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CMS QUALITY MEASURES FOR NURSING HOMES: CHANGES AND CHALLENGES

CMS created the Five-Star Quality Rating System to help consumers, families, and facilities evaluate performance of nursing homes. Included in the ratings are Quality Measures which are derived from resident assessment data collected at specified intervals during a stay in the nursing home. The intended purposes of the Quality Measures are:

  • Provide information about the Quality of Care at nursing homes to help the public choose a nursing home
  • Prompt consumers to talk to nursing home staff about the Quality of Care
  • Provide data to the nursing home to help with Quality Improvement efforts
  • Provide data to the State Survey Agency for Inspection

With the implementation of the MDS 3.0, Quality Measures have changed.  The new Quality Measures will become an enhanced set of publicly reported information available on Nursing Home Compare in mid-July. Providers will have a 1-month preview before the data is publicly released.

The Quality Measures continue to be categorized into two types: short stay (or post-acute) and long stay (or chronic) measures. 

Short stay measures are related to:

  • Self-reported moderate to severe pain
  • Provision of flu vaccine
  • Provision of pneumococcal vaccine

Long stay measures are related to:

  • Provision of flu vaccine
  • Provision of pneumococcal vaccine
  • Self-reported moderate to severe pain
  • High risk residents with pressure ulcers
  • Utilization of physical restraints
  • Falls with major injury
  • Depressive symptoms
  • Urinary tract infection
  • Catheter inserted and left in bladder
  • Low risk residents who lose Bowel/Bladder control
  • Excessive weight loss
  • Increase in need for help with ADL’s

Although the measures do not appear to be significantly different from those based on the MDS 2.0, there are changes in the resident and record selection processes. 

Resident Sample Selection

 An episode is a period of time consisting of one or more stays. It starts with a new admission and ends with a permanent discharge.  During that time, the resident may be out of the facility for a hospitalization, leave of absence, etc.  These days are not counted in calculating Cumulative Days in Facility (CDIF).

A stay is the time that a resident is physically in the facility or CDIF. When the resident leaves the facility for any reason, this completes a stay and when the resident returns a new stay begins.

The Cumulative Days in Facility (CDIF) defines the resident sample, with Short Stay CDIF up to 100 days and Long Stay CDIF counting from 101 days. As a result of the methodological shift, more residents are included in the Short Stay measures. The MDS 2.0 measures were limited, using PPS assessments to Day 14. Now all assessments, including OBRA and PPS assessments for residents are included for Short and Long Stays.

Record Selection

Requirements for a qualifying assessment are not based on having an ARD within the Target Period, but are based on the resident’s Episode. Due to this, as assessment can be included even if the ARD is not in the Target Period.  In addition, some measures include a look-back scan, in which all assessments within an episode are included. For example, the measure for falls with major injury could include assessments going back to one year if they are contained in an episode.

As a result of these changes, it is critical that providers know where residents are in terms of episodes and stays. Providers must have a reliable, effective means of using clinical data to determine trends, challenges and risks, and promote quality improvement. Being quality focused will improve clinical outcomes, reduce professional liability claims, potentially lower insurance premiums, and improve resident satisfaction. Well performing facilities benefit from fewer survey deficiencies, higher occupancy rates and a positive public perception.

Tags: nursing home operations, medicare