adults by implementing multiple data-driven modifications to the entire clinical care pathway from the emergency department to the operating room to the inpatient units and beyond.

3. The Age Friendly Measure is Feasible

· Components of the Age Friendly Hospital Measure have been implemented nationally, demonstrating feasibility and usability of the measure. As of 2023, over 3400 sites of care participate in IHI’s Age-Friendly Health Systems

recognition in the movement, and GEDA verified programs are across 470 sites. ACS currently has thousands of delivery systems participating in programs with measures that follow the same framework as the Age Friendly Hospital Measure—over 60 hospitals participate in the ACS GSV program, and components of the GSV programs are in more than 500 ACS verified Trauma centers and 1500 CoC sites, to name a few. The GSV program has also been successfully implemented in multiple rural hospitals, demonstrating that it is feasible to meet these standards in various care settings.

4. History of Age Friendly Measure Revisions and Reviews

· The Age Friendly Hospital Measure (MUC 2023-196) is an updated measure that combines two measures previously reviewed by the National Quality Forum’s (NQF) Measures Application Partnership (MAP) in 2022: the Geriatrics Hospital Measure (MUC-2022-112) and the Geriatrics Surgical Measure (MUC-2022-032). The MAP Hospital Workgroups were very supportive of both measures, they conditionally supported the Geriatrics Surgical Measure with mitigating factors: 1) combining the two geriatric measures into a single measure that is less burdensome, or 2) focusing on only one measure.

· CMS has highlighted a need for a comprehensive measure that addresses the aging population during hospital stays. To support this effort, the Agency solicited comments on the measure concept in the 2024 Inpatient Prospective Payment System (IPPS) proposed rule.

5. Hospital-wide Age Friendly Hospital Measure Updated Based on Stakeholder Feedback

· Based on feedback received from the 2022 MUC process and FY 2024 IPPS proposed rule public comment, ACS developed the Age Friendly Hospital measure to streamline the previous measures and reduce burden. The measure now includes domains which target high-yield points of intervention for older adults—Eliciting Patient Healthcare Goals, Responsible Medication Management, Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition), Social Vulnerability (social isolation, economic insecurity, ageism, limited access to healthcare, caregiver stress, elder abuse), and Age-Friendly Care Leadership. The measure encourages hospital systems to rethink how they approach care for older patients with multiple medical, psychological, and social needs at highest risk for adverse events. It also emphasizes the importance of defining patient (and caregiver) goals.

· In January 2023, the Age Friendly Hospital Measure was included as part of the CMS/Battelle Pre-rulemaking Measure Review (PRMR), which reviews the upcoming measures under consideration for future inclusion of CMS quality programs. During the January 2023 PRMR Hospital Recommendation Meeting, 73.6% of the Recommendation Committee members voted in support of recommending the measure for inclusion in the Hospital IQR, but consensus is 75% which is why we are asking for additional support during this comment period. The measure concept has received broad support across organizations who care for older adults and was recently highlighted in Health Affairs (https://www.healthaffairs.org/content/forefront/need-geriatrics-measures). During the first round of PRMR comments, CMS received a total of 25 public comments on the Age Friendly Hospital Measure, with 20 comments in support of the measure and four in opposition. The ACS also submitted a sign-on letter that included signatures from 16 organizations that supported the implementation of the measure in the Hospital IQR.

AS Baby Boomers are aging and entering into our hospital system, we need to be better equipped to provide a age friendly program to identify needs and how to address them. There will be an increasing burden placed onto hospital systems and hospital staff without this program.  It is time to become more patient-centered and focus on specific challenges faced by patients  Please support the Age Friendly Hospital Measure into practice.

Jasmine Demos DNP, ANP-BC

My name is Deahna Visscher. I represent myself as a patient safety advocate. I am submitting this Public Comment because work is still needed in the world of patient safety.  Having lost my son to a medical error I am very aware of this need. I applaud CMS for developing a Measures Under Consideration list that prioritizes patient safety and health equity. Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable. An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis. 

This year we’ll reach the 25th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes. 

We also are grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review (PRMR) Process. We are pleased to know our experience matters and that our input was heard. 

Resources: 

• To Err is Human: To Err is Human: Building a Safer Health System - PubMed (nih.gov)

• One in four patients harmed: 

o Bates et al, New England Journal of Medicine: The Safety of Inpatient Health Care | NEJM

o Office of the Inspector General: Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018 OEI-06-18-00400 05-09-2022 (hhs.gov)

• Diagnostic safety in the United States: 795,000 deaths or injuries annually, British Medical Journal: Burden of serious harms from diagnostic error in the USA | BMJ Quality & Safety

Specific PRMR Recommendations: We encourage patient safety and health equity advocates to especially pay attention to the following measures and address them in your Public Comment: 

MUC2023-188: Patient Safety Structural Measure Background: This is a measure that asks hospital leaders to attest to whether their organization has established best practices in patient safety across 5 domains: 1) Leadership Commitment, 2) Strategy & Policy, 3) Culture of Safety & Learning, 4) Accountability & Transparency, and 5) Patient & Family Engagement. PFPS US strongly supports this recommendation. In the PRMR process, adoption was recommended with these conditions: “Publication of an implementation guide that documents how safety is to be measured and using data to narrow the scope before approving the measure for programs.” 

Talking Point: I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices. 

Concerning the conditions articulated, we note: 1) The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work. 2) There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others. While we welcome additional tools, there is no reason to wait on their development. 

Resources: 

• Patient Safety Structural Measure: Full text : PSSM PFPS US webinar 120623.pdf (cdn-website.com)

• Safer Together: National Action Plan to Advance Patient Safety | Institute for Healthcare Improvement (ihi.org)

• The National Action Plan to Advance Patient SafetyL 
• The National Action Plan Online Self-Assessment Tool: 
• The National Action Plan Implementation Resource Guide: 
• The Declaration to Advance Patient Safety template 
• Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool: Framework for Effective Board Governance of Health System Quality | Institute for Healthcare Improvement (ihi.org)
• CANDOR (Communication and Optimal Resolution) Toolkit : Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality (ahrq.gov)
• World Health Organization’s Global Patient Safety Action Plan: Global Patient Safety Action Plan 2021-2030 (who.int) 
• Ascension Health Public Comment: Ascension Comments_2023 Proposed MUC_12.22.23 (p4qm.org)

MUC2023-196: Age-Friendly Hospital Measure Background: The Age-Friendly Hospital Measure includes 5 domains that target high-yield points of intervention for older adults – 1) Eliciting Patient Healthcare Goals, 2) Responsible Medication Management, 3) Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition, 4) Social Vulnerability (social isolation, economic insecurity, ageism, limited access to health care, caregiver stress, elder abuse), and 5) Age-Friendly Care Leadership. The measure encourages hospitals to reconceptualize the way they approach care for older patients with multiple medical, psychological, and social needs at the highest risk for adverse events and attest to whether they are implementing evidence-based best practices. It also emphasizes the importance of defining patient and caregiver goals not only for the immediate treatment decision but also for long-term health and aligning care with what the patient values. It was developed by a consortium of medical societies, led by the American College of Surgeons, that have identified older patients as a particularly vulnerable population. During the PRMR process, the measure received substantial support for intent and content, but questions were raised as the value of attestation measures vs. outcome or process measures. No consensus was reached and so the measure was not recommended. PFPS US disagrees with this recommendation and strongly supports inclusion in the Proposed Rule. 

Resources: 

• Hartford Foundation Public Comment on the Age-Friendly Hospital Measure: JAHF Letter of Support Age-Friendly Hospital Measure Sign-On_0.pdf (p4qm.org)

Talking Point: I am disappointed by the failure of the PRMR process to recommend the Age[1]Friendly Hospital Measure, especially given how much support there was articulated for its intent and evidence-based content. We agree with the comments expressed by the Hartford Foundation and the consortium of professional associations, led by the American College of Surgeons, who are the developers of this measure, that it has the potential to improve patient safety and outcomes for an increasingly vulnerable population of older Americans. Measures like this, which have a structural “attestation” component, are a useful complement to other outcome and process measures. They send a signal to organizational leadership and governance about what patients, policymakers, and medical professionals expect to see prioritized. Public reporting of the measure has the potential to be actionable information for older patients and their caregivers. 

MUC2023-199: Connection to Community Service Provider 

MUC2023-210: Resolution of At Least 1 Health-Related Social Need 

Background: These two measures were discussed together during the PRMR process. MUC2023-199 tracks referrals of patients with health-related social needs (HRSNs) -- including food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety – who are referred to a Community Service Provider. MUC2023-210 tracks whether at least one of the HRSNs referred to a community service provider was resolved. There was support for the intent of the measure during the PRMR discussion, but a lot of concern was expressed that hospitals that make referrals to community organizations would be judged badly if the HRSN was not resolved by the community-based service provider. PFPS US disagrees with the recommendation and strongly supports the implementation of these two measures. 

Talking Point: I am disappointed by the failure to recommend the Connection to Community Service Provider measure and the Resolution of At Least 1 Health-Related Social Need measure. I know that many hospitals are responsible for connecting patients in need to community resources and believe that organizations who are doing this should be acknowledged and given credit. I question whether hospitals will be viewed badly when a health-related social need is not resolved by a community-based service provider after a referral from the hospital. On the contrary, I see the value in shining a light on gaps in community resources when a hospital's demonstrated willingness to make referrals cannot be accomplished because needed safety net services are not available. 

MUC2023-138: ESRD Dialysis Patient Life Goals Survey (PaLS) 

Background: The PaLS is a patient self-report survey that includes eight items related to dialysis facility care team discussions about patient life goals, including whether the organization tracks who talks to patients about their life goals. The goal of the measure is to provide contextual information for both the patient and the facility to guide care team discussions. During the PRMR process, concern was expressed about patient survey fatigue. Also, at the current time, the patient-reported survey tool is only available in English 

Talking Point: I believe it is important for dialysis treatment providers to prompt discussion with ESRD patients about life goals to ensure treatment aligns with individual preferences. While I share the concern that the tools needed to implement this measure are only available in English, I support the implementation of this measure and further work in expanding its availability in other languages.

My name is Deahna Visscher. I represent myself as a patient safety advocate. I am submitting this Public Comment because work is still needed in the world of patient safety.  Having lost my son to a medical error I am very aware of this need. I applaud CMS for developing a Measures Under Consideration list that prioritizes patient safety and health equity. Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable. An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis. 

This year we’ll reach the 25th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes. 

We also are grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review (PRMR) Process. We are pleased to know our experience matters and that our input was heard. 

Resources: 

• To Err is Human: To Err is Human: Building a Safer Health System - PubMed (nih.gov)

• One in four patients harmed: 

o Bates et al, New England Journal of Medicine: The Safety of Inpatient Health Care | NEJM

o Office of the Inspector General: Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018 OEI-06-18-00400 05-09-2022 (hhs.gov)

• Diagnostic safety in the United States: 795,000 deaths or injuries annually, British Medical Journal: Burden of serious harms from diagnostic error in the USA | BMJ Quality & Safety

Specific PRMR Recommendations: We encourage patient safety and health equity advocates to especially pay attention to the following measures and address them in your Public Comment: 

MUC2023-188: Patient Safety Structural Measure Background: This is a measure that asks hospital leaders to attest to whether their organization has established best practices in patient safety across 5 domains: 1) Leadership Commitment, 2) Strategy & Policy, 3) Culture of Safety & Learning, 4) Accountability & Transparency, and 5) Patient & Family Engagement. PFPS US strongly supports this recommendation. In the PRMR process, adoption was recommended with these conditions: “Publication of an implementation guide that documents how safety is to be measured and using data to narrow the scope before approving the measure for programs.” 

Talking Point: I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices. 

Concerning the conditions articulated, we note: 1) The best way to generate additional data across the 5 PSSM domains is to implement the PSSM as soon as possible so that attestation data about what hospitals are doing can be gathered, analyzed, and used in improvement work. 2) There currently exists several best practice implementation guides readily available to hospitals, including Safer Together: The National Action Plan to Advance Patient Safety, the National Action Plan Online Self-Assessment Tool, the National Action Plan Implementation Resource Guide, the Declaration to Advance Patient Safety template, the Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool, the CANDOR (Communication and Optimal Resolution) Toolkit, and the World Health Organization’s Global Patient Safety Action Plan, among others. While we welcome additional tools, there is no reason to wait on their development. 

Resources: 

• Patient Safety Structural Measure: Full text : PSSM PFPS US webinar 120623.pdf (cdn-website.com)

• Safer Together: National Action Plan to Advance Patient Safety | Institute for Healthcare Improvement (ihi.org)

• The National Action Plan to Advance Patient SafetyL 
• The National Action Plan Online Self-Assessment Tool: 
• The National Action Plan Implementation Resource Guide: 
• The Declaration to Advance Patient Safety template 
• Framework for Governance of Health System Quality and attendant support guides, The Governance of Quality Assessment tool: Framework for Effective Board Governance of Health System Quality | Institute for Healthcare Improvement (ihi.org)
• CANDOR (Communication and Optimal Resolution) Toolkit : Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality (ahrq.gov)
• World Health Organization’s Global Patient Safety Action Plan: Global Patient Safety Action Plan 2021-2030 (who.int) 
• Ascension Health Public Comment: Ascension Comments_2023 Proposed MUC_12.22.23 (p4qm.org)

MUC2023-196: Age-Friendly Hospital Measure Background: The Age-Friendly Hospital Measure includes 5 domains that target high-yield points of intervention for older adults – 1) Eliciting Patient Healthcare Goals, 2) Responsible Medication Management, 3) Frailty Screening and Intervention (i.e., Mobility, Mentation, and Malnutrition, 4) Social Vulnerability (social isolation, economic insecurity, ageism, limited access to health care, caregiver stress, elder abuse), and 5) Age-Friendly Care Leadership. The measure encourages hospitals to reconceptualize the way they approach care for older patients with multiple medical, psychological, and social needs at the highest risk for adverse events and attest to whether they are implementing evidence-based best practices. It also emphasizes the importance of defining patient and caregiver goals not only for the immediate treatment decision but also for long-term health and aligning care with what the patient values. It was developed by a consortium of medical societies, led by the American College of Surgeons, that have identified older patients as a particularly vulnerable population. During the PRMR process, the measure received substantial support for intent and content, but questions were raised as the value of attestation measures vs. outcome or process measures. No consensus was reached and so the measure was not recommended. PFPS US disagrees with this recommendation and strongly supports inclusion in the Proposed Rule. 

Resources: 

• Hartford Foundation Public Comment on the Age-Friendly Hospital Measure: JAHF Letter of Support Age-Friendly Hospital Measure Sign-On_0.pdf (p4qm.org)

Talking Point: I am disappointed by the failure of the PRMR process to recommend the Age[1]Friendly Hospital Measure, especially given how much support there was articulated for its intent and evidence-based content. We agree with the comments expressed by the Hartford Foundation and the consortium of professional associations, led by the American College of Surgeons, who are the developers of this measure, that it has the potential to improve patient safety and outcomes for an increasingly vulnerable population of older Americans. Measures like this, which have a structural “attestation” component, are a useful complement to other outcome and process measures. They send a signal to organizational leadership and governance about what patients, policymakers, and medical professionals expect to see prioritized. Public reporting of the measure has the potential to be actionable information for older patients and their caregivers. 

MUC2023-199: Connection to Community Service Provider 

MUC2023-210: Resolution of At Least 1 Health-Related Social Need 

Background: These two measures were discussed together during the PRMR process. MUC2023-199 tracks referrals of patients with health-related social needs (HRSNs) -- including food insecurity, housing instability, transportation problems, utility help needs, or interpersonal safety – who are referred to a Community Service Provider. MUC2023-210 tracks whether at least one of the HRSNs referred to a community service provider was resolved. There was support for the intent of the measure during the PRMR discussion, but a lot of concern was expressed that hospitals that make referrals to community organizations would be judged badly if the HRSN was not resolved by the community-based service provider. PFPS US disagrees with the recommendation and strongly supports the implementation of these two measures. 

Talking Point: I am disappointed by the failure to recommend the Connection to Community Service Provider measure and the Resolution of At Least 1 Health-Related Social Need measure. I know that many hospitals are responsible for connecting patients in need to community resources and believe that organizations who are doing this should be acknowledged and given credit. I question whether hospitals will be viewed badly when a health-related social need is not resolved by a community-based service provider after a referral from the hospital. On the contrary, I see the value in shining a light on gaps in community resources when a hospital's demonstrated willingness to make referrals cannot be accomplished because needed safety net services are not available. 

MUC2023-138: ESRD Dialysis Patient Life Goals Survey (PaLS) 

Background: The PaLS is a patient self-report survey that includes eight items related to dialysis facility care team discussions about patient life goals, including whether the organization tracks who talks to patients about their life goals. The goal of the measure is to provide contextual information for both the patient and the facility to guide care team discussions. During the PRMR process, concern was expressed about patient survey fatigue. Also, at the current time, the patient-reported survey tool is only available in English 

Talking Point: I believe it is important for dialysis treatment providers to prompt discussion with ESRD patients about life goals to ensure treatment aligns with individual preferences. While I share the concern that the tools needed to implement this measure are only available in English, I support the implementation of this measure and further work in expanding its availability in other languages.

I always thought I was getting patient-centered age-friendly medical care until I began working in a hospital system.  Then it became very clear that there was no such thing.  Older adults are often not treated with the same respect, value, and compassion as other demographics. Even with the IHI initiative too few systems are making an effort to become an age-friendly system and those that have the designation are performing at a minimal level (just enough to get the designation.)  There needs to be a much higher standard for age-friendly designation. The new measure seems to be raising the bar but until it is consistent throughout all systems the designation truly means compliance despite the complexity, it will not mean much.  There needs to be a deadline by which all hospitals and clinics should reach the designation of age-friendly and implement a comprehensive system that provides older adults with more continuity of care, more respect as valued human beings, and more specialty services.  I am very passionate about this issue and fully support the Age-Friendly Hospital Measure, as long as it is implemented with accountability and expertise. 

I'm in favor of the Age Friendly Hospital measure that encourages hospital systems to improve the care for older patients with multiple medical, psychological, and social needs at highest risk for adverse hospital events. I also like that it emphasizes the importance of defining patient goals and caregiver goals which should drive what we are striving for in our health care systems.

We need to understand that outpatient surgeries nowadays include surgeries that were, in the past, categorized as inpatient surgeries.  So what postoperative patient communication and education looks like to some surgery patients should look very different to others:  eg. a patient recovering from surgery on their wrist -versus a patient whose surgical repair of multiple skull fractures (orbital floor blowout, broken nose, moderate TBI) requires much more at home recovery instructions and the timing at which instructions are given (prior to surgery) should also differ- but unfortunately does not. 

Patients are provided after visit summary booklets without a staff taking enough time with the patient to go over and explain important details. 

Patient conditions such as grogginess from anesthesia, severe dizziness, severe pain or sensory impairments after surgery are not taken into account as learning barriers when this information is unrealistically dumped all at once onto them, especially when it is critical they learn because they will be recovering at home alone. 

Traumatic experience (eg. physical accident) that brought on the need for surgery also can affect cognitive communication skills which may cause a barrier to learning new information. 

Brain Injury (BI) and head trauma survivors, for instance, are not provided adequate learning accommodations- we are verbally given information despite our obvious impaired cognitive functioning and sensory overload (recovering from anesthesia felt like another concussion).  The instructions and after visit care summaries do not include how to address many of our BI symptoms- except to "get rest".  From learned experience, what would have been more effective:  1) provide accommodations especially when the patient is sensory- or communication- impaired, translations as necessary, provide in written form highlighting with a marker the important parts, apply other learning strategies, use alternative learning modalities, such as a video link to view later (eg. for demonstrating wound care), 2) a nurse calling by phone to check on us in 24 hrs  3) an at home visit by a Community Health Worker, SW or OT to repeat the discharge information, to examine our home environment for safety issues, to connect us with services to ensure the patient's safety, etc.   By safety I mean how not to burn your house down while preparing your food, fall prevention, home safety check, etc.

Dumping information onto the patient just before their release is not providing the individualized care we need, not an effective approach to delivering care;  it is done so they can check the box. 

They provide these educational communications of care within a 15 minute time frame when all the action taking place is busy and distracting. 

I am wondering whether this measure will distinguish between vulnerable patient populations, patients undergoing more urgent/ critical surgeries versus patients who are undergoing minor or more routine surgeries?   Will it encourage facilities to go over this information with the patient before surgery, rather than after, and to perform a more thorough assessment of their recovery needs, especially for certain vulnerable patient populations?

I do not know what the 9 items are on the survey, so I do not know whether they are sufficient to prepare a surgery outpatient, like myself, for their return to home- especially after a life-changing health event such as a complex head injury.  I hope my peers who are involved in this measure review are listening. 

Minnesota Department of Health Oral Health Program received a HRSA grant to implement an age-friendly dental health system. We strongly suggest adding oral health measures as mouth is a part of the body and oral health is related to general health.

As shared in our December 21, 2023 comments, the Kansas Hospital Association is concerned that the Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure to Rescue) disregards site of death. KHA believes that disregard for site of death in this measure introduces many scenarios outside of a hospital's control. It appears that this measure is an updated version of Patient Safety Indicator 4 (PSI 4), a longstanding IQR measure with low reliability. Assuming this measure continues to be based solely on billing data, it will continue to be of low reliability and subject to disconnects between performance captured in billing data and clinical reality that have long limited the utility of the PSI measures used in CMS programs. We appreciate that the committee acknowledges potential unintended consequences of this measure, but we disagree with the committee’s decision to recommend with conditions. KHA urges CMS not to adopt this measure until further study is conducted regarding the impact of disregarding site of death and potential changes needed to the exclusion criteria to make this a meaningful metric.  

The Kansas Hospital Association questions the validity of the excess days in acute care (EDAC) measures as noted in our December 21, 2023, comments. The EDAC measures: 117 - After Hospitalization for Acute MI (AMI); 119 - After Hospitalization for Heart Failure (HF); and 120 - After Hospitalization for Pneumonia (PN) with the readmissions being for all causes. If the measure is specific to a diagnosis, we believe that the readmission measure should be specific to the diagnosis as well. It seems inappropriate to add these measures for specific conditions, but then open up to all causes. This measure is especially concerning with regard to complex patients with multiple co-morbidities. Additionally, KHA questions whether the statute authorizing the Hospital Readmissions Reduction Program (HRRP) permits CMS to use the EDAC measures in the program. This concern stems from the statutory definition of readmissions at 42 USC 1395ww (q)(5)(E): “The term "readmission" means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge.” The HRRP statute does not contain the terms “emergency department” or “observation stay”. Furthermore, the definitions of “admissions” to inpatient beds, emergency department visits and observation stays are not used interchangeably in other CMS regulations. For example, emergency department visits in which a patient returns home to the community are not “admissions”. KHA notes that the PRMR committee did not reach consensus on 117, and recommended 119 and 120 with conditions. We urge CMS not to adopt the EDAC measures for the HRRP.

The Kansas Hospital Association questions the validity of the excess days in acute care (EDAC) measures as noted in our December 21, 2023, comments. The EDAC measures: 117 - After Hospitalization for Acute MI (AMI); 119 - After Hospitalization for Heart Failure (HF); and 120 - After Hospitalization for Pneumonia (PN) with the readmissions being for all causes. If the measure is specific to a diagnosis, we believe that the readmission measure should be specific to the diagnosis as well. It seems inappropriate to add these measures for specific conditions, but then open up to all causes. This measure is especially concerning with regard to complex patients with multiple co-morbidities. Additionally, KHA questions whether the statute authorizing the Hospital Readmissions Reduction Program (HRRP) permits CMS to use the EDAC measures in the program. This concern stems from the statutory definition of readmissions at 42 USC 1395ww (q)(5)(E): “The term "readmission" means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge.” The HRRP statute does not contain the terms “emergency department” or “observation stay”. Furthermore, the definitions of “admissions” to inpatient beds, emergency department visits and observation stays are not used interchangeably in other CMS regulations. For example, emergency department visits in which a patient returns home to the community are not “admissions”. KHA notes that the PRMR committee did not reach consensus on 117, and recommended 119 and 120 with conditions. We urge CMS not to adopt the EDAC measures for the HRRP.

The Kansas Hospital Association questions the validity of the excess days in acute care (EDAC) measures as noted in our December 21, 2023, comments. The EDAC measures: 117 - After Hospitalization for Acute MI (AMI); 119 - After Hospitalization for Heart Failure (HF); and 120 - After Hospitalization for Pneumonia (PN) with the readmissions being for all causes. If the measure is specific to a diagnosis, we believe that the readmission measure should be specific to the diagnosis as well. It seems inappropriate to add these measures for specific conditions, but then open up to all causes. This measure is especially concerning with regard to complex patients with multiple co-morbidities. Additionally, KHA questions whether the statute authorizing the Hospital Readmissions Reduction Program (HRRP) permits CMS to use the EDAC measures in the program. This concern stems from the statutory definition of readmissions at 42 USC 1395ww (q)(5)(E): “The term "readmission" means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge.” The HRRP statute does not contain the terms “emergency department” or “observation stay”. Furthermore, the definitions of “admissions” to inpatient beds, emergency department visits and observation stays are not used interchangeably in other CMS regulations. For example, emergency department visits in which a patient returns home to the community are not “admissions”. KHA notes that the PRMR committee did not reach consensus on 117, and recommended 119 and 120 with conditions. We urge CMS not to adopt the EDAC measures for the HRRP.

The Kansas Hospital Association appreciates that CMS is working to modernize the HCAHPS survey. However, our organization questions the validity and reliability of the newly proposed hospital patient experience of care questions. Specifically with regard to 147, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be treated and monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity, frequency of required monitoring, medication, therapies and other services. Further, KHA questions if all sub-measures would replace existing questions or be added to an already lengthy survey. Other questions include how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines. KHA requests that all of the newly proposed hospital patient experience of care measures undergo further validity and reliability testing before they are proposed for a CMS program.

The Kansas Hospital Association appreciates that CMS is working to modernize the HCAHPS survey. However, our organization questions the validity and reliability of the newly proposed hospital patient experience of care questions. Specifically with regard to 147, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be treated and monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity, frequency of required monitoring, medication, therapies and other services. Further, KHA questions if all sub-measures would replace existing questions or be added to an already lengthy survey. Other questions include how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines. KHA requests that all of the newly proposed hospital patient experience of care measures undergo further validity and reliability testing before they are proposed for a CMS program.

The Kansas Hospital Association (KHA) appreciates that CMS is working to modernize the HCAHPS survey. However, our organization questions the validity and reliability of the newly proposed hospital patient experience of care questions. Specifically with regard to 147, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be treated and monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity, frequency of required monitoring, medication, therapies and other services. Further, KHA questions if all sub-measures would replace existing questions or be added to an already lengthy survey. Other questions include how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines. KHA requests that all of the newly proposed hospital patient experience of care measures undergo further validity and reliability testing before they are proposed for a CMS program.

The Kansas Hospital Association (KHA) appreciates that CMS is working to modernize the HCAHPS survey. However, our organization questions the validity and reliability of the newly proposed hospital patient experience of care questions. Specifically with regard to 147, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be treated and monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity, frequency of required monitoring, medication, therapies and other services. Further, KHA questions if all sub-measures would replace existing questions or be added to an already lengthy survey. Other questions include how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines. KHA requests that all of the newly proposed hospital patient experience of care measures undergo further validity and reliability testing before they are proposed for a CMS program.

The Kansas Hospital Association (KHA) appreciates that CMS is working to modernize the HCAHPS survey. However, our organization questions the validity and reliability of the newly proposed hospital patient experience of care questions. Specifically with regard to 147, Restfulness of Hospital Environment, patients who require care in an inpatient setting will be treated and monitored, which by necessity will likely cause disruption in a patient's rest based on the patient's acuity, frequency of required monitoring, medication, therapies and other services. Further, KHA questions if all sub-measures would replace existing questions or be added to an already lengthy survey. Other questions include how data gleaned from these sub-measures could be used to improve performance, as the preliminary analysis noted that the measures are not based upon clinical practice guidelines. KHA requests that all of the newly proposed hospital patient experience of care measures undergo further validity and reliability testing before they are proposed for a CMS program.

The Kansas Hospital Association (KHA) appreciates the opportunity to comment on the social determinants of health and health equity measures. These three measures appear to be identical to the measures adopted in the Inpatient Quality Reporting program. Extending these measures to the Outpatient Quality Reporting (OQR) Program raises concerns in regard to resources needed for assessments and resolution of screened patients when hospitals continue to be challenged with significant workforce shortages. Additionally, KHA asks that CMS provide feedback on how the agency intends to use these health equity-related measures in the OQR. Does the agency intend to utilize the measures as it has with other measures used in both programs, such as the COVID-19 Vaccination Among Healthcare Personnel measure, where a single rate is reported at the facility level that includes both inpatient and outpatient services? KHA urges CMS to consider that many frontier and rural communities lack the resources needed to address health related social needs. Flexibility to screen for and refer to services that are available in rural communities is needed, as screening for issues for which there are no resources to address could undermine the health care provider - patient relationship.

The Kansas Hospital Association (KHA) appreciates the opportunity to comment on the social determinants of health and health equity measures. These three measures appear to be identical to the measures adopted in the Inpatient Quality Reporting program. Extending these measures to the Outpatient Quality Reporting (OQR) Program raises concerns in regard to resources needed for assessments and resolution of screened patients when hospitals continue to be challenged with significant workforce shortages. Additionally, KHA asks that CMS provide feedback on how the agency intends to use these health equity-related measures in the OQR. Does the agency intend to utilize the measures as it has with other measures used in both programs, such as the COVID-19 Vaccination Among Healthcare Personnel measure, where a single rate is reported at the facility level that includes both inpatient and outpatient services? KHA urges CMS to consider that many frontier and rural communities lack the resources needed to address health related social needs. Flexibility to screen for and refer to services that are available in rural communities is needed, as screening for issues for which there are no resources to address could undermine the health care provider - patient relationship.

The Kansas Hospital Association (KHA) appreciates the opportunity to comment on the social determinants of health and health equity measures. These three measures appear to be identical to the measures adopted in the Inpatient Quality Reporting program. Extending these measures to the Outpatient Quality Reporting (OQR) Program raises concerns in regard to resources needed for assessments and resolution of screened patients when hospitals continue to be challenged with significant workforce shortages. Additionally, KHA asks that CMS provide feedback on how the agency intends to use these health equity-related measures in the OQR. Does the agency intend to utilize the measures as it has with other measures used in both programs, such as the COVID-19 Vaccination Among Healthcare Personnel measure, where a single rate is reported at the facility level that includes both inpatient and outpatient services? KHA urges CMS to consider that many frontier and rural communities lack the resources needed to address health related social needs. Flexibility to screen for and refer to services that are available in rural communities is needed, as screening for issues for which there are no resources to address could undermine the health care provider - patient relationship.

The Kansas Hospital Association (KHA) is concerned that 199 - Connection to Community Service Provider - does not take into account many critical issues associated with connecting patients to services in rural and frontier communities. Many rural, especially frontier communities, do not have community service providers that can address or have the resources available to address health related social needs. We ask that there be an exclusion for patients residing in communities where there are no community service providers to address the patients' health related social needs, such as transportation, housing, food instability. Further, a significant safety concern is for patients who identify interpersonal safety as an issue. Documentation of any health related social need for patients who are victims of domestic violence could put those patients at increased risk. We believe that thoughtful consideration must be given to protecting patients who are victims of domestic violence and consider the unintended consequences of required reporting on this measure, and who would have access to the information provided to connect these patients to services.

Additionally, KHA is concerned that 210 - Resolution of at Least 1 Health-Related Social Need - will penalize hospitals in communities that do not have community service providers (CSPs) or other resources to address one or more health-related social needs. Rural and frontier communities lack CSPs with resources to address health-related social needs. Very few CSPs exist in rural Kansas communities that are able to address transportation, housing needs or food instability. Further, our organization has the same concern as expressed regarding measure 199 - Connection to a Community Service Provider - and protecting the identity of patients who are victims of domestic violence. Our organization requests that this measure be tabled until a reimbursement structure is developed to reimburse hospitals for connecting patients to CSPs who are able to resolve their health-related social needs. Further, we ask that patients who reside in communities that do not have a CSP to address their health-related social need be excluded. KHA is concerned that performance on this measure will be more reflective of factors outside of a hospital’s control, such as the economic health of the patient’s community or availability of community providers, than of provider performance.

The Kansas Hospital Association (KHA) is concerned that 199 - Connection to Community Service Provider - does not take into account many critical issues associated with connecting patients to services in rural and frontier communities. Many rural, especially frontier communities, do not have community service providers that can address or have the resources available to address health related social needs. We ask that there be an exclusion for patients residing in communities where there are no community service providers to address the patients' health related social needs, such as transportation, housing, food instability. Further, a significant safety concern is for patients who identify interpersonal safety as an issue. Documentation of any health related social need for patients who are victims of domestic violence could put those patients at increased risk. We believe that thoughtful consideration must be given to protecting patients who are victims of domestic violence and consider the unintended consequences of required reporting on this measure, and who would have access to the information provided to connect these patients to services.

Additionally, KHA is concerned that 210 - Resolution of at Least 1 Health-Related Social Need - will penalize hospitals in communities that do not have community service providers (CSPs) or other resources to address one or more health-related social needs. Rural and frontier communities lack CSPs with resources to address health-related social needs. Very few CSPs exist in rural Kansas communities that are able to address transportation, housing needs or food instability. Further, our organization has the same concern as expressed regarding measure 199 - Connection to a Community Service Provider - and protecting the identity of patients who are victims of domestic violence. Our organization requests that this measure be tabled until a reimbursement structure is developed to reimburse hospitals for connecting patients to CSPs who are able to resolve their health-related social needs. Further, we ask that patients who reside in communities that do not have a CSP to address their health-related social need be excluded. KHA is concerned that performance on this measure will be more reflective of factors outside of a hospital’s control, such as the economic health of the patient’s community or availability of community providers, than of provider performance.

The Kansas Hospital Association (KHA) supports MUC-212, Level 1 Denials Upheld Rate. KHA urges CMS to provide greater transparency around the extent to which Medicare Advantage Organizations (MAOs) engage in inappropriate coverage denials as well as accountability for those MAOs with high rates of denials. MUC-212 provides insight into whether MAOs are making appropriate initial coverage denial decisions by measuring the extent to which health plans themselves uphold their own Level 1 coverage denials. Lower performance on the measure would indicate that an MAO is being too aggressive in its initial coverage denial decisions and possibly applying more restrictive criteria than Traditional Medicare, thereby contributing to delays in beneficiaries receiving necessary care. This is especially important in the context of recent findings from the U.S. Department of Health and Human Services Office of Inspector General, which found that MAOs overturned 75 percent of their own initial denials upon appeal during a 2 year period, raising concerns that MA enrollees and their providers are routinely being denied services and payments that should have been provided. Inappropriate coverage denial decisions contribute significant administrative and cost burden to patients and health care providers. The inclusion of MUC-212 in the MA Star Ratings system would provide public visibility and financial consequences for denial rates, thereby discouraging MAOs from denying care inappropriately.

The United States continues to grapple with the opioid epidemic. From 1999-2021, approximately 280,000 people died due to prescription opioid overdoses, with the number having increased 5-fold since 1999. Prescription opioids account for more than 20% of all opioid-related deaths.

A key to addressing this continuing public health crisis, the Initial Opioid Prescribing – Long Duration measure fills a recognized need in opioid measurement and seeks to uncover opportunities to reduce progression to chronic opioid use and misuse upstream. Prescribing quantities based on duration of expected pain minimizes the risk of addiction, dependence, and overuse. Patients who progress to chronic opioid therapy will likely need support with future dose tapering and other unintended consequences that could be avoided through a proactive reduction in the initial opioid quantities prescribed.

In addition, the 2022 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain recommends that clinicians prescribe only the quantity needed for the treatment of acute pain based on the clinical scenario. Post-surgical prescribing represents a substantial proportion of the population included in this measure. Numerous studies have demonstrated that patients who receive opioids post-surgery either do not use opioids at all or in quantities substantially lower than prescribed. The CDC guideline also recommends against proactively prescribing additional opioids in case pain continues for longer than anticipated.

This measure promotes a patient-centered approach; failure to address initial causes of chronic opioid use may have the unintended consequence of putting patients at greater risk for long-term dependence and the associated morbidity and mortality risks.

We urge CMS to move the Age Friendly Hospital Measure forward into the hospital program as a participation measure. Age friendly care for older adults in the surgical setting is profoundly lacking as our hospitals and perioperative nurses struggle to meet older patients' complex medical, psychological and psychosocial needs. This new streamlined measure will help hospitals provide patient-centered and clinically effective surgical care for older patients. Importantly, this measure focuses on an initial understanding of older patient's health-related goals and treatment preferences, and includes ongoing medication management, frailty screening and intervention, and social vulnerability. Its use will also improve care by providing an age friendly patient champion or hospital committee to ensure compliance. Assessing hospital commitment to improving care for older patients will ensure friendlier and more effective hospital and surgical care for our nation's aging population. Thank you. 

I strongly support the implementation of the Patient Safety Structural Measure (PSSM) without delay, because it has the potential to improve patient safety and reinforce commitment to reducing health inequities. Some hospitals are doing an exemplary job of building a culture of safety that embraces best practices, while others lag. Public reporting of the attestations of hospital leaders will help Americans identify which hospitals have implemented patient safety and health equity best practices.

Inpatient falls go unnoticed and unreported; we do not know how often these events occur unless an noticeable outcome results, such as a major injury.  It would be rational to think that health professionals and their institutions who are patient safety-minded would want to reinforce the importance of collecting patient falls data by encouraging reporting from their staff, self-reports from their patients, by spreading a wide net, not this narrow a net which excludes the patient falls that result in "minor injuries".  

By excluding "minor injury" falls, the data obtained this measure will not indicate the frequency of falls that could have led to major injuries -but happened not to, just by chance.  The measure's value is less than it could be as a quality measure; it fails to quantify how often patients are exposed to situations and locations where they are at risk of fall during their hospital stay. 

Another opportunity missed by this measure is to elicit self-reports from their patients and families to further involve them in their care and to ensure that more of these safety events are reported.  By doing so it would use this opportunity to communicate and build relationship and trust with the patients, to collect more meaningful safety data and encourage patient participation in their own care. 

Another reason it would be important to patients that this measure include falls that result in a "minor injury": rarely is the person who fell evaluated for a possible traumatic brain injury (TBI).  A high percentage of attendees of brain Injury support groups with persistent symptoms had suffered a concussion from a fall: many go without diagnosis and suffer without treatment for months.  Likewise, we see with many patients who suffer physical trauma (eg. from a car accident) and are not evaluated for a TBI after release from the emergency department.  "Minor injury" may include a mild traumatic brain injury that can result in long term sequalae and therefore need to be included in this data.  

Also, this measure would provide more actionable information by tracking the causes of these "minor injury" falls (eg. patients were suffering conditions like vision impairments, balance conditions, are taking medications that lead to tiredness, dizziness, brain injury...) and whether the patient had been recognized as "at risk of fall", the information was noted in their medical records and monitored, yet they still fell despite being provided supposed interventions during their stay. 

This measure misses a critical opportunity to collect valuable information and greater insights for continuous quality improvement and patient safety.   

I serve on the Geriatric Surgery Verification Committee of the American College of Surgeons. Between 2018-2023 I led the initial pilot and the subsequent implementation of the Geriatric Surgery Verification standards in Kaiser Permanente Northern California in a 21 hospital system. We demonstrated improvements in the Death and Serious Morbidity (DSM) rates as measured by the National Surgical Quality Improvement Program (NSQIP) and also avoid non beneficial surgical treatment in select patients as evaluated by a multidisciplinary team of providers. This data has been presented at the national ACS Quality and Safety Conferences. I support the inclusion of Age Friendly Hospital designation criteria by CMS  as it would direct the care of the elderly to benefit those who would need the care as per their wishes but also use our resources in the areas of effective and appropriate care.

Our program has now been adopted in Kaiser Permanente Southern California.

I retired from Kaiser Permanente in 2023. I continue to serve on the ACS committee.

Please reach out to me if you have any questions 

MUC2023-179 -Initiation and Engagement of Substance Use Disorder Treatment (IET) Overall, a metric capturing the rate at which patients are started on MAT would be helpful to better understand where the gaps are in service delivery as well as understanding where patients are most successfully initiating on MAT. But I can see how this structured measure would be a data reporting burden as well as risk unfairly penalizing providers who may have offered MAT but the patient refused for various reasons. 

MUC2023-199 -Connection to Community Service Provider -

• Specifies a patient who screens positive for a health-related social need must “have contact” with a “community service provider” (CSP) within 60 days. CSPs are defined as “any independent, for-profit, non-profit, state, territorial, or local agency capable of addressing core or supplemental health-related social needs” This does not take into account patient eligibility to receive services offered in the community. Additionally, capacity for CSPs to receive new clients within 60 days varies by community.
• This measure does not include a hospital’s ability to address immediate social needs onsite, for example providing groceries from an on-site food pantry.
• It is unclear the value of tracking “contact” with a CSP. Unless hospitals are accessing Health Information Exchanges (HIEs) to monitor closed-loop referrals with CSPs, we cannot assume that “contact” is synonymous with resolution of social needs or that services were even received.
• Instead of a hospital quality measure, it would be helpful to better understand at a state level, and by community, what the demand for social services (housing, food, transportation) is and how well public entities are able to meet these needs. This measure assumes that services are plentiful, easily accessible by patients and sustainable given current funding and that hospitals need only promote “contact” between patients who screen positive and the CSP. Experiences of hospital social workers suggests other barriers to access exist.
• Strongly recommend partnering with UCSF SIREN professionals to develop this measure further. See specifically the newly published SIREN Social Care Conceptual Model.

MUC2023-210 -Resolution of At Least 1 Health-Related Social Need - • Measures “resolution” of identified social need within one year of discharge. What is defined as “resolution”? If a patient receives temporary housing or a few bags of groceries, this may fill an immediate need, but within the year the issue may not be resolved permanently. If the goal is to transition an individual into permanent housing, this is a better measure for HUD to use with local housing agencies and state departments of health.
• One year is a very long timeframe for an acute care hospital to be tracking patient progress. This is an important goal, but also denotes the need for a case manager. Frequently a Medicaid or community case manager may provide navigation of social services for patients. Housing, for example, can take many months or years to address adequately. This is perhaps a better payer or outpatient care quality measure.
• Uptake of community based social services is challenging to track without a health information exchange (HIE), community registry or other type of closed loop feedback system. Patients do not usually call a hospital to provide updates on resolution of social needs. While community health workers (CHWs) or cultural navigators can work intensively with patients to access services and troubleshoot challenges, this high-resource intervention is reserved for most vulnerable patients. Unfortunately, hospitals likely lack funding and staffing to offer CHW support to every patient who screens positive for a social need.
• Strongly recommend partnering with UCSF SIREN professionals to develop this measure further. See specifically the newly published SIREN Social Care Conceptual Model.
 

MUC2023-199 -Connection to Community Service Provider -

• Specifies a patient who screens positive for a health-related social need must “have contact” with a “community service provider” (CSP) within 60 days. CSPs are defined as “any independent, for-profit, non-profit, state, territorial, or local agency capable of addressing core or supplemental health-related social needs” This does not take into account patient eligibility to receive services offered in the community. Additionally, capacity for CSPs to receive new clients within 60 days varies by community.
• This measure does not include a hospital’s ability to address immediate social needs onsite, for example providing groceries from an on-site food pantry.
• It is unclear the value of tracking “contact” with a CSP. Unless hospitals are accessing Health Information Exchanges (HIEs) to monitor closed-loop referrals with CSPs, we cannot assume that “contact” is synonymous with resolution of social needs or that services were even received.
• Instead of a hospital quality measure, it would be helpful to better understand at a state level, and by community, what the demand for social services (housing, food, transportation) is and how well public entities are able to meet these needs. This measure assumes that services are plentiful, easily accessible by patients and sustainable given current funding and that hospitals need only promote “contact” between patients who screen positive and the CSP. Experiences of hospital social workers suggests other barriers to access exist.
• Strongly recommend partnering with UCSF SIREN professionals to develop this measure further. See specifically the newly published SIREN Social Care Conceptual Model.

MUC2023-210 -Resolution of At Least 1 Health-Related Social Need - • Measures “resolution” of identified social need within one year of discharge. What is defined as “resolution”? If a patient receives temporary housing or a few bags of groceries, this may fill an immediate need, but within the year the issue may not be resolved permanently. If the goal is to transition an individual into permanent housing, this is a better measure for HUD to use with local housing agencies and state departments of health.
• One year is a very long timeframe for an acute care hospital to be tracking patient progress. This is an important goal, but also denotes the need for a case manager. Frequently a Medicaid or community case manager may provide navigation of social services for patients. Housing, for example, can take many months or years to address adequately. This is perhaps a better payer or outpatient care quality measure.
• Uptake of community based social services is challenging to track without a health information exchange (HIE), community registry or other type of closed loop feedback system. Patients do not usually call a hospital to provide updates on resolution of social needs. While community health workers (CHWs) or cultural navigators can work intensively with patients to access services and troubleshoot challenges, this high-resource intervention is reserved for most vulnerable patients. Unfortunately, hospitals likely lack funding and staffing to offer CHW support to every patient who screens positive for a social need.
• Strongly recommend partnering with UCSF SIREN professionals to develop this measure further. See specifically the newly published SIREN Social Care Conceptual Model.
 

I am concerned that this measure does not include data from outpatients who had undergone surgery,  were released after surgery and then suffered harm and died within 30 days. We are now performing outpatient surgeries that had been considered in the past- and should still be categorized- as inpatient surgeries; we are releasing patients postoperative before they are ready to return home, before they meet release criteria.  How many surgery outpatients are sustaining harm or death as a result of these policies and practices, in addition to the inpatient postoperative deaths this measure would count? 

References: 

2023 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.  (Introduction)  https://www.cms.gov/oact/tr/2023

Televised News Report on Hospitals Patient Dumping before they are ready to return home. https://youtu.be/rFJsFdgMkYE?si=VYFAZPaw8e4F-ei5

A Patient Experience and Analysis of Outpatient Surgery that should be categorized as Inpatient Surgery. https://www.youtube.com/watch?v=2xh45ml9NgQ&t=5s

Will the measure collect the exact cause of death in addition to quantitative data?  We know several risk factors, such as age, chronic obstructive pulmonary disease, congestive heart failure, smoking, functional dependence, etc. can cause PRF.  Also, will the data collected by this measure include the age, race, etc.- a demographic breakdown of the patient?  

A televised news report shows us footage from a Milwaukie, Oregon police officer's body cam revealing that an unnamed hospital professional did not recognize the awake but unresponsiveness and nearly-skeletal body form of the patient on the gurney as "malnourished".  The man looked as though he survived a concentration camp.  But instead of administering care, the health professional told the police officer "This is behavioral, there is no medical reason to keep this patient," and requested the officer escort the discharged patient out of the hospital whereupon he died immediately in police custody.  

This televised case is one of thousands occurring in the US as clear evidence that our health professionals:  1)  discriminate against our most vulnerable patients  2) are too insensitive or ignorant of signs and symptoms to recognize a patient in need of malnutrition screening or 3) perform their nutritional screening poorly  3) use screening guidelines, process and tools that fail to identify malnourished patients  4) fail to act upon positive screening results, or are ignorant of services/ to whom they should refer the patient for further specialized care  5)  are more concerned about maintaining efficient patient flow and reducing hospital costs than harm done to patients  6) fail patients at other steps in the screening process.  A strong quality measure would help assess at which steps during this screening process are there gaps that patients fall through and identify where the system fails its patients.   

Reference: Investigations continue after patient discharged from Providence Milwaukie dies in police custody.  (video) https://www.youtube.com/watch?v=L0pnWL-biXw

My name is Sally Kerr and  I am submitting this Public Comment because  my 24 yr old daughter died in 2020 due to medical error. I have gone through the painful experience of reviewing detailed medical records and talking/learning the language of the medical field as the hospital did their best to deny accountability, not report the incident and to cover up the harm that caused  my daughter's death.  Having personally gone through the awfulness of this experience, I have since learned that I am not that unusual and that medical harm and denial is common throughout the industry; all to avoid the financial costs and reputational harm that the organization might incur. There needs to be accountability and learning from these types of experience, not just for the harmed patient and family, but to prevent such preventable situations from happening again.

I applaud CMS for developing a Measures Under Consideration list that prioritizes patient safety and health equity.  Preventable harm, bias, discrimination, and problems with timely, accurate diagnoses are embedded problems in our healthcare system that affect so many patients. Recent data indicates that 1 out of 4 patients experience harm in hospitals, much of it preventable. An alarming new study also finds that 795,000 people annually die or are harmed due to missed or delayed diagnoses, or the failure to communicate an accurate diagnosis.

This year we’ll reach the 25th Anniversary of To Err is Human, the National Academy of Sciences call to action on improving patient safety. We have not come close to reaching the patient safety goals outlined in that report. These challenges make CMS leadership on patient safety and health equity extremely important. As Americans, we expect our health systems to be safe for every patient, regardless of race, ethnicity, age, disability, LGBTQ+ status, or other patient demographics that now, too often, lead to disparate patient outcomes.

We also are grateful to see that patient experiences and expectations were considered in the Pre-Rulemaking Measure Review Process. We are pleased to know our experience matters and that our input was heard. Please do the right thing and help.
 

The term "Excess Days" concerns me, as a patient who required post-operative pain management after release from outpatient surgery -skull fracture repair which should be categorized as inpatient surgery- but did not receive it, and who a decade later experiences chronic nerve pain and required additional surgeries to repair postoperative damage.  So I ask: from whose perspective would a patient's need to stay in the hospital additional days be referred to as "excessive"?  Does this measure collect data on the true costs of harm done to patients who have been released too early and consequentially require additional care, to compare with recovery data from patients who had initially been provided a longer stay? 

Our national health system prioritizes optimizing patient flow efficiency and cutting costs¹ - to the point where we are kicking patients out of the hospital before they are ready to be discharged (they do not meet discharge criteria).  We watch televised news reports about patients being dumped on street corners still wearing their hospital gowns (Louisville, KY).²  Given these trends, we cannot honestly say that patients are receiving patient-centered care; we should instead say they receive "business model-driven care", care that fails to offer respect and dignity to them as a human being.  Patients are not gadgets being produced by a factory, but this is the underlying message the title delivers to patients like me.  We are 335 million Americans who need individualized patient care and with hundreds of thousands of us annually medically harmed by being discharged home too soon or otherwise denied care that we needed, I would like to see the language of this measure and its title changed.  The language of the measure's title feeds a narrative that erodes our patient rights to obtaining the care we need.

By considering only "days spent in Acute Care", I am concerned the measure does not collect data on the amount of medical harm done and the costs incurred by too early of a release: the amount of additional visits, procedures, treatments, etc. that must be performed as a result of too early of a release. This measure misses the opportunity to collect useful and meaningful data to help improve hospital care and patient safety for patients with AMI.

References: 

1) 2023 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.  Introduction.  https://www.cms.gov/oact/tr/2023

2)"It's like I'm worthless": Troubleshooters investigate patient dumping allegations. (video)  https://www.youtube.com/watch?v=rFJsFdgMkYE&list=PL_b37gS9bTWlNuk5m9m_AFNSbn1sy2tPs&index=3

Please see the attaches letter of support. 

RE: Feedback on Release of Measures Under Consideration List for 2023-2024 Review Cycle

I appreciate the opportunity to submit comments in support of MUC2023-114, the expansion of the Global Malnutrition Composite Score from 65 years of age and older to 18 years of age and older. Morrison Healthcare is one of the world’s largest Food and Nutrition Services contract companies, contracted with 900+ U.S. hospitals to employ and manages approximately 3,000 registered dietitian nutritionists (RDNs). As the Vice President of Nutrition and Wellness, I manage a team of RDNs that lead our clinical nutrition programs, wellness, and sustainability, a fully accredited dietetic internship, and oversee the organization’s regulatory and standardization processes. In 2020, we expanded the team to include a Corporate Director of Malnutrition, indicative of our value in identifying and treating patients with malnutrition. We now have added 3 Malnutrition Managers to help support our malnutrition program.

There is a high prevalence of malnutrition among hospitalized patients, but it frequently goes unrecognized, compounding other health conditions.  Up to 50% of all patients are at risk for or are malnourished at the time of hospital admission.¹ Only 7% of patients are typically diagnosed with malnutrition during their hospital stay.²  Malnutrition has a significant impact on patient outcomes as malnourished hospitalized adults have a 54% higher likelihood of hospital 30-day readmissions than those who are well-nourished.³ Patients with a malnutrition diagnosis and nutrition care plan had a 24% reduction in readmission risk vs those without a care plan for outlining intervention and treatment.⁴ 

Malnutrition is a leading cause of morbidity and mortality, especially among hospitalized adults. Hospitalized patients who are malnourished have a greater risk of complications, falls, pressure injuries, infections, and readmissions, and experience 4 to 6 days longer length of stay.  Because of the importance of identifying and treating malnutrition, we have developed an industry-leading program for our clinical nutrition managers to help them successfully move their malnutrition program forward. 

The endorsement and inclusion of MUC2023-114, expansion of the Global Malnutrition Composite Score from 65 years of age and older to 18 years of age and older, in the Hospital Inpatient Quality Reporting (IQR) program, will ultimately improve patient care outcomes through standardized identification and treatment of malnutrition.  In its recent committee meeting, the Pre-Rulemaking Review (PRMR) committee identified areas for consideration with corresponding conditions for expanding the GMCS to include all adults ages 18 and over.  Please see our comments below regarding specific areas of concern.

• Our malnutrition program focuses on all patients, not just those over 65. Expanding the GMCS to include 18 years of age and older will not burden the facility more because we are already identifying and treating malnutrition in patients of all ages. 
• One component of our program is establishing an interdisciplinary malnutrition committee to meet monthly. This communication helps ensure that all interdisciplinary team members have a voice regarding malnutrition care, which includes patient representation. 
• The dietitians’ scope of practice emphasizes the importance of person-centered care based on collaboration with patients and caregivers in planning nutrition interventions. 
• Morrison Healthcare’s policy on clinical nutrition care includes that a nutrition assessment be completed on all patients who exceed the average length of stay in the hospital. Since research shows that a patient’s nutrition status can decline during their hospital stay, we want to ensure these patients are assessed and treated for malnutrition if they do not screen at-risk upon admission. This is our standard of practice. 

On behalf of Morrison Healthcare, I appreciate the opportunity to submit these comments in support of MUC2023-114, the expansion of the Global Malnutrition Composite Score. This measure will not only enhance the quality of care for patients with malnutrition, but also address the social determinants of health that contribute to food insecurity and health disparities in our communities.  As an essential hospital partner, Morrison Healthcare is committed to advancing health equity and improving nutrition outcomes for all patients, regardless of age, race, ethnicity, income, or disability.

The term "Excess Days" concerns me as a patient who suffered post-operative harm because my hospital did not provide me the care I needed after my surgery. The term "Excess Days" concerns me because the phrase is not patient-centric, nor does it recognize the patient as an individual with individual needs that may deviate from standard hospital practices. 

Patient Safety also includes the use of language that does not cause emotional or psychological harm; the term "heart failure" could and should be replaced with another phrase such as "heart condition".  To use an analogy, if our children were categorized and labeled by school staff as "Academic Failure," their parents would be up in arms.  It has a demeaning effect on the individual, creates a poor mental outlook, increases the chance of self-fulfilling prophecy and can over time cause depression -where it is absolutely unnecessary and contrary to the health professionals' mission.  Similar to young students, patients fit the description of an emotionally, socially, psychologically and physically vulnerable population, too.  People with a trauma-informed approach understand the importance of using positivity whenever possible and treating patients with the respect and dignity they are due- we should not continue using the phrase merely out of professional habit. 

By only considering "days spent in Acute Care", the measure does not collect data on the amount of medical harm done to the patient, costs incurred by too early of a release, the amount of additional visits, procedures, treatments, etc. that must be performed as a result of their release too early.  Does this measure include data collection from patients who were discharged (too early) and then die at home?  Would this measure collect data from other outcomes?  It seems that this measure could collect a larger, more descriptive amount of data that could be more useful and meaningful to help improve hospital care and safety for patients with heart conditions.