1. Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE
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
www. JudyWilhide.com

2. 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.

3. Nursing Home Compare & Five Star Rating System Review

6. Actual Survey Reports (redacted for HIPPA)
Details each citation with state and national average citations

7. Staffing
PT staff hours do not count in rating.

8. ★ ★ ★ Short Stay Long Stay Long Stay NH Compare Quality Measures
Flu Vaccine
New/worsened PrU
New Antipsychotic
Self Report Mod/Severe Pain
Pneumovax ★
Long Stay
Hi Risk PrU
Antipsychotic Use
Self Report Mod/Severe Pain
UTI
Catheter
ADL Decline ★
Fall Major Injury
Restraint Use
Lo risk Incontinence
Weight loss
Depressive symptoms
Pneumovax
Flu Vaccine
Long Stay ★
NH Compare Quality Measures

9. Special Focus Facilities:
have had a history of serious quality issues and
are included in a special program to stimulate improvements in their quality of care.

10. 2/23/15
Virginia
North Carolina
Florida

11. 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

12. 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

13. Overall Survey Staffing QM ★★ ★ ★★★★ ★★★ ★★★★★ Peaceful Place Rocking
Example:
Overall
Survey
Staffing QM
Happy
Valley ★★ ★
★★★★
★★★★★
Peaceful Place
Rocking
Retirement
★★★
Swinging
City
Terminal Towers

14. Quintile definition: divided into five equal groups, based on performance
Best
Second best
Third best (or third worst)
Next to worst
Worst

15. 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

16. 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.

17. 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

18. 18

20. Complaint Survey Weights
1/6
1/2
1/3

21. Revisits to Clear
Revisit Number
Noncompliance Points
First
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 21

22. 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.

23. You Shall Rise and Show Respect to the Aged
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

24. Staffing based on two case-mix adjusted measures, with equal weight.
Total Nurse RN

25. 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

26. Staffing Stars assigned
Illustration: Q1 Q2 Q3 Q4
Target Date
Jun 29
Survey Date
July 6
Census
Q1 RUG Data
No RUG Data
for Q2 yet
Staffing Stars assigned

27. Some time in the future:Q1 Q2 Q3 Q4
Target Date
Jun 29
Survey Date
July 6
Census
Q2 RUG Available
Staffing Stars assigned
New Staffing Stars assigned

28. Doing the math Hoursadjusted =
(Hoursreported/Hoursexpected)*HoursNational average
Total Nurse Example
3 reported/ 6 expected = ½ x =
adjusted hours
National Average Hours per Resident Day
Calculated April 2012
Total Nurse:
RN:
You Shall Rise and Show Respect to the Aged

29. 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

30. 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)
Newly received antipsychotic (Exclusions: Schizophrenia, Tourette's, Huntington’s) 30

31. IMPACT Act: SNF Quality Reporting System (QRS)

32. 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

33. HHA IRF LTCH SNF Post Acute Settings Standardization Therapy
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
LTCH
Stay > 25 days, rehab, resp ther, head trauma,pain mgt
Standardization

34. 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

35. 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
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.

36. 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

37. 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)
Existing
SNF QMs
Percent of patients/residents with an admission and discharge functional assessment and a care plan that addresses function (Part A stay)
New

38. 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

39. 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

40. 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

41. 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

42. 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 2020
We have one year to perfect data collection systems!
We can expect more/different measures going forward

43. 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

44. In first three days of SNF stay, must be at least one fxn goal
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

45. 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

46. 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

47. Value Based Purchasing Initiative
Protecting Access to Medicare Act (PAMA) of 2014
Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)
Value Based Purchasing Initiative

48. 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.

49. Funding: CMS will withold 2% of SNF Medicare payments starting 10/1/18
CMS will keep 30-50%
50-70% will be incentive payments to SNFs.

50. 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

51. 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

52. 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

53. 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

54. Payroll Based Journal (PBJ)

55. 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

56. 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.

57. 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.

58. 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.

59. 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.

60. 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.

61. Focused Surveys: A new horizon

62. 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

63. 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

64. Questions/Discussion