Nursing Home Quality Initiatives and Five-Star Quality Rating System Diane Henry, RN, LHHA State RAI Coordinator Quality Improvement & Evaluation Service Oklahoma State Department of Health QIES Help Desk We are responsible for: Educating surveyors and nursing home providers on MDS requirements Providing consultative assistance regarding the MDS process Providing clinical guidance to assist in the development of the resident s plan of care Serving as a resource for quality improvement efforts Assisting in the education of CMS and/or State initiatives Coordinating database functions Assisting and interpreting validation reports Instructing on the error correction process Objectives Learn CMS s Five-Step Action Plan for improved quality of care in nursing homes Identify current CMS Nursing Home Quality Initiatives Understand how quality initiatives impact the Five-Star Rating System Learn how Five-Star ratings are calculated
What s In It for Me? SNF Quality Reporting Program (SNF-QRP) SNF Value Base Purchasing Program (SNF VBP) Comprehensive Joint Replacement (CJR) Payment Model All relevant to Nursing Home Compare (NHC) and/or Five-Star Rating System CMS s Five Step Action Plan CMS s comprehensive strategy: 1. Survey, Standards and Training Processes 2. Enforcement Activities 3. Quality Approaches through Partnerships 4. Quality Improvement 5. Consumer Awareness and Assistance Consumer Awareness & Assistance Steps to enhance consumer awareness: 1) Five-Star Quality Rating System 2) Improving Staffing Data on Nursing Home Compare
Five-Star Rating System Health Inspections Staffing Rating Quality Measures OVERALL FACILITY RATING HEALTH INSPECTION MEASURES 1. Health Inspection Results Most recent 3 standard surveys; Complaint investigations during the most recent 3-year period; and 2. Repeat Visits Any repeat revisits needed to verify that required corrections have brought the facility back into compliance. To Calculate Deficiency Points
Formula for Health Inspection Rating Health Inspection Rating = Cycle 1 + Cycle 2 + Cycle 3 Cycle 1 = (deficiency points on most recent standard survey + deficiency points on complaint surveys for the most recent 12 months + revisit points) X 1/2 PLUS Cycle 2 = (deficiency points on 1 st prior standard survey + deficiency points on complaint surveys from 13-24 months ago + revisit points) X 1/3 PLUS Cycle 3 = (deficiency points on 2 nd prior standard survey + deficiency points on complaint surveys from 25-36 months ago + revisit points) X 1/6 Rating Methodology for Health Inspection Ratings for Health Inspection Domain are based on relative performance of facilities within a State. Top 10% Middle 70% (divided equally) or or Bottom 20% Individual facility ratings held constant until new survey, complaint or revisit data becomes available. Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare STAFFING DOMAIN
STAFFING MEASURES 1. Total nursing hours per resident day (RN + LPN + Nurse Aide Hours) 2. RN hours per resident day Scoring Rules Both staffing measures are given equal weight Overall Staffing Rating of 5stars= Must have 5 star rating for both RN and total staffing Overall Staffing Rating of 4 stars= At least a 3-star on one (either RN or total staffing) AND Rating of 4 or 5-stars on the other Staffing Points and Rating
Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare QUALITY MEASURE DOMAIN NEW QUALITY MEASURES 5 New QMs added July 2016 Phased in between July 2016-January 2017 January 2017 assigned same weight as other measures 1 Long-Stay and 1 Short-Stay measure 3 Claims-based measures 1 st time CMS has added Claims-based measures QUALITY MEASURES MDS 3.0 Ratings are based on performance of 13of 24of the MDS-based quality measures and 3 Medicare claims-based measures Long-Stay (LS) Residents (in facility > 100 days): New as of July,2016 % of residents whose ability to move independently worsened
QUALITY MEASURES MDS 3.0 Short-Stay (SS) Residents New as of July, 2016 % of residents whose physical function improves from admission to discharge Measures if independence in three mobility functions increases during NH care episode. Transfer Locomotion Walking Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare Three Claims-Based Quality Measures PERCENTAGE OF RESIDENTS WHO WERE REHOSPITALIZED AFTER A NURSING HOME ADMISSION Timeframe measured is 30 days for readmission to a hospital Included regardless if D/C dfrom NH prior to readmission to hospital Calculated using Medicare claims Planned hospital readmissions are excluded
PERCENTAGE OF SHORT-STAY RESIDENTS WHO HAVE HAD AN OUTPATIENT EMERGENCY DEPARTMENT VISIT Measures if the resident had an OutptED visit within 30 days of entry or reentry to a nursing home. Counted even if the resident was discharged from the NH prior to the ED visit. PERCENTAGE OF SHORT-STAY RESIDENTS WHO WERE SUCCESSFULLY DISCHARGED TO THE COMMUNITY The resident was discharged to the community within 100 calendar days of entry and for 30 subsequent days: Did not die Was not admitted to a hospital for an unplanned inpatient stay; and Was not readmitted to a nursing home QUALITY MEASURE CALCULATIONS Ratings are calculated using 4 of the most recent quarters for which data are available 20 to 100 points are assigned for each measure Points are summed across all QMs to create a total score for each facility Possible score ranges between 325 and 1,600 points in January 2017
Quality Measures Scoring Rules Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare CALCULATION OF OVERALL STAR RATING CALCULATING OVERALL STAR RATING Step 1 Step 2 Step 3 Step 4 Start with health inspection rating Add 1 star if staffing rating is 4 or 5 Stars and is greater than health inspection rating Subtract 1 star if staffing rating is 1 star Add 1 star if QM rating is 5 stars Subtract 1 star if QM rating is 1 star If health inspection rating is 1 star, overall quality rating cannot be upgraded by more than 1 star based on staffing or QM ratings
OVERALL NURSING HOME RATING The Health Domain (survey rating) is the most important category in the overall rating. The facility s overall rating may be up to 2 stars higher or lower than the survey rating. If facility has no health inspection rating, no overall rating can be assigned. What Makes My Ratings Change? New Data Received for Facility Complete survey package added to the CMS database. Approximately annually, or a new complaint. If RUG data for the quarter in which the staffing data were collected was not available, then subsequently became available. Change in quality measures QM data updated quarterly. Change in Data for Other Facilities
Review Monthly Preview Reports Access through CASPER Facilities that are Special Focus candidates will be notified on the Preview Report. QIES HELP DESK (405) 271-5278 DO NOT CONFUSE CMS 5-Star Quality Rating System with Oklahoma Health Care Authority s 5-Star Focus on Excellence Program Resources Companion website for official data https://data.medicare.gov/ CMS Five-Star Quality Rating System http://www.cms.gov/medicare/provider-enrollment- and- Certification/CertificationandComplianc/FSQRS.html Send questions, comments and ideas for Five-Star to: BetterCare@cms.hhs.gov
Questions? Diane Henry, State RAI Coordinator Quality Improvement & Evaluation Service 1000 N. E. 10 th Street Oklahoma City, OK 73117 405.271.5278 DianeH@health.ok.gov