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Public Act 096-1130


 

Public Act 1130 96TH GENERAL ASSEMBLY

  
  
  

 


 
Public Act 096-1130
 
SB3743 EnrolledLRB096 20325 KTG 36190 b

    AN ACT concerning public aid.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 1. Short title. This Act may be cited as the Long
Term Acute Care Hospital Quality Improvement Transfer Program
Act.
 
    Section 5. Purpose of Act. The General Assembly finds that
it is vital for the State of Illinois to find methods to
improve the health care outcomes of patients served by the
healthcare programs operated by the Department of Healthcare
and Family Services. Improving a patient's health not only
benefits the patient's quality of life but also results in a
more efficient use of the resources needed to provide care.
Estimates show that the Long Term Acute Care Hospital Quality
Improvement Transfer Program established under this Act could
save approximately $10,000,000 annually. The program focuses
on some of the most severely injured and ill patients in the
State of Illinois. It is designed to better utilize the
specialized services available in the State to improve these
patients' health outcomes and to enhance the continuity and
coordination of care for these patients. This program serves as
one of the many pieces needed to reform the State of Illinois'
healthcare programs to better serve the people of the State of
Illinois.
 
    Section 10. Definitions. As used in this Act:
    (a) "CARE tool" means the Continuity and Record Evaluation
(CARE) tool. It is a patient assessment instrument that has
been developed to document the medical, cognitive, functional,
and discharge status of persons receiving health care services
in acute and post-acute care settings. The data collected is
able to document provider-level quality of care (patient
outcomes) and characterize the clinical complexity of
patients.
    (b) "Department" means the Illinois Department of
Healthcare and Family Services.
    (c) "Discharge" means the release of a patient from
hospital care for any discharge disposition other than a leave
of absence, even if for Medicare payment purposes the discharge
fits the definition of an interrupted stay.
    (d) "FTE" means "full-time equivalent" or a person or
persons employed in one full-time position.
    (e) "Hospital" means an institution, place, building, or
agency located in this State that is licensed as a general
acute hospital by the Illinois Department of Public Health
under the Hospital Licensing Act, whether public or private and
whether organized for profit or not-for-profit.
    (f) "ICU" means intensive care unit.
    (g) "LTAC hospital" means a hospital that is designated by
Medicare as a long term acute care hospital as described in
Section 1886(d)(1)(B)(iv)(I) of the Social Security Act and has
an average length of Medicaid inpatient stay greater than 25
days as reported on the hospital's 2008 Medicaid cost report on
file as of February 15, 2010, or a hospital that begins
operations after January 1, 2010 and is designated by Medicare
as a long term acute care hospital.
    (h) "LTAC hospital criteria" means nationally recognized
evidence-based evaluation criteria that have been publicly
tested and includes criteria specific to an LTAC hospital for
admission, continuing stay, and discharge. The criteria cannot
include criteria derived or developed by or for a specific
hospital or group of hospitals. Criteria and tools developed by
hospitals or hospital associations or hospital-owned
organizations are not acceptable and do not meet the
requirements of this subsection.
    (i) "Patient" means an individual who is admitted to a
hospital for an inpatient stay.
    (j) "Program" means the Long Term Acute Care Hospital
Quality Improvement Transfer Program established by this Act.
    (k) "STAC hospital" means a hospital that is not an LTAC
hospital as defined in this Act or a psychiatric hospital or a
rehabilitation hospital.
 
    Section 15. Qualifying Hospitals.
    (a) Beginning October 1, 2010, the Department shall
establish the Long Term Acute Care Hospital Quality Improvement
Transfer Program. Any hospital may participate in the program
if it meets the requirements of this Section as determined by
the Department.
    (b) To participate in the program a hospital must do the
following:
        (1) Operate as an LTAC hospital.
        (2) Employ one-half of an FTE (designated for case
    management) for every 15 patients admitted to the hospital.
        (3) Maintain on-site physician coverage 24 hours a day,
    7 days a week.
        (4) Maintain on-site respiratory therapy coverage 24
    hours a day, 7 days a week.
    (c) A hospital must also execute a program participation
agreement with the Department. The agreement must include:
        (1) An attestation that the hospital complies with the
    criteria in subsection (b) of this Section.
        (2) A process for the hospital to report its continuing
    compliance with subsection (b) of this Section. The
    hospital must submit a compliance report at least annually.
        (3) A requirement that the hospital complete and submit
    to the Department the CARE tool (the most currently
    available version or an equivalent tool designated and
    approved for use by the Department) for each patient no
    later than 7 calendar days after discharge.
        (4) A requirement that the hospital use a patient
    satisfaction survey specifically designed for LTAC
    hospital settings. The hospital must submit survey results
    data to the Department at least annually.
        (5) A requirement that the hospital accept all
    clinically approved patients for admission or transfer
    from a STAC hospital with the exception of STAC hospitals
    identified in paragraphs (1) and (2) under subsection (a)
    of Section 25 of this Act. The patient must be evaluated
    using LTAC hospital criteria approved by the Department for
    use in this program and meet the appropriate criteria.
        (6) A requirement that the hospital report quality and
    outcome measurement data, as described in Section 20 of
    this Act, to the Department at least annually.
        (7) A requirement that the hospital provide the
    Department full access to patient data and other data
    maintained by the hospital. Access must be in compliance
    with State and federal law.
        (8) A requirement that the hospital use LTAC hospital
    criteria to evaluate patients that are admitted to the
    hospital to determine that the patient is in the most
    appropriate setting.
 
    Section 20. Quality and outcome measurement data.
    (a) For proper evaluation and monitoring of the program,
each LTAC hospital must provide quality and outcome measurement
data ("measures") as specified in subsections (c) through (h)
of this Section to the Department for patients treated under
this program. The Department may develop measures in addition
to the minimum measures required under this Section.
    (b) Two sets of measures must be calculated. The first set
should only use data for medical assistance patients, and the
second set should include all patients of the LTAC hospital
regardless of payer.
    (c) Average LTAC hospital length of stay for patients
discharged during the reporting period.
    (d) Adverse outcomes rates: Percent of patients who expired
or whose condition worsens and requires treatment in a STAC
hospital.
    (e) Ventilator weaning rate: Percent of patients
discharged during the reporting period who have been
successfully weaned off invasive mechanical ventilation.
    (f) Central Line Infection Rate per 1000 central line days:
Number of patients discharged from an LTAC hospital during the
reporting period that had a central line in place and developed
a bloodstream infection 48 hours or more after admission to the
LTAC hospital.
    (g) Acquired pressure ulcers per 1000 patient days.
    (h) Falls with injury per 1000 patient days: Number of
falls among discharged LTAC hospital patients discharged
during the reporting period, who fell during the LTAC hospital
stay, regardless of distance fallen, that required an ancillary
or surgical procedure (i.e. x-ray, MRI, sutures, surgery, etc.)
 
    Section 25. Quality improvement transfer program.
    (a) The Department may exempt the following STAC hospitals
from the requirements in this Section:
        (1) A hospital operated by a county with a population
    of 3,000,000 or more.
        (2) A hospital operated by a State agency or a State
    university.
    (b) STAC hospitals may transfer patients who meet criteria
in the LTAC hospital criteria and are medically stable for
discharge from the STAC hospital.
    (c) A patient in a STAC hospital may be exempt from a
transfer if:
        (1) The patient's physician does not issue an order for
    a transfer;
        (2) The patient or the individual legally authorized to
    make medical decisions for the patient refuses the
    transfer; or
        (3) The patient's care is primarily paid for by
    Medicare or another third party. The exemption in this
    paragraph (3) of subsection (c) does not apply to a patient
    who has exhausted his or her Medicare benefits resulting in
    the Department becoming the primary payer.
 
    Section 30. LTAC hospital duties.
    (a) The LTAC hospital must notify the Department within 5
calendar days if it no longer meets the requirements under
subsection (b) of Section 15.
    (b) The LTAC hospital may terminate the agreement under
subsection (c) of Section 15 with 30 calendar days' notice to
the Department.
    (c) The LTAC hospital must develop patient and family
education materials concerning the Program and submit those
materials to the Department for review and approval.
    (d) The LTAC hospital must retain the patient's admission
evaluation to document that the patient meets the LTAC hospital
criteria and is eligible to receive the LTAC supplemental per
diem rate described in Section 35 of this Act.
 
    Section 35. LTAC supplemental per diem rate.
    (a) The Department must pay an LTAC supplemental per diem
rate calculated under this Section to LTAC hospitals that meet
the requirements of Section 15 of this Act for patients:
        (1) who upon admission to the LTAC hospital meet LTAC
    hospital criteria; and
        (2) whose care is primarily paid for by the Department
    under Title XIX of the Social Security Act or whose care is
    primarily paid for by the Department after the patient has
    exhausted his or her benefits under Medicare.
    (b) The Department must not pay the LTAC supplemental per
diem rate calculated under this Section if any of the following
conditions are met:
        (1) the LTAC hospital no longer meets the requirements
    under Section 15 of this Act or terminates the agreement
    specified under Section 15 of this Act;
        (2) the patient does not meet the LTAC hospital
    criteria upon admission; or
        (3) the patient's care is primarily paid for by
    Medicare and the patient has not exhausted his or her
    Medicare benefits, resulting in the Department becoming
    the primary payer.
    (c) The Department may adjust the LTAC supplemental per
diem rate calculated under this Section based only on the
conditions and requirements described under Section 40 and
Section 45 of this Act.
    (d) The LTAC supplemental per diem rate shall be calculated
using the LTAC hospital's inflated cost per diem, defined in
subsection (f) of this Section, and subtracting the following:
        (1) The LTAC hospital's Medicaid per diem inpatient
    rate as calculated under 89 Ill. Adm. Code 148.270(c)(4).
        (2) The LTAC hospital's disproportionate share (DSH)
    rate as calculated under 89 Ill. Adm. Code 148.120.
        (3) The LTAC hospital's Medicaid Percentage Adjustment
    (MPA) rate as calculated under 89 Ill. Adm. Code 148.122.
        (4) The LTAC hospital's Medicaid High Volume
    Adjustment (MHVA) rate as calculated under 89 Ill. Adm.
    Code 148.290(d).
    (e) LTAC supplemental per diem rates are effective for 12
months beginning on October 1 of each year and must be updated
every 12 months.
    (f) For the purposes of this Section, "inflated cost per
diem" means the quotient resulting from dividing the hospital's
inpatient Medicaid costs by the hospital's Medicaid inpatient
days and inflating it to the most current period using
methodologies consistent with the calculation of the rates
described in paragraphs (2), (3), and (4) of subsection (d).
The data is obtained from the LTAC hospital's most recent cost
report submitted to the Department as mandated under 89 Ill.
Adm. Code 148.210.
 
    Section 40. Rate adjustments for quality measures.
    (a) The Department may adjust the LTAC supplemental per
diem rate calculated under Section 35 of this Act based on the
requirements of this Section.
    (b) After the first year of operation of the Program
established by this Act, the Department may reduce the LTAC
supplemental per diem rate calculated under Section 35 of this
Act by no more than 5% for an LTAC hospital that does not meet
benchmarks or targets set by the Department under paragraph (2)
of subsection (b) of Section 50.
    (c) After the first year of operation of the Program
established by this Act, the Department may increase the LTAC
supplemental per diem rate calculated under Section 35 of this
Act by no more than 5% for an LTAC hospital that exceeds the
benchmarks or targets set by the Department under paragraph (2)
of subsection (a) of Section 50.
    (d) If an LTAC hospital misses a majority of the benchmarks
for quality measures for 3 consecutive years, the Department
may reduce the LTAC supplemental per diem rate calculated under
Section 35 of this Act to zero.
    (e) An LTAC hospital whose rate is reduced under subsection
(d) of this Section may have the LTAC supplemental per diem
rate calculated under Section 35 of this Act reinstated once
the LTAC hospital achieves the necessary benchmarks or targets.
    (f) The Department may apply the reduction described in
subsection (d) of this Section after one year instead of 3 to
an LTAC hospital that has had its rate previously reduced under
subsection (d) of this Section and later has had it reinstated
under subsection (e) of this Section.
    (g) The rate adjustments described in this Section shall be
determined and applied only at the beginning of each rate year.
 
    Section 45. Program evaluation.
    (a) After the Program completes the 3rd full year of
operation on September 30, 2013, the Department must complete
an evaluation of the Program to determine the actual savings or
costs generated by the Program, both on an aggregate basis and
on an LTAC hospital-specific basis. The evaluation must be
conducted in each subsequent year.
    (b) The Department and qualified LTAC hospitals must
determine the appropriate methodology to accurately calculate
the Program's savings and costs.
    (c) The evaluation must also determine the effects the
Program has had in improving patient satisfaction and health
outcomes.
    (d) If the evaluation indicates that the Program generates
a net cost to the Department, the Department may prospectively
adjust an individual hospital's LTAC supplemental per diem rate
under Section 35 of this Act to establish cost neutrality. The
rate adjustments applied under this subsection (d) do not need
to be applied uniformly to all qualified LTAC hospitals as long
as the adjustments are based on data from the evaluation on
hospital-specific information. Cost neutrality under this
Section means that the cost to the Department resulting from
the LTAC supplemental per diem rate must not exceed the savings
generated from transferring the patient from a STAC hospital.
    (e) The rate adjustment described in subsection (d) of this
Section, if necessary, shall be applied to the LTAC
supplemental per diem rate for the rate year beginning October
1, 2014. The Department may apply this rate adjustment in
subsequent rate years if the conditions under subsection (d) of
this Section are met. The Department must apply the rate
adjustment to an individual LTAC hospital's LTAC supplemental
per diem rate only in years when the Program evaluation
indicates a net cost for the Department.
    (f) The rate adjustments described in this Section shall be
determined and applied only at the beginning of each rate year.
 
    Section 50. Duties of the Department.
    (a) The Department is responsible for implementing,
monitoring, and evaluating the program. This includes but is
not limited to:
        (1) Collecting data required under Section 15 and data
    necessary to calculate the measures under Section 20 of
    this Act.
        (2) Setting annual benchmarks or targets for the
    measures in Section 20 of this Act or other measures beyond
    the minimum required under Section 20. The Department must
    consult participating LTAC hospitals when setting these
    benchmarks and targets.
        (3) Monitoring compliance with all requirements of
    this Act.
    (b) The Department shall include specific information on
the Program in its annual medical programs report.
    (c) The Department must establish monitoring procedures
that ensure the LTAC supplemental payment is only paid for
patients who upon admission meet the LTAC hospital criteria.
The Department must notify qualified LTAC hospitals of the
procedures and establish an appeals process as part of those
procedures. The Department must recoup any LTAC supplemental
payments that are identified as being paid for patients who do
not meet the LTAC hospital criteria.
    (d) The Department must implement the program by October 1,
2010.
    (e) The Department must create and distribute to LTAC
hospitals the agreement required under subsection (c) of
Section 15 no later than September 1, 2010.
    (f) The Department must notify Illinois hospitals which
LTAC hospital criteria are approved for use under the program.
The Department may limit LTAC hospital criteria to the most
strict criteria that meet the definitions of this Act.
    (g) The Department must identify discharge tools that are
considered equivalent to the CARE tool and approved for use
under the program. The Department must notify LTAC hospitals
which tools are approved for use under the program.
    (h) The Department must notify Illinois LTAC hospitals of
the program and inform them how to apply for qualification and
what the qualification requirements are as described under
Section 15 of this Act.
    (i) The Department must notify Illinois STAC hospitals
about the operation and implementation of the program
established by this Act. The Department must also notify LTAC
hospitals that accepting transfers from the STAC hospitals
identified in paragraphs (1) and (2) under subsection (a) of
Section 25 of this Act are not required under paragraph (5) of
subsection (c) of Section 15 of this Act. The Department must
notify LTAC hospitals that accepting transfers from the STAC
hospitals identified in paragraphs (1) and (2) under subsection
(a) of Section 25 of this Act shall negatively impact the
savings calculations under the Program evaluation required by
Section 40 of this Act and shall in turn require the Department
to initiate the penalty described in subsection (d) of Section
40 of this Act.
    (j) The Department shall deem LTAC hospitals qualified
under Section 15 of this Act as qualifying for expedited
payments.
    (k) The Department may use up to $500,000 of funds
contained in the Public Aid Recoveries Trust Fund per State
fiscal year to operate the program under this Act. The
Department may expand existing contracts, issue new contracts,
issue personal service contracts, or purchase other services,
supplies, or equipment.
    (l) The Department may promulgate rules as allowed by the
Illinois Administrative Procedure Act to implement this Act;
however, the requirements under this Act shall be implemented
by the Department even if the Department's proposed rules are
not yet adopted by the implementation date of October 1, 2010.
 
    Section 99. Effective date. This Act takes effect upon
becoming law.

Effective Date: 7/20/2010