Measuring Quality in a SNF

for Medical Directors

5 Star Rating System
Quality Reporting Program
Value Based Purchasing

Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE

judy@judywilhide.com
909-800-9124

www. JudyWilhide.com
 Five Star Rating System
• Tool created by CMS in 2008 to help
consumers select and compare skilled nursing
care centers.
• Uses information from Health Care Surveys
(standard, focus and complaint), Quality
Measures, and Staffing
• CMS intends to move to a five star-rating
system for all of its "Compare" sites, "with a
goal of full transition to star ratings by 2016,”
– This will include hospitals.
Nursing Home Compare & Five Star Rating System
Review
 Actual Survey Reports
(redacted for HIPPA)
Details each citation with
state and national average
citations
Staffing

PT staff hours do not count in rating.

 Short Stay Long Stay Long Stay

New/worsen Fall Major

ed PrU Hi Risk PrU Injury

New Antipsychotic Restraint Use

Antipsychotic Use

Lo risk
Self Report Self Report Incontinence
Mod/Severe Mod/Severe
Pain Pain
Weight loss
Flu Vaccine UTI
Depressive
symptoms
Pneumovax Catheter
Pneumovax

ADL Decline
Flu Vaccine
NH Compare Quality Measures
Special Focus Facilities:
(a) have had a history of serious quality issues
and
(b) are included in a special program to
stimulate improvements in their quality of
care.
 2/23/15

Virginia North Carolina Florida

 New York Times 8/24/14
• Receiving a high star rating has never been
more important to nursing homes.
– Hospitals often use star ratings in referral
decisions
– Insurers consider them when setting up preferred
networks
– Often a first stop for investors and lenders, who
consult them to decide whether a nursing home
company is a safe bet.
– Many bundled payment projects require at least 3
stars
 Five Star Rating System Details
Survey ★
3 years Annual 36 months complaint

Staffing ★
+1 for 4 or 5 stars if above survey stars -1 for 1 Star

Quality Measures ★
+1 for 5 stars -1 for 1 Star

Overall Star Rating ★

You Shall Rise and Show Respect to the Aged

 Example:

Overall Survey Staffing QM

Happy
Valley ★★ ★ ★★★★ ★★★★★
Peaceful
Place ★★ ★★ ★★ ★★★★
Rocking
Retirement ★★★★ ★★★ ★★★★ ★★★★
Swinging
City ★★★★★ ★★★ ★★★★ ★★★★★
Terminal
Towers ★★ ★★★★ ★ ★
Quintile definition: divided into five equal
groups, based on performance

Best

Second best

Third best (or third worst)

Next to worst

Worst
 Each Domain Divides all NFs into quintiles
• All domains use different methods
• End result: assignment of 1-5 stars overall

★★★★★ Much above average

★★★★ Above average

These quintiles are not

★★★
always equally divided.
Average

★★ Below average

★ Much below average

 Survey Domain
• Comparison for survey stars is intra-state
– Accounts for different types of surveys and different approaches
to the survey process among states
• Deficiencies are assigned points based on scope
and severity
• All NFs in a state are lined up from best to worst
and split into quintiles
– Top 10% = 5 stars
– Bottom 20% = 1 star
• Line-up and rating are based on intrastate
comparisons
– Survey agencies and processes vary widely across the
country.
 Intra State Survey Comparisons

8.3 Virginia
Average
number of
3.7 North Carolina citations
2/23/15

5.3 Kentucky

7.3 Illinois
US Average: 6.8
 Complaint Survey Weights

1/6

1/2

1/3
 Revisits to Clear
Revisit Number Noncompliance Points
First 0
Second 50% of survey score added on
Third 70% of survey score added on
Fourth 85% of survey score added on

CMS experience is that providers that fail to demonstrate

restored compliance with safety and quality of care
requirements during the first revisit have lower quality of care
than other nursing homes. More revisits are associated with
more serious quality problems.

You Shall Rise and Show Respect to the Aged

 Intra-State Considerations
Since it’s all a ‘quintile system based on what percentage did the best and
worst, there is a wide variation between states in what the raw survey
score number translates to.

20% 23.3 23.3 23.3 10%

Cut point table posted every month. The month your survey is calculated, they
use this table to see how many stars to give you. Then your stars are fixed until
you get another survey.
 Staffing

• Considerable evidence of a relationship between nursing

home staffing levels and resident outcomes.
• Staffing Study found a clear association between nurse staffing
ratios and nursing home quality of care, identifying specific
ratios of staff to residents below which residents are at
substantially higher risk of quality problems.

You Shall Rise and Show Respect to the Aged

Staffing based on two case-mix adjusted measures, with equal weight.

Total
RN
Nurse
 Staffing Details
• Not a valid/reliable way to verify staffing
adequacy
• Facility reports staff hours worked in the last
full two week pay period that ends closest to
day 1 of the survey
• Census is from day 1 of survey
• Acuity is from end of last quarter closest to da
1 of survey
– Based on RUG scores
 Illustration:

Q1 Q2 Q3 Q4

Target Survey
Date Date Census
Jun 29 July 6
Q1
RUG No RUG Data
Data for Q2 yet

Staffing Stars
assigned
Some time in the future:

Q1 Q2 Q3 Q4

Target Survey
Date Date Census
Jun 29 July 6

Q2 RUG Available

Staffing Stars New Staffing Stars

assigned assigned
 Doing the math
Hoursadjusted =
(Hoursreported/Hoursexpected)*HoursNational average

Total Nurse Example

3 reported/ 6 expected = ½ x 4.0309 =
2.0154 adjusted hours

National Average Hours per Resident Day

Calculated April 2012
Total Nurse: 4.0309
RN: 0.7472

You Shall Rise and Show Respect to the Aged

 Five Star Quality Measures

The measures were selected based on their

validity and reliability, the extent to which facility
practice may affect the measure, statistical
performance, and importance.

Three quarters of MDS data is averaged

SNFs are assigned stars based on comparative
data with other SNFs
 5 Star Quality Measures
8 long stay (over 100 CDIF)
• ADL decline (Bed mob, toilet, transfer, eating)
• High-risk residents with pressure ulcers (St 2, 3 and 4 only)
• Indwelling catheter (exclusions: Neurogenic bladder, obstructive uropathy)
• Physically restrained (other than side rail, daily)
• UTI (Must have MD dx, tx, specific s/s, sig lab in 30 day lookback for MDS)
• Self-report moderate to severe pain (From MDS interview only)
• Fall with major injury (Fracture, dislocation, closed head inj w/altered
consciousness, subdural hematoma)
• Antipsychotic Use (Exclusions: Schizophrenia, Tourette's, Huntington’s)
• 3 short stay (< or = 100 CDIF)
• New/worsened pressure ulcers (St 2, 3, 4 only)
• Self-report moderate to severe pain (From MDS interview only)
• Newly received antipsychotic (Exclusions: Schizophrenia, Tourette's,
Huntington’s)
 IMPACT Act: SNF Quality Reporting System (QRS)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html
9/18/14: Improving Medicare Post-Acute
Care Transformation Act of 2014
• Requires development of cross post-
acute setting quality comparisons for
–Assessment and Quality Measures
–Quality care and improved outcomes
–Discharge Planning
–Interoperability
–Care coordination
 Post Acute Settings

IRF HHA LTCH

SNF Be
Therapy homebound Stay > 25
Require days, rehab,
skilled 15 hr wk Require resp ther,
therapy intermittent head
2 disc skilled
5xW or trauma,pain
MD 3xW therapy or mgt
skilled Nsg nsg
7xW

Standardization
Standardized Patient Assessment Data
• Requirements for reporting assessment data:
– Providers must submit standardized assessment data
through PAC assessment instruments
– Data must be collected at admission and discharge for
each patient, or more frequently as required
• Data categories:
– Functional status
– Cognitive function and mental status
– Special services, treatments, and interventions
Use of Standardized
– Medical conditions and co-morbidities Assessment Data:
– Impairments HHAs: no later than
– Other categories required by the Secretary January 1, 2019
SNFs, IRFs, and LTCHs: no
later than October 1,
2018
34
 QRP Measure Domains to be standardized:
Skin integrity and changes in skin integrity

Functional status, cognitive function, and changes in function and cognitive function

Incidence of major falls

Finalized in FY16 Rule;

Will be collected Oct 1 – Dec 31 2016
To be developed
Payment penalties will be for FY18

Medication reconciliation

Transfer of health information and care preferences when an individual transitions

Resource use measures, including total estimated Medicare spending per beneficiary

Discharge to community

All-condition risk-adjusted potentially preventable hospital readmissions rates.

Going Forward: New Measure Development will
Evolve Over Time

Measure Collect Data for Impose

Specification that measure 1 penalties 2 yrs
thru rulemaking year later later
SNF QRP Measures Finalized in FY16 rule making

Percent of Residents or Patients with

Pressure Ulcers That Are New or
Worsened (short stay)
Existing
SNF QMs
Percent of Residents Experiencing One or
More Falls with Major Injury (long stay)

Percent of patients/residents with an

admission and discharge functional
assessment and a care plan that New 37
addresses function (Part A stay)
 Data Collection
• For these QRP Measures:
– Collect data upon SNF admission & SNF discharge
• This is a new way to calculate QMs
• Data only collected/calculated on resident in a
Part A SNF stay
 QRP Measures
• First round with these 3 will be collected for
three months only
– Oct, Nov, Dec 2016
• Will only be collected on residents in a
Medicare Part A stay
– No other pay source, no MA plans
• Will be collected using:
– PPS 5 day MDS (existing)
– SNF Discharge (new)
• Upon discharge from a Part A stay
– Even if remaining in the SNF afterwards
QRP Measures Initial Year
Data collected Q1 FY17
Will have 5 ½ months
to submit/correct data
(5/15/17)
2% reduction in market
basket update for
ENTIRE FY18 for non-
compliance
 Non-Compliance
• Beginning FY18, 80% of all MDSs submitted
must contain 100% of the data elements
required to calculate the 3 QRP measures.
– No dashes in ANY calculator fields!
• Direct items
• Covariates
• Exclusions
• CMS intends to raise threshold going forward
through rulemaking
 Data collection period for penalties:
Phase In
(If CMS plans come to fruition)
Data Collected Penalties Apply
Q1 FY 2017 FY 2018
Q2, Q3, Q4 FY 2017 FY 2019
FY 2018 FY 2020

We have one year to perfect data collection systems!

We can expect more/different measures going forward
 Future updates to Pressure Ulcer QM under CMS
consideration: Would require revising QM and MDS

• Would include:
– New unstageable pressure ulcers, including
suspected deep tissue injuries (sDTIs)
– Stage 1 or 2 Pressure ulcers that become
unstageable due to slough/eschar
 Percent of patients/residents with an admission and
discharge functional assessment and a care plan that
addresses function

• In first three days of SNF stay, must be at least

one fxn goal
• New section added to SNF MDS upon admit and
DC only
• At the time of discharge, function is reassessed
using the same 6-level rating scale, to evaluate
success in achieving goals
– Unplanned discharge: Fxl status reporting will not be
required
 Percent of patients/residents with an admission and
discharge functional assessment and a care plan that
addresses function

• Requires new data elements on PPS 5 day and

“SNF discharge” assessments
– SNF DC assessment will be at the time of DC from
the Part A stay, even if resident does not leave
• 30% of SNF residents stay in facility after SNF discharge
• Initial goals and fxl status must be determined
no later than day 3 of SNF stay
 SNF measures under future consideration

• SNF 30-day all-cause readmission measure

• Application of the payment standardized
Medicare spending per beneficiary
• Percentage of residents at discharge
assessment, who are discharged to a higher
level or to the community
• Potentially preventable readmissions
• Drug regimen review with follow-up for
identified issues
 Protecting Access to
Medicare Act (PAMA)
of 2014

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

VALUE BASED PURCHASING

INITIATIVE
 Overview
• SNF payment rate must be based, in part, on
performance on this measure starting Oct 1, 2018
• SNFs with the highest rankings must receive the
highest incentive payments
– SNFs with the lowest rankings receiving the lowest (or
zero) incentive payments.
– Lowest 40 percent of SNFs (by ranking) will be
reimbursed less than they otherwise would be
reimbursed without the SNF VBP program.
Funding: CMS will withold 2% of SNF
Medicare payments starting 10/1/18

50-70%
CMS will will be
keep 30- incentive
50% payments
to SNFs.
Measure estimates risk-standardized rate of all-cause, unplanned
hospital readmissions of SNF Medicare beneficiaries within 30 days
of discharge from their prior proximal acute hospitalization

• Claims based

• Readmissions within 30-day window are counted regardless of

whether the beneficiary is readmitted directly from SNF or had
been discharged from SNF

• Risk-adjusted based on patient demographics, principal

diagnosis in prior hospitalization, comorbidities, and other health
status variables that affect probability of readmission

• Excludes planned readmissions since these are not indicative of

poor quality
 Exclusions:
• Hospital principal dx
– cancer
– rehabilitation, fitting of prosthetics, adjustment of devices
– pregnancy
• Pts who did not have Medicare A coverage for 12 months
preceding hospital discharge
– Or for full 30 day window
• Post acute admission in 30 day window
• More than 1 day between the hospital discharge and the SNF
admission
• Discharge AMA
 Calculation:

Based on Standardized Risk Ratio (SRR):

Ratio > 1 = high quality

Ratio < 1 = poorer quality

SNF’s Risk Standardized Readmission Rate (RSSR):

SRR x Overall national raw readmission rate for all SNFs
• CMS is required to replace this measure with
an all-condition, risk-adjusted potentially
preventable hospital readmission rate. CMS
advises it intends to address this topic in
future rulemaking.
– Under development
PAYROLL BASED JOURNAL (PBJ)
 PBJ: Payroll Based Journal
• Staffing and census data be collected for each fiscal quarter
through the QIES ASAP System
• Includes hours worked by each staff member each day within
the quarter
– administration, physician services, nursing services, pharmacy
services, dietary services, therapeutic services, dental services,
podiatry services, mental health services, vocational services, clinical
laboratory services, diagnostic x-ray services, administration & storage
of blood, housekeeping services, other services.
• Census data is census on the last day of the quarter.
• Strict guidelines for timeliness of submission
– If out of compliance subject to enforcement actions not yet defined.

• Voluntary October 1, 2015.

• Mandatory July 1, 2016
 PBJ: Goals
• Staffing is a vital components of a nursing home’s
ability to provide quality care.
• Over time, CMS has utilized staffing data for a
myriad of purposes in an effort to more
accurately and effectively gauge its impact on
quality of care in nursing homes.
• The data, when combined with census
information, can then be used:
– To report on SNF staffing levels
– To report on employee turnover and tenure
• Which can impact the quality of care delivered.
 Submission Timeliness
• Submissions must be received by the end of
the 45th calendar day (11:59 PM Eastern
Standard Time) after the last day in each fiscal
quarter.
• Facilities may enter and submit data at any
frequency throughout a quarter.
• The last accepted submission received before
the deadline will be considered the facility’s
final submission.
 Accuracy:

• Staffing information is required to be an

accurate and complete submission of a
facility’s staffing records. CMS will conduct
audits to assess a facility’s compliance related
to this requirement.
Medicare and Medicaid Programs; Reform of Requirements for
Long-Term Care Facilities PFR 7/16/15

• When this improved staffing data is collected

at the nursing home level, more accurate and
reliable estimates of the care hours provided
by staff categories will be available, potentially
leading to updated research and
reconsideration of HPRD requirements and
recommendations.
Medicare and Medicaid Programs; Reform of Requirements for
Long-Term Care Facilities PFR 7/16/15

• Our intent is to require facilities to make

thoughtful, informed staffing plans and decisions
that are focused on meeting resident needs,
including maintaining or improving resident
function and quality of life.
• We maintain that such an approach is essential to
person-centered care.
• At this time, we have deferred deciding on any
potential specific requirement pending evaluation
of additional data that will be collected on payroll
based staffing data.
FOCUSED SURVEYS: A NEW
HORIZON
 Focused Surveys
• MDS/Staffing: Pilot complete; In nationwide
roll-out, Phase 1
• Dementia Care: Pilot complete, Expansion in
2015 on a voluntary basis
– Texas conducting a comprehensive survey effort
with more states expected to participate
• 7/17/15: Focused Survey on Medication
Safety Systems has begun pilot testing
 Impact
• Small number chosen by methods not
publically reported
• Surveys open or continue an enforcement
cycle
• Once out of “pilot” also contribute to 5 Star
rating
• May not be combined with annual survey
• DISCUSSION
Questions/Discussion