quality measurement in skilled nursing facilities five star ......quality measures stars change:...

And you shall rise and show respect to the aged.

11/10/18

JudyWilhide.com (c) 1

Quality Measurement in Skilled Nursing FacilitiesFive Star Rating System

Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, [email protected]

November 2018

Overview

Quality Measures

MDS Based

Five Star

Survey

SNF QRP

Claims Based

Five Star

SNF QRP

SNF VBP


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Five Star Rating System

Overview: Survey Rating will be overall rating unless influenced by Staffing or QM Ratings

Survey Rating Overall rating

Staffing Rating If 4 or 5 stars and above survey rating, add a star

QM Rating If 5 stars add a star


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Overview: Survey Rating will be overall rating unless influenced by Staffing or QM Ratings

Survey Rating Overall rating

Staffing Rating If one star, subtract a star

QM Rating If one star, subtract a star

Name Overall Survey Staffing QM

1 ★★ ★★ ★ ★★★★★2 ★★★★★ ★★★★ ★★★★★ ★★★3 ★★★★ ★★★★ ★★★ ★★★★4 ★★★★ ★★★ ★★★★★ ★★★5 ★ ★★ ★ ★★★6 ★★★★★ ★★★★ ★★★ ★★★★★

Examples


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5 Star Details: Ratings posted monthly

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Survey Stars Change:

With any survey packet that is forwarded or a successful appeal*

Staffing Stars Change:

Quarterly

Quality Measures Stars Change:

Quarterly

*‘frozen’ year after 11/28/17

Understanding the Preview Report


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Preview of what will post at the end of the month.

Five Star Preview Report

This one was posted in shared Casper folder “the middle” of April for posting at

the end of April 2018

Quality Measures Included in the QM Rating


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Preview Report

Preview Report


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M U K I D I

Survey Star Rating

Survey Star RatingWill be overall rating unless influenced by staffing or quality measures

Will not include surveys done after 11/28/17* for “approximately” one year

Includes two most recent annual surveys prior to 11/28/17 (Cycle 1 = most recent annual, Cycle 2 = annual prior

to Cycle 1 annual survey)

Includes substantiated complaints for two most recent complaint cycles prior to 11/28/17

Complaint cycle 1: 11/28/16 – 11/27/17Complaint cycle 2: 11/28/15 – 11/27/16


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Surveys since 11/27/17 WILL be posted to NH Compare, but will not be counted in star rating for approx. one year.

60% 40%

Note: complaint reporting periods do not match Star calculation periods

Cycle 1 Cycle 2

Immediate Jeopardy to Health

or Safety*

No Actual Hard with Potential for

than Minimal Harm

Actual Harm

No Actual Harm with Potential

for Minimal Harm

J50 Points

(75 Points)

G20 Points

K100 Points

(125 Points)

H30 Points

(40 Points)

L150 Points

(200 Points)

I45 Points

(50 Points)

D4 Points

A0 Points

E8 Points

B0 Points

F16 Points

(20 Points)

C0 Points

*If IJ * past non-compliance, G-level (20 points) assigned

Scope & Severity Grid

Few Some Many


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J50 Points

(75 Points)

K100 Points

(125 Points)

H30 Points

(40 Points)

L150 Points

(200 Points)

I45 Points

(50 Points)

F16 Points

(20 Points)

Certain tags under:• 483.10 Resident Rights• 483.40 Behavioral Health Services • 483.45 Pharmacy Services • 483.70 Administration (SW

qualifications > 120 beds)• 483.80 Infection Control (influenza

and pneumococcal vaccines)

All tags under:• 483.12 Freedom from Abuse,

Neglect, and Exploitation • 483.24: Quality of Life• 483.24: Quality of Care

Substandard quality of care

Cycle 1 Annual60%

Cycle 2 Annual40%

February 2018: Standard and Complaint Survey Weighing in Survey Stars

*Surveys done for first year of new LTCSP will not be used for Survey Star Rating for that first year.


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Reported on NH Compare, not used in calculations

2 Ds 1 D

(8*.60) + (4*.40) = 6.4

Preview Report

Revisits to ClearRevisit Number Noncompliance Points

First 0Second 50% of survey score added on

Third 70% of survey score added onFourth 85% of survey score added on

Bulk point add-on for revisits


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Survey Star Details

Cutpoints vary based on current state distribution

SNF rating held constant until you have survey event

While Special Focus Facility, overall max can be 3 stars

If 1 star in survey, max overall can be 2 stars

Same citation in annual & complaint counted once if within 15 days, worst one counts

10%5 Stars20%

1 Star

23.3%4 Stars

23.3%3 Stars

23.3%2 Stars

Survey Star Distribution


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Staffing Stars

Staffing Star Computation

Staffing star ratings are calculated quarterly based on PBJ data submitted prior to deadline, always a quarter behind.

April 18 July 18 Oct 18 Jan 19

CY Q4 17 CY Q1 18 CY Q2 18 CY Q3 18

CY = Calendar Year


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RNTotal Nurse

Staffing based on two case-mix adjusted measures, with equal weight.

Registered Nurse Director of Nursing

Registered Nurse with Administrative Duties

Registered NurseLicensed Practical/Vocational

Nurse with Administrative Duties

Licensed Practical/Vocational Nurse

Certified Nurse AideNurse Aide in Training

Medication Aide/Technician

RN Staffing

Registered Nurse Director of Nursing

Registered Nurse with Administrative Duties

Registered Nurse

Total Nurse Staffing

Note: LPNs with administrative

duties do not count as RNs


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Doing the math

Total Nurse Example3 reported/ 6 expected = ½ x 3.2285 =

1.61425 adjusted hours

Hoursadjusted =

(Hoursreported/Hoursexpected)*HoursNational average

National Average Hours per

Resident Day

Calculated April 2018

Total Nurse: 3.2285

RN: 0.3804

National average hours = National mean of expected hours across all facilities

active on March 31, 2018 and that had submitted valid nurse staffing data for

October 1 – December 31, 2017 (CY Q4).

• Z0100 Medicare RUG IV-66 Score from most

recent OBRA or scheduled PPS MDS assessment

for current residents on last day of quarter.

• Active resident = resident who, on the last day of

quarter, has most recent (non-DC/Death) MDS

transaction less than 180 days old

• For CY Q1 2018: Last OBRA/scheduled PPS closest

to 3/31/18, will use ARD 10/2/17 or later.

• Another way missing DC/death will hurt your rating.

• Census will be too large and acuity will count RUG IV-66 scores for folks not present on last day of quarter.

Hours Expected:


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Hours Expected

• Expected hours calculated by summing nursing times in minutes (from STRIVE Study

Appendix Table A1 Five Star Guide) connected to each RUG category across all residents in category and across all categories.

• Total minutes then divided by number of residents included in calculations.

Time in Minutes

RUG RN Total Nurse ResidentsRUC 27.8 243.16 6HB1 21.65 178.92 8

RN Example:Time in minutes * number in category: (27.8*6)+(21.65*8) = 340.0Divided by total number in all categories: 340/14 = 24.2875Divided by 60: 24.2875/60 = .4048Expected RN HPRD = .4048

Adjusted RN = 0.379Adjusted total = 3.1159

The percentile cut points (data boundaries between star categories) were determined using the data available as of March 2018. • First update of cut points since December 2011• Changes in expected staffing due to transition to RUG-IV• Cut points set so that changes due to RUG-IV would not impact overall distribution

of the five-star ratings• So proportion of nursing homes in each rating category would initially (April

2018) be the same as it was in March 2018. • CMS will evaluate whether further rebasing is needed on a quarterly basis.


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Census using MDS Data• Select reporting period: Q4 2017• Extract MDS assessment data for all residents of a facility beginning 1 year prior

to the reporting period to identify all residents that may resident in the facility.• For Q4 17, scan Oct 1 2016 – Dec 31, 2017 looking for submitted records

• Identify discharged residents:• If there is a discharge assessment, use that discharge date.• If there is an MDS assessment followed by at least 150 days with no

subsequent MDS record, assume discharge on day 150.• Everyone with an MDS assessment and an interval shorter than 150 days will be

assumed to be a resident for that particular day.• All MDS data extractions will be after required completion and submission

deadlines have passed.

Take home message: All MDS records must be completed and submitted timely. Once the staffing data is calculated, it will not be recalculated for subsequent MDS submissions. The larger your census artificially appears, the more short-staffed you will appear.

Five Star

Quality Measures


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Overview: 16 Five Star Quality Measures

13MDS Based

3Claims Based

4 Short Stay

9 Long Stay

Not based on pay source

Calculated once per resident, per quarter

If QM Rating is Five Stars

Short Stay Original Part A only

Calculated per stayCould be more than once per resident

If QM Rating is One Star

Add overallstar

Subtractoverall star

QM Star Rating Unchanged in April 2018 Updates

Cumulative Days in the Facility CDIF: Does not count temporary absences

>100 CDIFLong Stay

<100 CDIFShort Stay

Temporary absence: Time between DCRA & Reentry


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JulAugSepOctNovDec

OctNovDecJanFebMar

JanFebMarAprMayJun

AprMayJunJul

AugSep

Short Stay MDS Based Measures: Include a rolling 6 month target period

Long Stay MDS Based Measures: Include a three month target period

OctNovDec

JanFebMar

AprMayJun

JulAugSep

Resident Level Preview Report has names of all SS and LS residents in MDS based QM computation


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LS High-risk pressure ulcers SS new/worse pressure ulcers

LS moderate to severe pain SS moderate to severe pain

LS antipsychotic use SS newly received antipsychotic

LS indwelling catheter

LS UTI

SS improvements in function LS ability to move worsened

LS physically restrained

LS fall with major injury

LS ADL decline

M U K I D I

Original Medicare A OnlyPer stay, not per resident

Four quarters of dataRecalculated every 6 months

April and October

Claims based measures

SS residents successfully community discharge

SS residents emergency department visit

SS residents re-hospitalization

Oct 2018: July 1 2017 – June 30 2018


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Provider 1234567 State National

2015Q2 2015Q3 2015Q4 2016Q1 4Q avgRating Points1 4Q avg 4Q avg

MDS 3.0 Long-Stay MeasuresLower percentages are better.Percentage of residents experiencing one or more falls with major injury

1.1% 1.1% 2.1% 4.4% 2.2% 80.00 3.5% 3.3%

Percentage of residents who self-report moderate to severe pain2

1.0% 3.3% 5.7% 5.9% 4.0% 80.00 9.2% 8.2%

Percentage of high-risk residents with pressure ulcers

6.4% 3.8% 6.1% 5.3% 5.4% 60.00 6.1% 5.8%

Quality Measure Points Low HighAverage from

preview report

Points assigned

LS Falls w/major injury

100 0.00000000 0.01315789

0.022 8080 0.01315790 0.0240384860 0.02403849 0.0351105240 0.03511053 0.0503597320 0.05035974 1.00000000

Cutpoint table from QM ManualUnchanged in April 2018

Each QM has it’s own cutpoint table

1 star 325 - 7892 stars 790-8893 stars 890-9694 stars 970-10545 stars 1055-1600

870


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SS new/worsened pressure ulcers

SS newly received antipsychotic

LS physically restrained

“Low Prevalence”Must have four quarter average of zero to get 100 points

SS New/worsened pressure ulcer

100 0.00000000 0.0000000075 0.00021394 0.0069269150 0.00692692 0.0156624725 0.01566248 1.00000000

SS Newly prescribed antipsychotic

100 0.00000000 0.0000000080 0.00000000 0.0099999860 0.00999999 0.0191256740 0.01912568 0.0348623720 0.03486238 1.00000000

LS Restraints100 0.00000000 0.0000000060 0.00067115 0.0142450320 0.01424504 1.00000000

M U K I D I

Claims Based

Measures

Hospital Readmission SS

100 0.00000000 0.13839278

19.6 6080 0.13839279 0.1871627960 0.18716280 0.2188620340 0.21886204 0.2568912120 0.25689122 1.00000000


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Deeper DiveTechnicalSpecifications

OBRA

• Admission• Quarterly• Annual• Significant

change• Significant

Correction

Scheduled PPS

• 5 Day• 14 Day• 30 Day• 60 Day• 90 Day

OBRA Discharge

• Return anticipated

• Return not anticipated

Target Records uses for both Long and Short Stay MDS Based Measures


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Almost Constantly

or Frequently

Almost Constant

Frequently

Occasionally

Rarely

Short Stay & Long

Stay

Moderate to

Severe Pain

INTERVIEW ONLY

5-9

Moderate or

Severe

10

Very Severe,

horrible

May be done any time in 5 day lookback

If more than one interview in lookback, RAI manual silent on which one to use.

Short Stay: New or Worsened Pressure Ulcers

• SS Look Back Scan is entire SS episode• Covariates•M0800 ONLY if A0310E = 0

Any number > 0 for any MDS in lookback scan

***Not on MDS 3.0 beginning Oct 1, 2018


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Long stay high risk pressure ulcer

High Risk ifany one present

St 2,3 or 4 PU in M0300

Bed Mobility 3,4,7,8

orTransfer 3,4,7,8

orComatose

andMalnutrition I5600

Percent of Short-Stay Residents Who Newly Received an Antipsychotic Medication (look back scan)

Initial Assessment

Any subsequent assessment = > 0

Exclusions:Schizophrenia (I6000)

Tourette’s Syndrome (I5350)Huntington’s Disease (I5250)


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Long Stay Antipsychotics

Exclusions

UTI

Long Stay UTI Target Assessment


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Long Stay Catheter

Neurogenic bladder

excluded

“urinary retention” is a “signs and symptoms” diagnosis

Obstructive uropathy excluded

Catheter on target

assessment

Symptoms and signs are acceptable for reporting when the provider has not established a related, definitive (confirmed) diagnosis.

Trunk restraint

Used Daily

Limb restraint Chair prevents

rising

Long Stay Restraint Use

Bed rails & Other Restraints do not trigger this QM


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ARD 10/5/16QuarterlyNo Major injury Fall

AnnualFall Major Injury

QuarterlyNo Major Injury Fall

Fall happened Mar 10, 2016

ARD 1/5/17

Q1: Jan 1 –Mar 31

Target AssessmentNo Major Injury Fall

ARD 7/5/16

275 Day lookback scan from ARD of target Assessment: June 5, 2016

ARD 6/4/16

Fall withMajor Injury

When Major Injury happens, set ARD to get clock running

300 points

ExclusionsADL Quality Measures

SS improvements in function

LS ability to move worsened

LS ADL decline


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O0100K: Hospice while resident Exclusions



LS ADL decline

J1400: Prognosis



LS ADL decline


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Long Stay ADL Decline

One declines by two points

Two decline by one point

Bed Mobility

Transfer

Eating

Toileting

Self Performance



Both risk adjusted in new ways: Covariates:

Move worsened: age, gender, vision, oxygen use, Assistance in other ADLs, severe cognitive impairment

Fxl improvements; age, gender, severe cognitive impairment, Assistance in other ADLs, heart failure, CVA, Hip fracture, Other fracture,


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5 Day or Admit

Discharge Return Not Anticipated

Transfers

3

2

Locomotion on Unit

3

3

Walking in Corridor on

unit

8

1

10

6

Mid-loss ADL (MADL)

Total

G011

0 Se

lf Pe

rform

ance

If total on DCRNA lower: ImprovedNote: 7 or 8 added as “4”

Short-stay improvements in function

Exclusions1.Residents satisfying any of the following conditions:1.1. Comatose (B0100 = [1]) on the 5-day or admissionassessment, whichever was used in the QM.1.2. Life expectancy of less than 6 months (J1400 = [1]) on the 5-day or admission assessment, whichever was used in the QM.1.3. Hospice (O0100K2 = [1]) on the 5-day or admission assessment, whichever was used in the QM.1.4. Residents with G0110B1, G0110D1, or G0110E1 missing on any of the assessments used to calculate the QM (i.e., discharge assessment, and 5-day or admission assessment, whichever was used in the QM).1.5. Residents with no impairment (sum of G0110B1, G0110D1 and G0110E1 = [0]) on the 5-day or admission assessment, whichever was used in the QM.1.6. Residents with an unplanned discharge on any assessment during the care episode (A0310G = [2])

Improvements in Function


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Assessment

Target

Prior

Locomotion on Unit

1

0

G0110 Self Performance

If score on target is higher than prior: worsened

Note: • 7 or 8 added as “4”

• Prior must be 45 to 165 days before target

Percentage of long-stay residents whose ability to move independently worsened

M U K I D I

Claims based measures

SS residents successfully community discharge

SS residents emergency department visit

SS residents re-hospitalization

Details


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Age and Sex ESRD

hospital LOS prior to SNF admitNumber of inpatient hospital stays in

year preceding SNF stay

Time in ICU prior to SNF admit Principal diagnosis (ICD code)

Ever got Medicare due to disability Co-morbidities (ICD codes)

Items used in risk adjustment for the three claims based measures: Obtained from hospital claims

Claims-based Measures

Part A stay that begain within one day of hospital discharge (IRF/LTCH excluded)

Included

None are simple fractions. Actual numberator & denominator are risk adjusted based on characteristics present around the start of SNF stay

Risk Adjustments

• Not enrolled in Medicare for risk period• Missing data • Hospice any time in risk period• Comatose on 1st MDS• No 1st MDS

Excluded Stays


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JudyWilhide.com

• Unplanned hospital inpatient or outpatient observation stay

• Within 30 days of entering SNF• Regardless of whether they were discharged

from SNF prior to hospital readmission

Part A Stays in which resident had:

Percentage of short-stay residents who were re-hospitalized after a nursing home admission

Eating Foot infection Radiation Seizure disorder Cough during meals Fell in last month

Walk in room Diabetic foot ulcer Trach Ulcerative colitis Dialysis Fell in 2-6

months

Walk in corridor Internal bleeding IV Med Wound infection Heart failure IV Fluid

Wanders Dehydrated Vent UTI Dementia (all) Feeding tubeTwo person

assist Daily pain Transfusions Chemo Rejected care Diabetes

Cognitive status not intact Surgical wound Antibiotics Pneumonia Insulin Respiratory

failure

Acute change in mental status

Total bowel incontinence Anemia Venous/ Arterial

ulcers Viral hepatitis Cancer

Rarely understood

Shortness of breath Septicemia Oxygen Ostomy care Prognosis

Entered from: Acute hospital CVA 1st MDS since entry is SignificantChange

MDS items used in risk adjustment: unplanned

readmission


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JudyWilhide.com

• Unplanned ED stay without acute admit or inpatient observation stay

• Within 30 days of entering SNF• Regardless of whether they were discharged

from SNF prior to hospital readmission

Part A Stays in which resident had:

Percentage of short-stay residents who have had an outpatient emergency department visit

Isolation Anticoagulant Radiation Seizure disorder Dialysis Fell in last month

Walk in room Internal bleeding Trach Respiratory therapy

Heart failure Fell in 2-6 months

Walk in corridor Dehydrated Orthostatichypotension

COPD Rejected care IV Fluid

Wanders Daily pain Vent UTI Insulin Feeding tube

Two person assist Surgical wound Transfusions Pneumonia Viral hepatitis Respiratory failure

Cognitive status not intact

Speech Therapy Antibiotics Venous/ Arterial ulcers

Ostomy care Cancer

Acute change in mental status

Shortness of breath

Anemia Oxygen Rarely Understood

Prognosis

1st MDS since entry is SignificantChange

MDS items used in risk adjustment: ED Visit


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Percentage of short-stay residents who were successfully discharged to the community

Beneficiary stay that:• Had an MDS discharge assessment indicating discharge to ‘community’

within 100 calendar days of the start of the episode; AND within 30 days of this discharge the beneficiary: • Was not admitted to a nursing home • Did not have an unplanned inpatient hospital stay• Did not die

Psychotic Disorder Schizophrenia Married Interpreter needed Resident expectations (Q) Malnutrition

HTN Hyperkalemia Hip/other fx CVA Anxiety disorder Manic Depression

ADL Dependence Foot infection Radiation Seizure disorder Depression Weight loss

Balance problem Diabetic foot ulcer Understands others Paraplegia Dialysis Fell in 2-6 months

Hemiplegia Swallowing disorder (K0100) IV Med Wound infection Heart failure IV Fluid

s/s delirium Suctioning Vent UTI Dementia (all) Feeding tube

Medicare RUG Vision Impairment Transfusions Chemo MS Diabetes

Cognitive Impairment Surgical wound Quadraplegia Pneumonia Huntington’s Parkinson’s

Acute change in mental status Incontinence Anemia ID/DD or related

condition Viral hepatitis Cancer

Makes self understood Shortness of breath Septicemia Oxygen injections Antipsychotics

Entered from:Psych hospital Any behavior, wander, reject care, hallucination, delusion Mech Alt diet COPD

MDS items used in risk adjustment: Successful

Discharge


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Other MDS Based Quality Measures, not part of Five Star


Antianxiety or hypnotic medication: Two separate measures

• Casper• Prevalence of Antianxiety/Hypnotic Use

(Long Stay) N033.1

Exclusions:• Schizophrenia (I6000 = [1]). • Psychotic disorder (I5950 = [1]). • Manic depression (bipolar disease)

(I5900 = [1]). • Tourette’s syndrome (I5350 = [1]). • Huntington’s disease (I5250 = [1]). • Hallucinations (E0100A = [1]). • Delusions (E0100B = [1]). • Anxiety disorder (I5700 = [1]). • Post-traumatic stress disorder

(I6100 = [1]).

• NH Compare & Casper• Percent of Residents Who Used

Antianxiety or Hypnotic Medication (Long Stay) N036.1

Exclusions: • Life expectancy of less than 6

months (J1400 = [1]). • Hospice care while a resident

(O0100K2 = [1]).


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• Long Stay Prevalence of Falls: All falls on any assessment in the LS look-back scan


Long Stay Behavior Symptoms Affecting Others:

Anything more than zero in any of these

boxes


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Long Stay Low Risk Bowel/Bladder Incontinence


Severe cognitive

impairment

Locomotion on unit4,7,8

Transfer4,7,8

Bed Mobility

4,7,8

High Risk

Everyone deemed low risk coded

frequently/always incontinent of

bowel or bladder

Exclusions: Ostomy, catheter

Long Stay weight Loss


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Non-physician prescribed weight loss


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Long Stay Depressive Symptoms


Score >=10And

Little interest or pleasure7-14 days

Down, depressed, hopeless7-14 days

OR

Uses Interview or

Staff Assessment

The Vaccine Quality Measures: Short & Long Stay

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Not on Casper Reports, Not Five Star

SNF State Nation


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Assessed and Appropriately

Given the Pneumococcal

Vaccine Up to date

Offered/declined

Medically Contraindicated

Special rules for influenza vaccination measures

• Flu vaccination measures are calculated once per year. In a normal year where the influenza season begins on October 1 and ends of March 31, the target period will coincide with these dates

• End-of-episode date will be March 31 for an episode that is ongoing at the end of the influenza season and that March 31 should be used as the end date when computing CDIF and for classifying stays as long or short for the influenza vaccination measures.



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Percentage of Appropriate Vaccines


Numerator

Or

Code 2, Received outside of this facility

Code 3, Not eligible—medical contraindication

Code 4, Offered and declined

Percent of Residents Assessed and AppropriatelyGiven the Seasonal Influenza Vaccine (Long Stay)


DenominatorAll long-stay residents with a selected influenza vaccination assessment, except those with exclusions.ExclusionsResident’s age on target date of selected influenza vaccination assessment is 179 days or less. {pediatric NH}


NO other exclusions!


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•Measure calculated once a year with target period October 1 of the prior year to June 30 of the current year and reports for the October 1 through March 31 influenza season.• Scan all assessments with target dates on or after October 1 of

the most recently completed influenza season.• Select the record with the latest target date with:• Qualifying reason for assessment

• OBRA, scheduled PPS or discharge• Target date on/after October 1st of the most recently completed influenza

season, and A1600 entry date is on or before March 31st of the most recently completed influenza season.


Long Stay Claims Based Measure: Number of hospitalizations per 1,000 LS Days

This claims-based quality measure will be reported on Nursing Home Compare

starting in October 2018, and integrated into the Five-Star Quality Rating System

in April 2019. It reports the ratio of unplanned hospitalizations per 1,000 long-stay

resident days for non-Medicare A Long Stay residents


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JudyWilhide.com

SNF VBP: One Measure only

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM NQF #2510)

First year:

To be replaced by:

FY 17 Proposed Measure:SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR)

Changes/additions/deletions to VBP measures would come in future rule-making

Two ways to earn points:

Achievement Performance: Happy Valley SNF’s rate of all-cause readmissions (SNFRM) in CY 2017 compared to the national rate in CY 2015

BenchmarkAchievement Threshold

0 pointsRate ≤ threshold

100 points

Rate ≥ benchmark

Mean of top decile of national SNF

performance (10th

percentile) during CY 2015

25th percentile of national SNF

performance during CY 2015

Achievement Score

1 to 99 points

Rate between the two


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Two ways to earn points:

Improvement Performance: Happy Valley SNF’s rate of all-cause readmissions (SNFRM) in CY 2017 compared to it’s own rate in CY 2015

BenchmarkImprovement Threshold

0 pointsRate ≤ threshold

100 points

Rate ≥ benchmark

Mean of top decile of national SNF performance

(10th percentile) during CY 2015

Your SNF’s performance during

CY 2015

Improvement Score

1 to 89 points

Rate between the two

Calculating Performance:

JudyWilhide.com

CMS is required to pay the better of Achievement or Improvement

Your rate would be 80%i.e.: 80%of residents included in measure were not rehospitalized

If actual readmission rate is 20%i.e.: 20% of residents included in measure were rehospitalized

Higher numbers will be betterCMS thinks this is easier for public to understand


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Questions/Discussion

quality measurement in skilled nursing facilities five star ......quality measures stars change:...

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