Thomas Martin

The Centers for Medicare & Medicaid Services has become laser focused on the post-acute realm. This is evidenced by the steady stream of initiatives regulating the skilled nursing landscape, including the SNF Value-Based Payment (VBP) Program, Payroll Based Journal, new Requirements of Participation, and new measures being added to the Five-Star Ratings program.

Not to mention what’s on the horizon next year with the rollout of the Patient-Driven Payment Model. Given this flurry of activity, many SNFs may have understandably missed or minimized CMS’ late October announcement of new measures under the SNF Quality Reporting Program (QRP). These measures have the potential to impact the way these facilities operate, as well as their relationships with both upstream and downstream partners, so it’s essential that all SNFs review the program.

A Summary of the New QRP Measures

MDS Measures

  • Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-stay)
  • 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

Claims Measures

  • Medicare Spending Per Beneficiary
  • Discharge to Community
  • Potentially Preventable 30-Day Post-Discharge Admissions (*Held back)

Note: The claims-based measures present a specific challenge in that the data is not current and are confined to the Medicare fee-for-service population, which for many SNFs comprises only a small segment of their total patient population.

Shifts in Referral Patterns

Whereas previously published quality measures for SNFs were developed specifically for the SNF care setting, the new QRP measures were designed with interoperability in mind so that SNFs, inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health (HH) all have a common set of metrics. Why is this important? Because the ability to compare different types of facilities may result in hospitals changing referral patterns and relying more heavily on lower cost care settings like HH.

Tracking Patients Outside of the SNF

Two of the QRP measures indicate that CMS wants SNFs to focus more attention on what happens to their patients after their stays—the measure on successful discharge back to the community and the rehospitalization measure. Although the latter was held back from the October announcement, it is perhaps the most significant measure in the program. Unlike rehospitalization measures in other CMS programs, the QRP rehospitalization measure begins at the point of discharge from SNF— not the point of admission — and evaluates outcomes 30 days out.

In other words, the entire period of measurement occurs outside of the facility.

Three Steps to Succeed Under the QRP

Step #1: Avoid the QRP Penalty

To avoid the program’s 2% penalty, SNFs must ensure that 80% of their MDS assessments are completed in such a manner that the three MDS-based measures can be calculated. Details on what constitutes a complete assessment and which MDS items are part of each measure can be found on CMS’ website. Importantly, staff need to ensure they are not using dashes (“-“) to complete questions, as dashes do not count as completed questions.

Step #2: Review Performance Against Peers

When hospitals and payers make patient referrals, they look at the group of regional PACs that they can discharge the patient to and evaluate which ones give the patient the best chance of a positive outcome. SNFs should not only compare themselves to other SNFs in their referral market (data on the measures are posted on Nursing Home Compare), but also be aware of how they compare to other types of PAC care settings (they’ll have to visit the LTCH, HH, and IRF CMS Compare websites to do this).

Step #3: Align with Downstream Partners

In addition to strengthening discharge planning strategies, SNFs can also partner with HH and other lower acuity providers to follow patients after they leave their facilities and transition to new care settings. The key to these partnerships—as well as to partnerships with upstream partners like hospitals and health systems—is sharing real-time, actionable patient data and opening the lines of communication between providers. SNFs should not wait until the rehospitalization measure is released to seek out partners.

More so than any single measure, the QRP needs to be viewed in terms of its total intended impact, which is to further enable providers to facilitate coordinated care, to improve patient outcomes, and to allow for overall quality comparisons. The most effective strategy for SNFs to employ under the QRP is to take an active interest in what’s happening to their patients across the entire care continuum.  

Thomas Martin is the director of post-acute care analytics at CarePort, a leading provider of care coordination software solutions.