Mclaren Northern Michigan


About the Facility

CMS Certification Number (CCN)
23T105
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
416 Connable Ave.
Phone Number
(502) 596-6346

Facility Medical Condition Statistics

All other conditions
33
Brain disease or condition (non-traumatic)
11
Brain injury (traumatic)
18
Hip or femur fracture
21
Hip or knee replacement, amputation or other bone or joint condition
31
Nervous system disorder (excluding stroke)
11
Spinal cord disease or condition (non-traumatic)
14
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
37

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
21
Predicted number of infections (B)
0.047
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
169
Denominator
169
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.7
Denominator
144
Average observed change score
12.4
Change in patients ability to move around
Average risk-adjusted change score
33.0
Denominator
144
Average observed change score
34.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
97
Denominator
144
Facility rate
67.4
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
89
Denominator
144
Facility rate
61.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
169
Facility rate
0.6
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
0.427
Comparative performance category
Better than the National Benchmark
Patient days
11,377
Predicted number of infections (B)
7.021
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
38
Number of health care workers
41
Rate of flu vaccination
92.7
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
22
Number of eligible stays
252
Unadjusted potentially preventable readmission rate
8.73
Risk-standardized potentially preventable readmission rate (RSRR)
9.24
Lower limit of the 95% confidence interval on the RSRR
7.27
Upper limit of the 95% confidence interval on the RSRR
11.50
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
12
Number of eligible stays
268
Unadjusted potentially preventable readmission rate
4.48
Risk-standardized potentially preventable readmission rate (RSRR)
5.10
Lower limit of the 95% confidence interval on the RSRR
3.46
Upper limit of the 95% confidence interval on the RSRR
7.59
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)
138
Number of eligible stays
198
Observed discharge to community rate
69.70
Risk-standardized discharge to community rate
66.01
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
60.54
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.51
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.97
Number of eligible episodes
223
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
168
Denominator
169
Facility rate
99.4
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
167
Facility observed rate
0.0
Facility risk-adjusted rate
0.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
34
Number of health care workers
37
Rate of COVID-19 vaccination
91.9