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
New/worsen
ed PrU
Hi Risk PrU
New
Antipsychotic
Antipsychotic
Use
Self Report
Mod/Severe
Pain
Self Report
Mod/Severe
Pain
Long Stay
Fall Major
Injury
Restraint Use
Lo risk
Incontinence
Weight loss
Flu Vaccine
UTI
Depressive
symptoms
Pneumovax
Catheter
Pneumovax
ADL Decline
NH Compare Quality Measures
Flu Vaccine
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
Happy
Valley
★★
Survey Staffing
★
QM
★★★★ ★★★★★
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
Average
Below average
Much below average
These quintiles are not
always equally divided.
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
3.7
North Carolina
5.3
Kentucky
7.3
Illinois
Average
number of
citations
2/23/15
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
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.
10%
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
Nurse
RN
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
Target
Date
Jun 29
Q1
RUG
Data
Survey
Date
July 6
No RUG Data
for Q2 yet
Staffing Stars
assigned
Q4
Census
Some time in the future:
Q1
Q2
Q3
Target
Date
Jun 29
Survey
Date
July 6
Q4
Census
Q2 RUG Available
Staffing Stars
assigned
New Staffing Stars
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-AssessmentInstruments/NursingHomeQualityInits/SNF-Quality-Reporting.html
9/18/14: Improving Medicare Post-Acute
Care Transformation Act of 2014
• Requires development of cross postacute setting quality comparisons for
–Assessment and Quality Measures
–Quality care and improved outcomes
–Discharge Planning
–Interoperability
–Care coordination
Post Acute Settings
SNF
Require
skilled
therapy
5xW or
skilled Nsg
7xW
IRF
Therapy
15 hr wk
2 disc
MD 3xW
HHA
Be
homebound
Require
intermittent
skilled
therapy or
nsg
Standardization
LTCH
Stay > 25
days, rehab,
resp ther,
head
trauma,pain
mgt
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
Medical conditions and co-morbidities
Impairments
Other categories required by the Secretary
Use of Standardized
Assessment Data:
HHAs: no later than
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
Payment penalties will be for FY18
To be developed
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
Specification
thru rulemaking
Collect Data for
that measure 1
year later
Impose
penalties 2 yrs
later
SNF QRP Measures Finalized in FY16 rule making
Percent of Residents or Patients with
Pressure Ulcers That Are New or
Worsened (short stay)
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
addresses function (Part A stay)
Existing
SNF QMs
New
37
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 noncompliance
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
Q1 FY 2017
Q2, Q3, Q4 FY 2017
FY 2018
Penalties Apply
FY 2018
FY 2019
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
CMS will
keep 3050%
50-70%
will be
incentive
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