Guest Columns

Five-Star is anything but frozen

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Steven Littlehale
Steven Littlehale

Somewhere between basking in the joy of a meaningful Thanksgiving Day celebration and contemplating the merits of an elasticized waistband for the holidays, you read the Centers for Medicare & Medicaid Services memo (Ref: S&C 18-04-NH) regarding changes to the survey process, Nursing Home Compare and Five-Star.

The day after Thanksgiving, CMS further defined its intensions with the Five-Star Quality Rating System; more specifically how the new survey process and derivative data will be used in its calculation of the Health Inspection domain.

Over the past several months, words like “frozen” and “held constant” have been used to describe the Five-Star Health Inspection domain in response to the new survey process, which began less than a month ago (Nov. 28, 2017). However, prior to this memo, we hadn't heard much about what appears to be a separate concept: a change in methodology.

Let's go a little deeper into the concepts of “frozen” and the new “methodological change.” Frozen or held constant does not mean that your Health Inspection domain is not going to be recalculated. In January, your Five-Star Health Inspection domain will be refitted to reflect the most recent state benchmarks and recalculated if any new survey and complaint data for events dated prior to Nov 28 have processed.

What is frozen is survey data reflecting events post-Nov. 28,, 2017. These new data are going into the freezer and CMS will later determine when they will set it on the counter to thaw.

Come January, CMS will use only the last two survey cycles' worth of standard survey and complaint data to calculate Five-Star Health Inspection domain. Remember, though, post-Nov. 28 data is in the freezer, right next to the leftover pies someone convinced you could freeze just fine (bad move!).

We're not certain when this data will be used in Five-Star calculations, but it will still be posted on the Nursing Home Compare website. This last comment feels more like a frost heave.

We conducted an analysis on Dec. 1 using the most up-to-date available data on 15,654 SNFs. Because of the “freeze” and “methodological shift,” there will be SNFs that are winners and SNFs that are losers in the Five-Star System come January 2018. For example:

*  Approximately 20% of SNFs are expected to see a change in their Health Inspection domain

o   1,332 will decrease in Health Inspection Star Rating

o   1,765 will increase in Health Inspection Star Rating

*  Approximately 15% of SNFs are expected to see a change in Overall Five-Star rating

o   1,016 will decrease in Overall Star Rating

o   1,271 will increase in Overall Star Rating

o   337 will lose their rating of 3 stars

o   401 will obtain a 3-star rating

These numbers will differ slightly come January for these reasons:

1) A technical specification is not yet available

2) Survey data pre-Nov. 28 will continue to come into CMS throughout the remainder of 2017 and

3) State survey cut-points for January have not been posted.

To add more texture, those facilities that “improved” likely had old survey points drop off. Those that “worsened” had cycle 1 or cycle 2 survey points that are weighted more heavily now.

So why would CMS choose to not look at post Nov. 28 data and only consider two cycles' worth of data? To their credit, CMS officials realized that the new survey process and the resulting data (deficiencies) might be different compared to that of the prior survey system. The new survey process blends QIS with traditional survey, and we know QIS states' data look different compared to traditional survey states.

Better to wait and see, study and plan. Good move!

Hat's off again to CMS for changing the three-year look back to two. Had they not, SNFs with negative survey outcomes from three-years ago - followed by two good or excellence survey years would be unfairly burdened by the extended echo of past performance.

Survey cycle 1 will be weighted 60% and survey cycle 2 will be weighted 40%. If you “worsen” come January, it's likely due to more recent surveys being weighted more heavily than before.

Check out this short video of me and our senior research analyst explaining this methodology here.

After the initial January 2018 Five-Star movement, there should be little-to-none more until the new data is taken out of the freezer. Any movement in stars will be due to staffing and quality changes.

Ok, what's your next move?

1.  Know what your January Five-Star rating will be. No one likes surprises.

2.  Educate families and residents about this change, even if you anticipate no change in your rating.

3.  Notify your referral sources, especially if an “overall 3-star” was the price of admission.

4.  Approach new referral sources, especially if you just jumped up to a 3-star.

5.  Notify your HUD lender, especially if this change created a drop.

6.  Ensure that your MDS data, which drives almost all of Five-Star, is 100% accurate.

Now, what to get you for the holidays? I've been struggling on the perfect gift … Oh, I know … would you like to know your January rating? Drop me a line and it's yours!

Have a joyful holiday season and peaceful New Year.

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

Guest Columns

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

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