April 12, 2018 Long Term Care Luncheon: The CMS Five-Star Quality Rating System Quality Ratings of U.S. Nursing Homes on Nursing Home Compare Jennifer Pettis, MS, RN, WCC Nurse Researcher / Associate Abt Associates Session Objectives After attending this session participants will be able to: List the domains included in the Five-Star Quality Rating System, Define recent changes to the Five-Star Quality Rating System, including how these changes have improved the quality of data being publicly reported to US consumers, and Discuss potential changes in provider behavior and changes in provider performance related to safety, quality, and value since the implementation of the Five-Star Quality Rating System. This work was supported through a contract with the Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality, Survey and Certification Group. Abt Associates pg 3 1
Abt Associates pg 4 Abt Associates pg 5 Nursing Home Compare 1998 Nursing Home Compare launched New QMs introduced July 2016 Methodological changes to Five-Star Quality Rating System 2008 Five-Star Quality Rating System introduced September 2016 Final Rule to Reform Requirements for Long-Term Care Facilities Quality Measure (QM) domain rebased February 2015 Antipsychotic QMs incorporated into rating system 2018 Staffing Rating based on Payroll-Based Journal (PBJ) Abt Associates pg 6 2
Three Domains of Quality in Rating System Staffing Health Inspections Quality Measures Overall Rating Abt Associates pg 7 Health Inspections Nursing homes that participate in the Medicare and/or Medicaid programs have an onsite recertification (standard) ( comprehensive ) inspection annually, on average. Inspections are unannounced and provide a comprehensive assessment of the nursing home. Abt Associates pg 8 Health Inspection Domain Ratings are based on the number, scope, and severity of deficiencies identified during: The two most recent annual recertification inspections occurring prior to November 28, 2017, and Substantiated findings from complaint investigations occurring in the 24 months prior to November 28, 2017. All deficiency findings are weighted by scope and severity. This measure also takes into account the number of revisits. Abt Associates pg 9 3
Health Inspection Domain (cont.) Abt Associates pg 10 Health Inspection Domain (cont.2) Abt Associates pg 11 Health Inspection Domain (cont.3) CMS calculates a total health inspection score for each facility calculated as the facility s weighted deficiency score. A lower health inspection score corresponds to better performance. More recent health inspections are weighted more heavily than earlier health inspections. Abt Associates pg 12 4
Health Inspection Domain (cont.4) Complaint inspections are assigned to a time period based on the 12-month period in which the complaint survey occurred. Complaint inspections that occurred between November 28, 2016 and November 27, 2017 receive a weighting factor of 60 percent, and those occurring between November 28, 2015 and November 27, 2016 have a weighting factor of 40 percent. Facilities with only one standard health inspection prior to November 28, 2017 are considered not to have sufficient data to determine a health inspection rating and are reported as Too New to Rate for the health inspection domain. Abt Associates pg 13 Health Inspection Domain (cont.5) CMS bases Five-Star quality ratings in the health inspection domain on the relative performance of facilities within a state. Top 10 percent Middle 70 percent (approximately 23.33 percent in each rating) Bottom 20 percent Abt Associates pg 14 Health Inspection Domain (cont.6) Rating thresholds are re-calibrated each month. However, the rating for a given facility is held constant until there is a change in the weighted health inspection score for that facility. While changes to health inspection scores (and thus rating changes) during the time period when surveys conducted under the new process will be rare, there are a few reasons why facilities may have a change (some refer to this as a freeze of the survey rating, beginning February 2018). Abt Associates pg 15 5
Health Inspection Rating Freeze Beginning in February 2018, for a period of 12 months, CMS will not use deficiencies cited on surveys on or after November 28, 2017 in calculating the Five-Star health inspection rating Standard surveys and complaint surveys that occurred on or after November 28, 2017 (under the new survey process) will be displayed on the Nursing Home Compare website but will not be utilized to calculate the Five-Star health inspection rating. Abt Associates pg 16 Staffing Domain In 2018, CMS will replace the existing staffing measures posted on Nursing Home Compare and used in the Five-Star Quality Rating System with measures using Payroll-Based Journal (PBJ) data submitted for the October 1 to December 31, 2017 reporting period by the February 14, 2017 deadline. March Provider Preview Reports included facilityspecific PBJ data that was submitted to CMS by the deadline. Physical therapist data are reported on NHC but not included in calculations for the Five-Star ratings. Abt Associates pg 17 Staffing Domain (cont.) The Nursing Home Compare website indicates whether providers have submitted data by the required deadline, and, if providers have submitted, whether those data are complete, incomplete, or inaccurate. Information about staffing data submission is available on the CMS website. Go to: https://www.cms.gov/medicare/quality-initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/Staffing-Data- Submission-PBJ.html Abt Associates pg 18 6
Benefits of PBJ Data The staffing data submitted on the CMS-671 captures only a two-week period prior to the facility s annual recertification survey, whereas the PBJ data captures facility staffing for every day in a quarter. The definitions of certain job categories have been revised for PBJ data submission compared to the instructions on the CMS-671 form, resulting in more precise reporting. The PBJ data includes the census for each day in a quarter. The PBJ program requires facilities to submit only those hours that staff are paid to work. Abt Associates pg 19 PBJ Fiscal Quarter Reporting Periods Fiscal Quarter 1 2 3 4 Reporting Period October 1 December 31 January 1 March 31 April 1 June 30 July 1 September 30 Due Date February 14 May 15 August 14 November 14 Abt Associates pg 20 QM Domain The facility rating for the QM domain is based on performance on: A subset of 13 (out of 24) of the Minimum Data Set (MDS)- based QMs and Three Medicare claims-based QMs Nine QMs are for long-stay residents. Seven QMs are for short-stay residents. Abt Associates pg 21 7
Measures for Long-Stay Residents 1. Percentage of residents whose need for help with activities of daily living has increased 2. Percentage of residents whose ability to move independently worsened (New, 7/2016) 3. Percentage of high risk residents with pressure ulcers (sores) 4. Percentage of residents who have/had a catheter inserted and left in their bladder 5. Percentage of residents who were physically restrained 6. Percentage of residents with a urinary tract infection 7. Percentage of residents who self-report moderate to severe pain 8. Percentage of residents experiencing one or more falls with major injury 9. Percentage of residents who received an antipsychotic medication Abt Associates pg 22 Measures for Short-Stay Residents 1. Percentage of residents whose physical function improves from admission to discharge (New, 7/2016) 2. Percentage of residents with pressure ulcers (sores) that are new or worsened 3. Percentage of residents who self-report moderate to severe pain 4. Percentage of residents who newly received an antipsychotic medication 5. Percentage of residents who were re-hospitalized after a nursing home admission (New, 7/2016) 6. Percentage of residents who have had an outpatient emergency department visit (New, 7/2016) 7. Percentage of residents who were successfully discharged to the community (New, 7/2016) Abt Associates pg 23 QM Domain Calculation CMS calculates ratings for the QM domain using the four most recent quarters for which data are available. Values for the three claims-based measures are calculated in a similar manner, except that the data used to calculate the measures use a full year of data. Abt Associates pg 24 8
Missing Data and Imputation MDS-based measures are reported if the measure can be calculated for at least 20 residents assessments. The claims-based measures are reported if the measure can be calculated for at least 20 nursing home stays over the course of the year. For facilities with missing data or an inadequate denominator size for one or more QMs, all available data from the facility are used. The remaining assessments (or stays) are imputed to get the facility to the minimum required sample size. Abt Associates pg 25 Scoring Rules for the QM Domain For each measure, points are assigned based on facility performance relative to the national distribution of the QM. For all of the measures, the groupings are based on the national distribution of the QMs, prior to any imputation. After any needed imputation for individual QMs, the points are summed across all QMs based upon the scoring rules above to create a total score for each facility. Once the summary QM score is computed for each facility as described above, the five-star QM rating is assigned. Abt Associates pg 26 Overall Nursing Home Rating (Composite Measure) Step 1: Start with the health inspection rating. Step 2: Add one star to the Step 1 result if the staffing rating is four or five stars and greater than the health inspection rating; subtract one star if the staffing rating is one star. The overall rating cannot be more than five stars or less than one star. Step 3: Add one star to the Step 2 result if the quality measure rating is five stars; subtract one star if the quality measure rating is one star. The overall rating cannot be more than five stars or less than one star. Note: If the health inspection rating is one star, then the overall rating cannot be upgraded by more than one star based on the staffing and quality measure ratings. If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall rating is three stars. Abt Associates pg 27 9
Change in Nursing Home Ratings Events that could change the health inspection score include: A new health inspection (prior to 11/28/17). New complaint deficiencies (prior to 11/28/17). A second, third, or fourth revisit (for a survey before 11/28/17). Resolution of Informal Dispute Resolutions (IDR) or Independent IDR (IIDR) resulting in changes to the scope and/or severity of deficiencies (for surveys before 11/28/17). New staffing data for the facility. Changes in the QM rating for the facility (mid-month January, April, July, and October). Abt Associates pg 28 July 2016 Changes to Five-Star Introduction of five new QMs, including the first measures that utilize Medicare claims, rather than only self-reported MDS assessments. These measures greatly increase the number of short-stay measures, and add domains not well covered by other measures. Several methodological changes to the calculation of the QM ratings. Abt Associates pg 29 Overall Quality Ratings: 2012 2018 Note: Several changes to 5- Star rating methodology were made in February 2015. Abt Associates pg 30 10
Health Inspection Ratings: 2012 2018 Note: By design, the distribution of health inspection ratings is fixed. Abt Associates pg 31 Staffing Ratings: 2012 2018 Note: Starting in February 2015, facilities required to have a 4- or 5- star staffing rating on either RN or total nurse staffing to have an overall staffing rating of 4-stars. Abt Associates pg 32 Quality Measure Ratings: 2012 2018 Note: In February 2015, the quality measure scale was re-set, increasing the standard for nursing homes to receive a high rating. Abt Associates pg 33 11
Questions and Contact Information Jennifer Pettis, MS, RN, WCC Nurse Researcher/Associate Abt Associates Email: jennifer_pettis@atbassoc.com Office phone: 617.520.3072 www.abtassociates.com Abt Associates pg 34 Copyright 2017, Abt Associates Inc., All Rights Reserved (prepared with data obtained under HHS/CMS contract HHSM-500-2013-13001I) References Abt Associates. (2014). Nursing Home Compare Five-Star Quality Rating System: Year five report. Retrieved from https://www.cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/Downloads/NHC-Year-Five- Report.pdf Abt Associates. (2016). Nursing Home Compare Five-Star Quality Rating System: Year Seven Annual Report. Currently in draft. Centers for Medicare & Medicaid Services. (2018). Design for Nursing Home Compare Five-Star Quality Rating System: Technical users guide. Retrieved from https://www.cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/downloads/usersguide.pdf Centers for Medicare & Medicaid Services. (2018). Staffing Data Submission PBJ. Retrieved from https://www.cms.gov/medicare/quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html Abt Associates pg 35 12