Steven Littlehale

If a skilled nursing facility were an overall Five Star performer, you would think that it would provide the best care and have the fewest rehospitalizations, right?  

In the current chapter of healthcare reform, many acute care providers, payers and others use Five Star ratings to predict how well a SNF does in terms of preventing rehospitalizations. The Five Star Rating System, as it was built, is not the best predictor of success in a “preferred provider network” focused on reducing rehospitalization rates. Plenty of two-and three-star facilities are excellent performers in the area of rehospitalization for specific clinical conditions.

Can data available in the public domain be used as a reliable predictor of future rehospitalization performance? A recent article in the Journal of the American Medical Association found that better performance on the publically reported quality measures was not an indicator of how well a facility performed on its rehospitalization rate. That surprising disconnect might lead you to believe that establishing a valid rehospitalization measure using public data (like Five Star or QMs) is impossible.

Actually, it’s not.

To assess performance, data about care processes (like pain management) and some staffing dimensions (whether PT or OT provides care, as opposed to assistants) are better indicators of success in managing rehospitalizations. Bring in clinical diagnoses and the predictive power grows!

For example, using NQF’s endorsed PointRight model that adjusts for risk, and comparing it to Five Star ratings for one diagnosis (CHF), reveals the following:

PointRight ratings: A 15.5%; B 17.3%; C 19.9%; D 21.2%; E 24.8%

CMS Five Star: 5 Star 20.7%; 4 Star 19.9%; 3 Star 19.5%; 2 Star 19.3%; 1 Star 18.9%

Look how much better this model does in differentiating performance in CHF rehospitalization Using the Five Star rating, everyone has about the same likelihood of sending a resident with CHF back to the hospital; the other model more clearly distinguishes those centers that are able to care for CHF residents in-house.

With metrics like these, SNFs can evaluate how they are managing different cohorts of residents and pinpoint areas of opportunity. Specific case mix adjusted metrics can isolate quality improvement opportunities or give you the data to compete in the marketplace.

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