Skilled nursing facilities must keep pace with several quality programs
There are over 40 different quality measures (QM) that affect skilled nursing (SNF) facilities across multiple programs. MDS 3.0 Quality Metrics, SNF Quality Reporting Program (QRP) Metrics, SNF Value Based Purchase Program (VBP) Metrics, Nursing Home Compare (NHC) Claims Based Metrics ) and the five-star quality rating system are just a few of the quality measures that nursing leaders must follow.
To add to the confusion, some measures are used in more than one program, such as the Changes in Skin Integrity Post-Acute Care (PAC): Pressure Ulcer/Injury SNF QRP measure which also considers MDS 3.0 quality measures. The crossover between the programs may become even more complex if the Centers for Medicare & Medicaid Services (CMS) finalizes changes to the SNF VBP and SNF QRP programs, as proposed in fiscal year 2023 SNF Prospective Payment System (PPS) proposed rule . SNF management will need to recognize the key differences between each of the programs to understand the impact of the measures on their facilities.
MDS 3.0 Quality Metrics
MDS 3.0 quality metrics provide the foundation for measuring quality for short-term and long-term residents of all payer types. Institutions use these measures for quality improvement, while investigators use them to identify potential problems. MDS 3.0 measures are reported by facilities using MDS assessment data submitted to the national database. Specifications for these metrics can be found in the MDS 3.0 Quality Metrics User Manual.
Five-Star Quality Rating System Metrics and NHC Claims-Based Quality Metrics
The Five-Star Quality Rating System makes public facility health inspection quality ratings, staffing, quality metrics, and an overall star rating. The Quality Metrics area compiles ratings from MDS 3.0 metrics, SNF QRP metrics, and NHC claims-based metrics to calculate a star rating for short-stay metrics, long-stay metrics, and an overall rating of quality measurement. Additionally, the staffing domain has recently developed two staffing metrics, which are expected to be incorporated into the star staffing methodology in July 2022.
The Five-Star quality measures are published on the Care Compare website, along with the results of several other measures of the MDS 3.0 and SNF QRP measures that are not used in the Five-Star QM domain methodology. Consumers use five-star ratings when comparing nursing homes, and hospitals consider them when making recommendations. Additionally, the five-star rating may impact the facility’s ability to obtain contracts with certain managed care plans or participate in an Accountable Care Organization (ACO).
SNF QRP measures
The SNF QRP is a reporting program. The IMPACT (Improving Medicare Post-Acute Care Transformation) Act requires SNFs and other post-acute care facilities to report standardized Medicare beneficiary data elements to enable comparison of outcomes between different facilities. Specifications and reporting requirements for each exercise are available on CMS’s SNF QRP Technical Information and Measures website. This program only penalizes establishments if they do not communicate the data necessary to calculate the SNF QRP measures. Institutions are not penalized based on the results of these measures. For the SNF QRP program, facilities must submit at least 80% of MDS assessments with 100 percent required MDS data as well as 100 percent data submitted to the National Health Care Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC). Failure to submit the required data results in a 2 percent reduction of the annual payment update for the year of the SNF QRP program. Although facilities are only penalized if they do not comply with reporting requirements, it is important to note that measurement results are made public on Care Compare.
SNF VBP measures
The SNF VBP program is the result of the Protecting Health Insurance Access Act (PAMA) and links health insurance reimbursement to quality outcomes. This program retains 2 percent of Medicare funds for the program year and redistributes 50 percent at 70 percent to NSFs as an incentive payment. Institutions are scored according to the higher of an achievement score (institution relative to all institutions) or an improvement score (institution relative to its own benchmark score). Since its inception, this program has relied on a single measure of readmission of Medicare beneficiaries; however, the Consolidated Appropriations Act of 2021 allows up to nine additional measures to be added to the program. Low performing facilities may receive no incentive payment and lose all 2 percent which has been selected, while the best performing facilities can earn incentive payments which could exceed the 2 percent detention.
Understanding Metrics in Multiple Programs
CMS proposed to adopt two existing SNF QRP metrics in the SNF VBP program: the Healthcare-Associated Infections (HAI) metric requiring hospitalizations for the 2026 program year and the Community Discharge metric for the 2027 program. These two measures are both 100 percent claims-based measures, which means that the data comes only from hospital health insurance claims and not from MDS assessments. This also means that installations are not penalized in the SNF QRP program since the installation does not report the data. However, these measures are both made public on Care Compare. In addition, the community discharge metric also applies to the five-star quality star rating, but uses the name “Rate of Successful Return to Home and Community from an SNF”. At this time, facilities do not face any direct penalties related to reporting or the results of these actions. However, if the proposal is finalized, the results of these measures will affect the incentive payments received under the VBP program.
In addition, CMS proposed a new measure for the FY2026 VBP program year: the staffing measure of total nursing hours per resident day. In the proposed rule, this metric refers to the methodology for total nursing hours per resident day in the five-star staffing area. However, this measure is different from the weekend staffing and turnover measures, which are also expected to impact the staffing area from July 2022. Although the staffing hours and the star ratings are made public and may have historically impacted consumer referrals and perspective, if finalized. , staffing metrics scores will also impact SNF VBP incentive payouts.
Basically, when an existing measurement is adopted into another program, the specifications of the measurement remain the same, but the data is used in a new way. This allows institutions to continue the quality improvement efforts currently in place for the measure, even if the impact of the measure on the institution has increased. When the focus is on overall quality improvement, both the facility and the residents benefit, regardless of which program the measure belongs to.
Jessie McGill, RN, RAC-MT, RAC-MTA, is a Curriculum Development Specialist for the American Association of Post-Acute Care Nursing (AAPACN).