Up Health System - Marquette


About the Facility

CMS Certification Number (CCN)
23T054
Ownership Type
Government
CMS Region
Chicago
Certification Date
Address
850 W Baraga Ave
Phone Number
(906) 449-3800

Facility Medical Condition Statistics

All other conditions
73
Brain disease or condition (non-traumatic)
27
Brain injury (traumatic)
28
Hip or femur fracture
19
Hip or knee replacement, amputation or other bone or joint condition
38
Nervous system disorder (excluding stroke)
33
Spinal cord disease or condition (non-traumatic)
11
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
44

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Catheter days
286
Predicted number of infections (B)
0.592
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
269
Denominator
269
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.5
Denominator
246
Average observed change score
14.3
Change in patients ability to move around
Average risk-adjusted change score
33.7
Denominator
246
Average observed change score
38.0
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
186
Denominator
246
Facility rate
75.6
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
173
Denominator
246
Facility rate
70.3
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
269
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.379
SIR 95% confidence interval - upper limit
4.052
Comparative performance category
No Different than the National Benchmark
Patient days
4,297
Predicted number of infections (B)
2.015
Number of infections reported (A)
3
SIR (A/B)
1.489
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
53
Number of health care workers
83
Rate of flu vaccination
63.9
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
19
Number of eligible stays
257
Unadjusted potentially preventable readmission rate
7.39
Risk-standardized potentially preventable readmission rate (RSRR)
8.47
Lower limit of the 95% confidence interval on the RSRR
6.76
Upper limit of the 95% confidence interval on the RSRR
10.54
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
6
Number of eligible stays
272
Unadjusted potentially preventable readmission rate
2.21
Risk-standardized potentially preventable readmission rate (RSRR)
3.76
Lower limit of the 95% confidence interval on the RSRR
2.47
Upper limit of the 95% confidence interval on the RSRR
5.59
Comparative performance category
No Different than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
165
Number of eligible stays
228
Observed discharge to community rate
72.37
Risk-standardized discharge to community rate
71.25
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
66.19
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
75.87
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.92
Number of eligible episodes
252
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
267
Denominator
269
Facility rate
99.3
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
268
Facility observed rate
0.7
Facility risk-adjusted rate
1.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
38
Number of health care workers
44
Rate of COVID-19 vaccination
86.4