Serving Colorado, Illinois and Iowa 2 1 5/22/2019 Housekeeping - PDF document

5/22/2019 Nursing Home Compare Five-Star Rating System: Resetting Your Course Lisa Bridwell, Program Specialist Telligen This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment. 11SOW-QIN-05/0919-3417 1 Serving Colorado, Illinois and Iowa 2 1

5/22/2019 Housekeeping • Due to large number of attendee’s the lines will be muted • The PPT will be sent out via email by 5/24/2019 • Please enter any questions in the chat • Chat questions that do not receive a response will be responded to via email, after we receive the attendee list 3 Objectives • Learn how to calculate the overall star rating • Recognize how each QM domain is calculated • Identify data sources used for calculating the Five- Star Rating • Identify scoring exceptions for the Staffing domain that result in a one star rating for RN and Total Staffing 4 2

5/22/2019 Nursing Home Compare 5 Critical Resources 6 3

5/22/2019 Critical Resource 7 April 2019 Changes in Technical User’s Guide Domains • Health Inspection: “Freeze” is over! – Using pre-freeze weighting • Quality Measures – New /Removed Measures – Weighting/Scoring changes – Thresholds may change every 6 month • Staffing Measures – PBJ data – Cut point updates – Automatic downgrade in Staffing Domain to 1 star if NHs report > 4 days in a quarter without an RN onsite 8 4

5/22/2019 Five- Star Rating Components • Measures based on outcomes from State Health Inspections Health Inspection Rating • Number, scope and severity of deficiencies • Standard and substantiated complaint survey • Measures based on nursing home staffing levels Staffing Rating • Data: PBJ RUGs Case Mix, MDS • Use a subset of publically reported QMs on Nursing Home Compare Quality Measures Rating • Data: MDS and Medicare Claims Overall Nursing • Composite Rating Home Rating 9 Calculation: Overall Nursing Home Rating • Special Focus Facilities (SFF) no longer have ratings displayed, have yellow warning sign • If a nursing home has no health inspection rating (to new or not), then no overall rating is assigned. https://www.cms.gov/medicare/provider-enrollment-and- certification/certificationandcomplianc/fsqrs.html 10 5

5/22/2019 Example Overall Nursing Home Rating Calculation Preview Report Example #1 NH ABC Example #2 NH DDD 11 Health Inspection Scoring 3 Cycles • 3 most recent substantiated standard surveys and complaint surveys within calendar year • Each deficiency is weighted by scope and severity • More recent surveys weighted more heavily 12 6

5/22/2019 Health Inspection Score https://www.cms.gov/medicare/provider-enrollment-and- certification/certificationandcomplianc/fsqrs.html 13 Weights for Repeat Revisits 14 7

5/22/2019 Health Inspection Example Survey Cycle #1 15 Health Inspection Example Calculating points The Math: In 2018 – 4Dx4=16 , 1Ex8=8, 36 points x .50 = 18 repeat revisit 24 points x .33 = 7.9 88 points x .167 = 14.7 36 points Grand Total 40.6 (½ score) Check Cut Point Table 1 for your In 2017 – 2Dx4=8, 2Ex8=16 state 24 points https://www.cms.gov/Medicare/ Provider-Enrollment-and- (1/3 score) Certification/CertificationandCo mplianc/Downloads/cutpointsta In 2016 – 6Dx4=24, 4Ex8=32, ble.pdf 2Fx16=32 88 points (1/6 score) 16 8

5/22/2019 Cut Point Table Example Grand Total = 40.6 https://www.cms.gov/medicare/provider-enrollment-and- certification/certificationandcomplianc/fsqrs.html 17 Quality Measures (QMs) Changes April 2019 • 17 QMs • Physical Restraints Removed from 5 star • QM Domain Split; Long Stay (LS) and Short Stay (SS) • Pressure Ulcer QMs include unstageable • Recalculated Cut points – Two weight categories: Deciles and Quintiles • Two New LS Claims-based Measures (5 Total Claims Based Measures) • Replacement of 2 (SS) QMs with 2 similar measures from SNF Quality Reporting Program – Pressure Ulcers and Successful discharge to community 18 9

5/22/2019 Quality Measure Imputation • MDS Measures – Reported if they can be calculated for at 20 > resident assessments summed across 4 quarters (denominator) • LS and SS Claims-based Measure • Reported if the measure can be calculated for 20 NH stay s over the course of a year (denominator) • Facilities with missing data or not meeting the above criteria • See Technical Users Guide to identify imputation strategy • Imputation strategy is based on pattern of missing data- page 14 19 Risk Adjusted QMs Claims Based MDS Based All Claims Based Measures Long Stay: – Number of Hospitalization per – Mobility decline 1000 LS resident days – Catheter – Number of ED visits per 1000 – Pain LS resident days – % of SS residents hospitalized Short Stay after admission – Functional improvement – % of SS residents who had an ED visit – Pressure Ulcers – Rate of successful return to home/community from SNF 20 10

5/22/2019 Quality Measures and Points Note: the short-stay QM rating thresholds are based on the adjusted scores (after applying the factor of 1250/900 to the unadjusted scores ) 21 Example QM Ranges for Point Values for QMs Technical Users Guide 22 11

5/22/2019 Quality Measure Domain Star Calculation • Points are assigned based on QM performance value • 4 quarter average is used for most MDS based QMs • Claims-based measures- use 4 quarters of data-anticipate quarterly update – Watch for future updates! • 5 Star Goal > 1606 points https://www.cms.gov/Medicare/Provider-Enrollment-and- 23 Certification/CertificationandComplianc/downloads/usersguide.pdf QM Scoring Thresholds Please Note: Table 6 thresholds are accurate as of 5/8/2019. CMS updates the Technical User’s Guide often and we recommend you always check the website : https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/CertificationandComplianc/downloads/usersguide.pdf 24 12

5/22/2019 Example Preview Report Score with Thresholds Preview Report 25 Staffing Domain Where Does Data Come From Now? • PBJ data that is submitted quarterly – Specific Job Codes for RN,LPN,CNA • MDS Census Data • Both the PBJ and MDS Census summed across a quarterly reporting period Critical Steps • Follow Technical Users Guide Instructions- page 9 – Extracting Census data – Identifying Discharged Residents 26 13

5/22/2019 Expected Staffing Weights Case-Mix Adjusted based on Resource Utilization Groups (RUG)-IV • Case Mix Hours: CMS Strive Study measured the average number of RN,LPN and CNA minutes associated with each RUG Group 27 Using the Provider Rating Preview Report https://data.medicare.gov/data/nursing-home-compare 28 14

5/22/2019 Staffing Cut Point and Weighting Technical User’s Guide (TUG) 29 Calculate Staffing Stars Provider Rating Preview Report • Nursing= 1.159 • Total Nursing Staff = 4.283 30 15

5/22/2019 Caution : Staffing Scoring Exceptions Resulting in ONE Star Staffing • 4> Days in the quarter without RN staffing hours on days when there are residents in the building • Failing to meet deadlines for staffing data submission • Failing to respond to CMS PBJ Audits or audits that identify significant discrepancies between hours reports and verified 31 What Can Change Your Overall Five Star Rating • A New Health Inspection • A New Complaint resulting in > deficiency citation • 2 nd , 3 rd or 4 th revisit • Resolution of Informal Dispute Resolutions, changing scope and or severity of deficiencies • “Aging” of complaint deficiency 32 16

5/22/2019 Telligen Tool https://www.telligenqinqio.com/resource/our-work/nursing-home-care/nursing- home-care-resources/how-to-access-the-nursing-home-compare-five-star- rating-preview-report/ 33 Telligen Tool Calculates 5 Star QM Score • Interactive • Teams see how each QM score impacts overall score • Use to prioritize improvement 34 17

5/22/2019 Telligen Nursing Home Compare Five Star Rating Calculation Tool 35 Resources to Learn How QMs are Triggered • MDS 3.0 Quality Measure Manual • Skilled Nursing Facility Quality Reporting…. User’s Manual (Claims) • RAI Manual 36 18

5/22/2019 Questions ? 37 Resources • Nursing Home Compare: www.medicare.gov • Design for Nursing Home Compare Five-Star Quality Rating Technical User’s Guide: • https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/CertificationandComplianc/downloads/usersguide.pdf • CMS User Manuals: https://www.cms.gov/medicare/quality- initiatives-patient-assessment- instruments/nursinghomequalityinits/nhqiqualitymeasures.html • MDS 3.0 RAI Manual v1. 16: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.html 38 19