Quality Measures impact various reports and programs for Skilled Nursing Facilities including:
- MDS 3.0 Quality Measures (QMs)
- Quality Reporting Program (QRP)
- Value Based Purchasing (VBP)
- Five Star
- Care Compare
- Provider Data Catalog (PDC)
This in turn impacts reimbursement via the Annual Percentage Update (APU) as part of the Quality Reporting Program and incentive payments as part of the Value Based Purchasing Program. Quality Measures can also impact Medicaid reimbursement in certain states. Finally, they can have reputational impact through publicly reported information provided on Care Compare and via the Five Star Ratings.
There is numerous quality measure data collected as part of the MDS 3.0 QMs, which are referred to as MDS Assessment-Based Measures. Claims-Based Measures also play a part. The measures collected may in turn impact Care Compare, Five-Star, QRP, and VBP. CDC NHSN information also factors into the QRP, while additionally Payroll Based Journal (PBJ) data factors into the VBP, Five Star, and Care Compare.
Let’s first talk about the Quality Reporting Program. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) established requirements for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). The IMPACT Act requires SNFs to report standardized patient assessment data for quality measures along with standardized patient assessment elements. The intent of the IMPACT Act is to standardize post-acute care data to improve outcomes for Medicare beneficiaries through care coordination and enhanced discharge planning.
The SNF QRP measures look at data for both long stay and short stay residents. The current measures are (Italicized measures are publicly reported):
MDS Assessment-Based Measures
- Percent of Resident’s experiencing One or More Falls with Major Injury (long stay)
- Drug Regimen Review Conducted with Follow-Up for Identified Issues
- Changes in Skin Integrity: Pressure Ulcer/Injury
- Discharge Self-Care Score (short stay)
- Discharge Mobility Score (short stay)
- Transfer of Health Information to the Provider (data collection began on 10/1/2023)
- Transfer of Health Information to the Patient (data collection began on 10/1/2023)
- Discharge Function Score (short stay) (data collection began on 10/1/2023)
- Percent of Residents who are up to date with COVID-19 Vaccine (data collection to begin on 10/1/2024)
CDC NHSN Measures
- COVID-19 Vaccination Coverage among Healthcare Personnel (data collection began 10/1/2023)
- Influenza Vaccination Coverage among Healthcare Personnel (Public reporting began 10/1/2023)
Medicare Fee-For-Service Claims-Based Measures
- Medicare Spending Per Beneficiary
- Discharge to Community
- Potentially Preventable 30-Day Post-Discharge Readmission Measure
- SNF Healthcare-Associated Infections (HAI) Requiring Hospitalizations
There are 3 measures which were recently removed from the current QRP as part of the FY 2024 SNF PPS Final Rule; however, they continue to be publicly reported based on the current quarters of data being reviewed. They are:
- Percent of Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (ended data collection on 10/1/2023)
- Change in Self-Care Score (ended data collection on 10/1/2023)
- Change in Mobility Score (ended data collection on 10/1/2023)
CMS provides quarterly Provider Preview Reports to be reviewed by Providers prior to information being publicly shared on Care Compare and the PDC.
Currently, the Value Based Purchasing Program looks at a single measure – SNF 30-Day All-Cause Readmission Measure (SNFRM). However, additional measure information is being collected and will begin to impact the VBP incentive payments beginning in FY 2026. Some of the new measures are familiar as part of the QRP, others are new:
- SNF within Stay Potentially Preventable Readmission – SNFWSPPR (FY 2028)
- SNF HAI requiring hospitalization – SNFHAI (FY2026)
- Total Nursing Hours per Day (FY 2026)
- Nursing Staff Turnover (FY 2026)
- Discharge to Community (FY 2027)
- Falls with Major Injury (FY 2027)
- Number of hospitalizations per 1,000 long-stay resident days (FY 2027)
Trinity Rehab Services will continue to offer insight into quality measures to help your facility move forward.