Five Star Quality Rating System Design For Nursing Home Compare - PowerPoint PPT Presentation

Understanding the Five Star Quality Rating System Design For Nursing Home Compare Nathan Shaw RN, BSN, MBA, LHRM, RAC CT 3.0 Director of Clinical Reimbursement March 23rd, 2015

Objectives

Objectives  Provide a background of the five-star rating  Review the three measures that comprise the overall five-star rating  Describe the methodology for constructing the ratings  Describe the scoring rules for each domain/measure  Discuss the overall scoring rules for the five-star rating  Discuss factors that might change a facility’s rating  Describe the impact of the Five Star rating related to Managed Care and ACOs.  Discuss future QMs planned for the Five Star rating

Background

Background  2008- CMS enhances its Nursing Home Compare website  Develops rating system in form of “stars”  Purpose- To enhance resident and family’s ability to assess as well as compare Nursing Home Quality

Background  February 2015- The Five Star system makes the following changes:  Changed Staffing Domain “Cut Table”  Added two QMs to the QM Domain (LS and SS Antipsychotics)  Changed QM Domain “Cut Table” and Calculation Rules

Nursing Home Compare Website

Nursing Home Compare Website  The Nursing Home Compare website displays each domain individually as well as the overall five-star rating  Each domain calculates an individual five star rating in addition to the overall five star rating  Please refer to URL: http://www.medicare.gov/nursinghomecompare/?Aspx AutoDetectCookieSupport=1

Nursing Home Compare Website

Example Five Star Overview

Example Five Star Overview  The Overall Rating builds upon the Health Inspection Domain of 3 stars.  Staffing Domain of 4 Stars adds 1 star towards the Overall rating.  QM Domain of 5 Stars adds 1 Star towards the Overall rating.  3 Stars (Health Inspection) + 1 Star (Staffing) + 1 Stars (QM) = 5 Stars

Example Five Star Overview

Ratings

Methodology for Constructing the Ratings  Based on the five-star rating for the health inspection domain, the direct care staffing domain and the MDS quality measure domain, the overall five-star rating is assigned in five steps as follows:  Step 1 : Start with the health inspection five-star rating.  Step 2 : Add one star to the Step 1 result if staffing rating is four or five stars and greater than the health inspection rating; subtract one star if staffing is one star. The overall rating cannot be more than five stars or less than one star.

Methodology for Constructing the Ratings  Step 3 : Add one star to the Step 2 result if quality measure rating is five stars; subtract one star if quality measure rating is one star. The overall rating cannot be more than five stars or less than one star.  Step 4 : If the Health Inspection rating is one star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings.  Step 5 : If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum Overall Quality rating is three stars.

Methodology for Constructing the Ratings Sample Overall Quality Rating Calculations

First Domain Health Inspections  Measures based on outcomes from State health inspections  Ratings based on the number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations  Deficiency findings are weighted by scope and severity  Takes into account the number of revisits required to ensure that deficiencies identified during the health inspection survey have been corrected

Methodology for Constructing the Ratings Health Inspection Domain  Based on the most recent three standard surveys; and  Results from any complaint investigations during the most recent three-year period; and  Any repeat revisits needed to verify that required corrections have brought the facility back into compliance

Methodology for Constructing the Ratings

Methodology for Constructing the Ratings

Methodology for Constructing the Ratings Calculation of the Health Inspection Domain Score  More recent surveys are weighted more heavily than earlier surveys  Most recent period (cycle 1) is assigned a weighting factor of 50%  Previous period (cycle 2) has a weighting factor of 33.33%; and  Second prior survey (cycle 3) has a weighting factor of 16.667%  Weighted time period scores are then summed to create the survey score for each facility

Health Inspection “Cut Table” “Cut Point” Table for Health Inspection Domain Star Cut Points for Health Inspection Scores – by State – (01-01-2016) Health Inspection Score Number 1 Star 2 Stars 3 Stars 4 Stars 5 Stars State Of Facilities Upper Lower Upper Lower Upper Lower Florida 688 >53.333 ≤53.333 >32.667 ≤32.667 >20.667 ≤20.667 >10.667 ≤10.667

Health Inspection Domain Calculation Example Facility Health Inspection Calculation Star Cut Points for Health Inspection Scores – by State – (01-01-2016) Health Inspection Score Number 1 Star 2 Stars 3 Stars 4 Stars 5 Stars State Of Facilities Upper Lower Upper Lower Upper Lower Florida 688 >53.333 ≤53.333 >32.667 ≤32.667 >20.667 ≤20.667 >10.667 ≤10.667

Second Domain Nurse Staffing  Measures based on nursing home staffing levels  Ratings on the staffing domain are based on two measures: 1. RN hours per resident day; and 2. Total staffing hours (RN+ LPN+ nurse aide hours) per resident day  Does not include other nursing home staff  The source data for the staffing measures is CMS form CMS-671 from CASPER.

Second Domain Nurse Staffing  The resident census is based on the count of total residents from CMS form CMS-672 (Resident Census and Conditions of Residents).  CMS will continue to require providers to submit Forms CMS 671 & CMS 672 at the time of survey. The data from these forms will be used in calculating the Staffing Domain of the Five Star Rating System until late 2017 or early 2018.  Data from the Payroll Based Journal Electronic Submission System will then be used to calculate the Staffing Domain.

Second Domain Nurse Staffing  Uses the following formula: Hours Adjusted = (Hours Reported/Hours Expected) * Hours National Average. Expected hours calculated using facility Case Mix (based on RUGS III-53 groupers). National average hours per resident per day used in calculation of adjusted staffing (as of April 2012) Type of Staff National Average Hours Per Resident Per Day Total Nursing Staff (Aides & LPN’s & RNs) 4.0309 Registered Nurses 0.7472

Second Domain Nurse Staffing  Casper data includes facility employees (full and part time) as well as contract employees  Casper data excludes private duty, Hospice staff and feeding assistants  A set of exclusion criteria identifies facilities with unreliable CASPER staffing data. Neither staffing data nor a staffing rating are reported for these facilities  The exclusion criteria intends to identify facilities with unreliable CASPER staffing data and facilities with outlier staffing levels

Second Domain Nurse Staffing Staffing Points and Rating (updated February 2015) RN Rating and Hours Total Nurse Staffing Rating and Hours (RN, LPN, and Nurse Aide) 1 2 3 5 5 <3.262 3.262 – 3.660 3.661 – 4.172 4.173 – 4.417 ≥4.418 1 <0.283 2 0.283 – 0.378 3 0.379 – 0.512 4 0.513 – 0.709 5 ≥0.710

Example Facility Staffing Calculation Adjusted Hours Per Resident Per Day Provider Name Adj. LPN Adj. RN Adj. Nurse Adj. Total 1.3407328 0.3923653 1.4742169 4.2202292 Staffing Points and Rating (updated February 2015) RN Rating and Hours Total Nurse Staffing Rating and Hours (RN, LPN, and Nurse Aide) 1 2 3 4 5 <3.262 3.262 – 3.660 3.661 – 4.172 4.173 – 4.417 ≥4.418 1 <0.283 2 0.283 – 0.378 3 0.379 – 0.512 4 0.513 – 0.709 5 ≥0.710

Calculation Needed To Attain Five Stars  Step 1 - RN Staffing Calculation

Calculation Needed To Attain Five Stars  Step 2 - LPN Hours Needed

QM Domain  Measures based on the Minimum Data Set (MDS) 3.0 QMs  Ratings for the QM domain are based on performance on 11 of the 18 QMs  8 Long Term QMs  3 Short Stay QMS  Facility rating for the QM domain is based on performance on a subset of 11 (out of 18) of the QMs- MDS 3.0 based

8 Long-Stay QMs 1. Percent of residents whose need for help with activities of daily living has increased 2. Percent of high risk residents with pressure sores 3. Percent of residents who have/had a catheter inserted and left in their bladder 4. Percent of residents who were physically restrained 5. Percent of residents with a urinary tract infection 6. Percent of residents who self-report moderate to severe pain 7. Percent of residents experiencing one or more falls with major injury 8. Percent of residents who received an antipsychotic medication

3 Short-Stay Resident QMs Percent of residents with pressure ulcers (sores) that 1. are new or worsened Percent of residents who self-report moderate to 2. severe pain Percent of residents who newly received an 3. antipsychotic medication