Steven Littlehale

Johnny Carson of “The Tonight Show” fame had a recurring character that he played named “Carnac the Magnificent,” a self-styled seer with a predictable schtick. Today, I call upon Carnac’s spirit to help answer this question: “What is your most dreaded SNF Quality Reporting Program (QRP) measure?”

 Oh great Carnac, we await your answer!

To jog your memory, here are the measures for public reporting — though I suspect you already have one in mind. Now think hard!

  • Discharge to Community
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure
  • Medicare Spending Per Beneficiary
  • Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) 
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

What’s this? Carnac the Magnificent, soothsayer and sage, would like to ask you three questions to determine your answer. OK, Carnac, ask away:

  1. “Is the measure also used in Five-Star and worth 150 points?”
  2. “Does it rely on data that is not in your control?”
  3. “Is success only determined after the resident leaves the SNF?”
  4. “Does the measure look back as far as 10/1/2016 and only include data up to 9/30/2018?”

Now hold on, Carnac, that’s four questions. We insist on an answer. What is our readers’ most despised QRP measure? 

Carnac brings the hermetically sealed envelope to his turban-covered head and closes his eyes …

“Discharge to Community.”

With all due respect to Carnac, getting this question right doesn’t take a third eye. This measure is one of the most difficult to understand, and it’s nearly impossible to incorporate into any improvement plan. From working with SNF providers across the country on improving their quality measures, it’s clear this one is the most vexing. Let us understand the measure, the frustration, and how to improve your performance. 

The Measure

This measure is based on Medicare FFS claims. It evaluates how effective you are in successfully discharging your Medicare residents from the SNF to the community. Success is not just getting them out the door, but doing so safely — which means no unplanned rehospitalizations and no deaths in the 31 days following discharge. Community is defined as home or self-care, with or without home health services, and this is gleaned from the Discharge Status Code you use on the Medicare FFS claim. The following codes count as a community discharge:

01 Discharged to home or self-care (routine discharge)

06 Discharged/transferred to home under care of organized home health service organization

81 Discharged to home or self care with a planned acute care hospital readmission

86 Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission

My first recommendation is to figure out who is doing the coding on your claim and which code they select at time of discharge. In helping clients improve their performance on this measure I’ve seen different coding practices, particularly around discharging to assisted living facilities (ALF). Rightly or wrongly, some use code 01 while others use 04, which would include discharges to a state designated ALF. 

Reviewing the specification and other source documents got me no closer to a solid understanding of which code to use for ALF — even Carnac came up short. I queried the SNF PAC QRP Help Desk, who offered this: “You are correct that residents who are admitted to a SNF from assisted living, or discharged from a SNF to assisted living, are not included in the measured cohort. The measure is specified this way to measure a population of patients who are admitted from and discharged to the relatively unstructured living situation of community, rather than the very structured living arrangement found in assisted living.”

Since most states do not pay for ALF, I don’t see how a discharge to an ALF would be discerned from the data if code 01 was being used. 

The Frustration

Carnac told me that you have heard the expression “you can’t manage what you can’t measure.” We might debate who first said it, Deming or Drucker, but we can probably agree that it’s not completely true. Being able to measure discharge to community, as it is reported, would be super helpful. 

However, this measure’s construction and its crazy look-back period keep it from being included in your QAPI strategies. And while the era of data-driven decision-making has long since arrived—and is not leaving soon — let’s acknowledge that many essential things cannot be measured yet still must be managed. Use your data, but sometimes hash marks on the back of an envelope are more effective than a prediction equation based on a logistic statistical model with a two-level hierarchical structure.

When I was analyzing this measure’s outcomes data, I noticed a disproportionate number of hospital-based SNF/Transitional Care Units (TCUs) were in the “best performing quintile.” Of course they are, by design, they do not keep residents long-term, they are not a nursing home. Discharging to the community is a requirement, there are limited options. 

Nation Wide (2020 Top Quintile Only)
Total SNFsHospital BasedFree-standing% of All SNFs% of all Hospital Based% of all Freestanding SNFs
© Zimmet Healthcare 2020

Improve Your Performance

Someone is getting those 150 points; why can’t it be you? And of course, safe discharges to the community are worth pursuing. The best practice guidelines that I’ll share come from SNF providers across the country. They have diligently improved their outcome by engaging the resident, family, and community. 

Aside from “doing the right thing,” they are motivated by having a financial stake in total Medicare spend, reducing rehospitalization, improving satisfaction, increasing referrals from preferred networks, and improving their community reputation. In my interviews throughout the last several years, the actual QRP measure was never mentioned, yet all the providers I spoke with had pragmatic and effective strategies that they employed. 

Because I am not Carnac, I took a dip into the data to highlight some specific providers who were CRUSHING IT on this metric. I looked at the top quintile of performers for the last two reporting periods. Here is what they told me. 

Set expectations with families/residents, and let them set yours

  • Meet with the resident/family day -1, or at the very least upon admission.
  • Share the target date of discharge and come to a consensus on the discharge date.
  • If home health (HH) is required, determine whether the family has a provider in mind.
  • Determine what shared resident-centered goals must be achieved to reach the target discharge date.

Narrow your downstream providers

  • Require HH providers to share their data for inclusion in your preferred network, and identify clear performance requirements:
    • Hospitalization rate X% lower than benchmark
    • Days to in-person visit — and ability to accommodate any special requests
    • Availability of telehealth monitoring
    • Outpatient visit support
    • DME support 
    • Satisfaction survey results

Jessica Pelligrino Tsoukalas, Director of Business Development and Strategy at Bridgeway Senior Healthcare in New Jersey, shared this: “Key to our success was improving our downstream provider relationships. We invited them to the table, but to return to the table, we made clear our expectations.” Jessica is my new hero! She explained that much of this data is available on Home Health Compare, but she required additional data, details, and explanations for any undesired outcomes. 

Remove the barriers to a safe discharge

  • Form a relationship with your local community pharmacy. Ensure the resident has their discharge medications in hand before leaving the SNF 
  • Have an HH rep visit with the resident 72 hours prior to their discharge home.
  • Schedule a follow-up visit with the resident’s MD within a reasonable time. (This requires you to pick up the phone and call to make sure the visit is scheduled in a reasonable time frame. Often our residents will accept “The next available appointment is in four weeks,” and not push back)
  • Monitor all hospital data, both for the HH agency and your discharged patients.

Jessica added, “We always used data to provide the best care, but now we use process and outcomes data to manage our home health provider relationships. This has been a winning combination.” Yes it has, Bridgeway Senior Healthcare! You have been in the top quintile of performance for quite some time. Can you say, “rock star?” I can, and you are Jessica. 

For the record, Johnny Carson was my parents’ and grandparents’ show. I was a little young for Carnac the Magnificent. However, you do not need to be a great seer to see both the frustration SNFs experience with this measure and the value in improving it. Focus on the intent: Increase the number of safe community discharges.

Busy yourselves with the excellent suggestions provided by other top-performing SNFs around the country. Ultimately, with time and patience, the QRP measure will reflect your high performance. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.