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Do the new QMs have you seeing stars?

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Steven Littlehale
Steven Littlehale

Actions providers take now will make or break their Five-Star Quality Rating experience in July.

That's because the Centers for Medicare & Medicaid Services has changed quality measures in a way that will affect all nursing homes. CMS held a SNF Open Door Forum conference call on March 3 to explain the potential impact on long-term care providers.

Changes will be seen on the Nursing Home Compare website and in the SNF Five-Star Quality Rating System. Beginning in April, CMS will add six new Quality (QMs) to the Nursing Home Compare website. Three of these measures are to be calculated from claims data, while the other three will be based on MDS 3.0 data.

These outcome measures capture four additional elements for the short-stay Medicare beneficiary, and two for the long-stay care recipient.

Regulations in 2014 made the development of readmission measures a high priority for CMS.  The claims-based measures look at 30-day all-cause readmissions, 100-day community discharge without readmission, and 30-day outpatient emergency department visits. Each of these metrics identifies Medicare beneficiaries who return to a higher cost center for care after admission at a SNF.

The claims-based measures use Medicare fee-for-service claims only. The measures are risk adjusted using items from a rolling 12 months period of time from the claims, as well as the Medicare enrollment database and the MDS, updated twice annually. While the technical user's manual is not yet available, an “Improvements” resource document by Abt Associates is available on the CMS web site here.

You'll easily grasp the MDS-based measures because of their similarity to the current Quality Measures. Different MDS items are tapped in the calculations and they are incidence-based, which means they measure change over time. Short-stay residents who made improvement in function between the 5-Day and Discharge assessment make up one of the new measures. This measure uses mid-loss activities of daily living that typically improve in the short stay population. They include transfers, locomotion on the unit, and walking in corridor; this composite measure is then used to arrive at an overall determination of improvement. The two long-stay MDS measures include the percent of residents whose ability to move independently worsened, and the percent of long stay residents who received anti-anxiety or hypnotic medications. Some risk adjustment and appropriate exclusions are applied to the measures.

The new measures will first appear on Nursing Home Compare beginning the fourth week of April, or just about a month from now. It won't be any kind of April fool's joke! Providers will get a preview of their quality measures one week before through the QIES system. CMS did indicate that these QMs will eventually be listed on the CASPER system, but that date has yet to be announced.

Five of the six new measures will be integrated into the Five-Star Quality Rating System. Only the use of antianxiety or hypnotic medication is not going to be used. The phase-in of these measures will begin in July and last until January 2017. There are many unanswered questions, including the potential for measure rebasing, changes in cut points and measure weighting.

What to do, what to do?! Past success strategies will serve you well. Every time your MDS coordinator investigates, clarifies and changes an MDS to improve accuracy, “false positives” will not trigger on your new QMs. The MDS remains a key source of data impacting the measures and the risk adjustment for all six quality measures. If you're not confident about your MDS data quality, begin by taking a look at the systems in place for verifying the accuracy of your MDS data. (Remember, this same system should be part of your Corporate Compliance plan!)

Review the coding conventions for the MDS items emphasized in the new QMs. It's good practice to return to the manual periodically. Remember, it's not just the individual MDS items used to calculate the outcome but also the assessment types used to capture items used in both the outcome measure and the risk adjustment. The devil is always in the details, so definitely watch for the technical user's manual sometime mid-spring.

For the other non-MDS measures, you will still want to take the same approach to your claims data. First, review the data sets and systems in place for the completion of the UB04. Are the right ICD-10 codes listed and properly prioritized? Are the dates correct? Risk adjustment items come from ICD codes indicating primary diagnosis and length of stay in the hospital, and MDS items associated with readmission rates. The MDS items used in the risk adjustment will be different across the three claims based measures.  

This is a particularly peculiar time for CMS. Remember that starting in January 2017, the Medicare fee-for-service CJR program kicks in and only SNFs whose overall Five-Star score was a 3 or better in seven of the previous 12 months will be eligible for inclusion in the three-day inpatient stay waiver program.

With so much uncertainty, there is one thing that is certainly clear: Skilled nursing facilities must stop at nothing to improve quality and be measurably successful. We will meet and exceed these challenges and as a result, be better providers of care.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.


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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.