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5 Star Quality Rating System Changes from CMS

Nursing Home Compare 3.0: Revisions to the Nursing Home Compare 5-Star Quality Rating System

On Friday, February 20, 2015, the Centers for Medicare & Medicaid Services (CMS) will unveil Nursing Home Compare (NHC) 3.0, an expanded and strengthened NHC 5-Star Quality Rating System for Nursing Homes on the CMS Nursing Home Compare website (Medicare.gov/nursinghomecompare). CMS will complete the following actions:  

  • Add 2 Quality Measures (QMs): for antipsychotic medication use in nursing homes to the 5- Star calculations.  One measure is for short-stay residents when a nursing home begins use of antipsychotics for people without diagnoses of schizophrenia, Huntington’s disease, or Tourette syndrome, and a second measure reflects continued use of such medications for long-stay nursing home residents without diagnoses of schizophrenia, Huntington’s disease, or Tourette syndrome.
  • Raise Performance Expectations: by raising the standards for nursing homes to achieve a high rating on all publicly reported measures in the Quality Measures category on the website.
  • Adjust Staffing Algorithms: to more accurately reflect staffing levels. Nursing homes must earn 4-stars on either the individual Registered Nurse (RN) only or the staffing categories to receive 4-stars on the Overall staffing rating and can have no less than a 3-star rating on any of those dimensions.
  • Expand Targeted Surveys: a plan for State Survey Agencies to conduct specialized, onsite surveys of a sample of nursing homes across the U.S. that assess adequacy of resident assessments and the accuracy of information reported to CMS that is used in calculating quality measures used in the rating system.  A report on the results of the pilot surveys completed in 2014 in five states will be available after February 23, 2015 at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html.

The changes in ratings reflect that CMS raised the bar for performance that should be recognized as high quality and anticipates nursing homes will make quality improvements to achieve these higher standards.  However, the changes in the quality measures star ratings released in February do not necessarily indicate a change in the quality of care provided.

Nursing Home Compare 
was launched in 1998 (“NH Compare 1.0”).  CMS added the 5-Star Quality Rating System in December 2008 (“2.0”).  The website gets more than 1.4 million visitors per year, with 85 percent of users reporting that they found the information they are looking for on nursing homes.   February 20th marks the third major revision to the website (“3.0”), with a fourth major improvement scheduled for 2016.  The 5-Star Quality Rating System offers the most comprehensive overview of nursing home quality in the U.S., in an easy to understand format, based on data from:

  • Onsite Inspections: Conducted by trained, objective surveyors from State public health departments and CMS, the rating system reflects the findings of approximately 180,000 onsite inspections of nursing homes over the most recent 3-year period.
  • For scoring of these survey results, NHs are compared against each other.  NHs can gain a higher star rating if they improve relative to other NHs in the same State.
  • Quality Measures: Information from the nursing homes is used to calculate quality measures, such as the prevalence of pressure ulcers, use of restraints, and the extent of injurious falls.  
  • For scoring the quality measures, CMS uses fixed numeric thresholds as the boundaries between the star categories. Providers can see the “number” they must attain in order to move up by one star.  Providers can increase their star rating regardless of whether other nursing homes also improve.
  • Staffing Levels: Staffing levels in nursing homes are reported on the website and used in the 5-Star ratings.  Research indicates that staffing level is important to overall quality in a nursing home.
  • Facility ratings on the staffing domain are based on two measures – RN hours per resident day and total staffing hours for RNs, Licensed Practical Nurses (LPNs), and certified nursing assistants (CNAs) hours per resident day. Other types of nursing home staff such as clerical, administrative, or housekeeping staff are not included in these staffing numbers.

Decreasing Use of Antipsychotics
CMS is adding the antipsychotics usage to the star ratings as part of its commitment to reduce inappropriate use of these medicines.  Progress has been made, but much more progress is needed.  By the end of 2013, nursing homes achieved a 15 percent reduction in the use of anti-psychotics compared to 2011 levels.  As part of the National Partnership to Improve Dementia Care, we anticipate a 30 percent reduction by the end of CY2016. It is important that our quality measures and star ratings reflect these expectations.

Raising Expectations for Quality Measures
In 2008, CMS set the initial scoring for the Quality Measure rating at a distribution that reflected the achieved status quo, with the expectation that there will be substantial progress, and changes to the quality measures star thresholds, over time. When progress is achieved, CMS resets the distribution to promote further progress and maintain the ability of consumers and families to identify meaningful differences in quality among nursing homes in their state. .  

A good example of raising performance expectations for nursing homes as a group is in the national effort to improve dementia care and reduce the use of anti-psychotic medications in nursing homes. CMS set an initial goal of a 15 percent reduction (achieved nationally after 21 months).  More recently, the goal was increased to 30 percent.  CMS anticipates greater reductions will be attainable in the future, and the scoring for that quality measures will be adjusted accordingly to facilitate achieving that goal.  

CMS Investments in Improving Nursing Home Care
Quality Improvement Organizations (QIOs) assist in improving quality by providing considerable technical assistance to nursing homes. The Advancing Excellence campaign works to make nursing homes better places to live, work, and visit by providing free, practical and evidence-based resources to support quality improvement efforts. CMS’ Special Focus Facility program offers more frequent inspections of nursing homes with trouble survey histories. This program also offers enhanced enforcement strategies to encourage nursing homes to return to compliance.  

Payroll-Based Staffing Reporting
CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. With funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014, CMS will begin collecting information under this new system with some nursing homes in CY 2015 and all nursing homes by the end of CY 2016.

(info from --http://www.cms.gov/)

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