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And you shall rise and show respect to theaged.11/10/18Judy Wilhide Brandt, RN, BA, RAC-MT,QCP, CPC, ide.comQuality Measurement in Skilled Nursing FacilitiesFive Star Rating SystemNovember 2018OverviewQualityMeasuresMDSBasedJudyWilhide.com (c)ClaimsBasedFive StarFive StarSurveySNF QRPSNF QRPSNF VBP1
And you shall rise and show respect to theaged.11/10/18Five Star Rating SystemOverview: Survey Rating will be overall rating unlessinfluenced by Staffing or QM RatingsSurvey RatingStaffing RatingQM RatingJudyWilhide.com (c)Overall ratingIf 4 or 5 stars and above survey rating, add a starIf 5 stars add a star2
And you shall rise and show respect to theaged.11/10/18Overview: Survey Rating will be overall rating unlessinfluenced by Staffing or QM RatingsSurvey RatingStaffing RatingQM RatingOverall ratingIf one star, subtract a starIf one star, subtract a starExamplesJudyWilhide.com (c)NameOverallSurveyStaffingQM1 2 3 4 5 6 3
And you shall rise and show respect to theaged.11/10/185 Star Details: Ratings posted monthlySurvey Stars Change:With any survey packet that is forwarded or asuccessful appeal*Staffing Stars Change:QuarterlyQuality Measures Stars �� year after 11/28/177Understanding the Preview ReportJudyWilhide.com (c)4
And you shall rise and show respect to theaged.11/10/18Preview of what will post at the end of the month.This one was posted in shared Casperfolder “the middle” of April for posting atthe end of April 2018Five Star Preview ReportQuality Measures Included inthe QM RatingJudyWilhide.com (c)5
And you shall rise and show respect to theaged.11/10/18Preview ReportPreview ReportJudyWilhide.com (c)6
And you shall rise and show respect to theaged.11/10/18Survey Star RatingMUKIDISurvey Star RatingWill be overall rating unless influenced by staffingor quality measuresWill not include surveys done after 11/28/17* for“approximately” one yearIncludes two most recent annual surveys prior to11/28/17 (Cycle 1 most recent annual, Cycle 2 annual priorto Cycle 1 annual survey)Includes substantiated complaints for two most recentcomplaint cycles prior to 11/28/17Complaint cycle 1: 11/28/16 – 11/27/17Complaint cycle 2: 11/28/15 – 11/27/16JudyWilhide.com (c)7
And you shall rise and show respect to theaged.11/10/18Surveys since 11/27/17 WILL be posted to NH Compare, but will not be counted instar rating for approx. one year.Cycle 1Cycle 260%40%Note: complaint reporting periods do notmatch Star calculation periodsScope & Severity GridJ50 Points(75 Points)K100 Points(125 Points)L150 Points(200 Points)G20 PointsH30 Points(40 Points)I45 Points(50 Points)Actual HarmD4 PointsE8 PointsF16 Points(20 Points)No Actual Harm with PotentialImmediate Jeopardy to Healthor Safety*for Minimal HarmNo Actual Hard with Potential forA0 PointsFewB0 PointsSomeC0 Pointsthan Minimal HarmMany*If IJ * past non-compliance, G-level (20 points) assignedJudyWilhide.com (c)8
And you shall rise and show respect to theaged.Substandard quality of care11/10/18J50 Points(75 Points)Certain tags under: 483.10 Resident Rights 483.40 Behavioral Health Services 483.45 Pharmacy Services 483.70 Administration (SWqualifications 120 beds) 483.80 Infection Control (influenzaand pneumococcal vaccines)K100 Points(125 Points)L150 Points(200 Points)H30 Points(40 Points)I45 Points(50 Points)F16 Points(20 Points)All tags under: 483.12 Freedom from Abuse,Neglect, and Exploitation 483.24: Quality of Life 483.24: Quality of CareFebruary 2018: Standard and Complaint Survey Weighing in Survey StarsCycle 2 Annual40%Cycle 1 Annual60%*Surveys done for first year of new LTCSP willnot be used for Survey Star Rating for that firstyear.JudyWilhide.com (c)9
And you shall rise and show respect to theaged.11/10/18(8*.60) (4*.40) 6.42 Ds1DReported onNH Compare,not used incalculationsPreview ReportBulk point add-on for revisitsRevisits to ClearJudyWilhide.com (c)Revisit NumberNoncompliance PointsFirst0Second50% of survey score added onThird70% of survey score added onFourth85% of survey score added on10
And you shall rise and show respect to theaged.11/10/18Survey Star DetailsCutpoints varybased on currentstate distributionSNF rating heldconstant until youhave survey eventSame citationin annual &complaintcounted onceif within 15days, worstone countsWhile Special FocusFacility, overall maxcan be 3 starsIf 1 star in survey,max overall canbe 2 starsSurvey Star Distribution20%1 Star10%5 Stars23.3%4 Stars23.3%2 Stars23.3%3 StarsJudyWilhide.com (c)11
And you shall rise and show respect to theaged.11/10/18StaffingStarsStaffing Star ComputationStaffing star ratings are calculated quarterly based on PBJ data submittedprior to deadline, always a quarter behind.April 18July 18Oct 18Jan 19CY Q4 17CY Q1 18CY Q2 18CY Q3 18CY Calendar YearJudyWilhide.com (c)12
And you shall rise and show respect to theaged.11/10/18Staffing based on two case-mix adjusted measures, with equal weight.TotalNurseRN StaffingRegistered Nurse Director ofNursingRegistered Nurse withAdministrative DutiesRegistered NurseNote: LPNs withadministrativeduties do not countas RNsJudyWilhide.com (c)RNTotal Nurse StaffingRegistered Nurse Director ofNursingRegistered Nurse withAdministrative DutiesRegistered NurseLicensed Practical/VocationalNurse with AdministrativeDutiesLicensed Practical/VocationalNurseCertified Nurse AideNurse Aide in TrainingMedication Aide/Technician13
And you shall rise and show respect to theaged.11/10/18Doing the mathHoursadjusted (Hoursreported/Hoursexpected)*HoursNational averageTotal Nurse Example3 reported/ 6 expected ½ x 3.2285 1.61425 adjusted hoursNational Average Hours perResident DayCalculated April 2018Total Nurse: 3.2285RN: 0.3804National average hours National mean of expected hours across all facilitiesactive on March 31, 2018 and that had submitted valid nurse staffing data forOctober 1 – December 31, 2017 (CY Q4).Hours Expected: Z0100 Medicare RUG IV-66 Score from mostrecent OBRA or scheduled PPS MDS assessmentfor current residents on last day of quarter. Active resident resident who, on the last day ofquarter, has most recent (non-DC/Death) MDStransaction less than 180 days old For CY Q1 2018: Last OBRA/scheduled PPS closestto 3/31/18, will use ARD 10/2/17 or later. Another way missing DC/death will hurt yourrating. Census will be too large and acuity will countRUG IV-66 scores for folks not present on lastday of quarter.JudyWilhide.com (c)14
And you shall rise and show respect to theaged.11/10/18Hours Expected Expected hours calculated by summingnursing times in minutes (from STRIVE StudyAppendix Table A1 Five Star Guide) connected to eachRUG category across all residents incategory and across all categories. Total minutes then divided by number ofresidents included in calculations.Time in MinutesRUGRUCHB1RN27.821.65Total Nurse Residents243.166178.928RN Example:Time in minutes * number in category: (27.8*6) (21.65*8) 340.0Divided by total number in all categories: 340/14 24.2875Divided by 60: 24.2875/60 .4048Expected RN HPRD .4048Adjusted RN 0.379Adjusted total 3.1159The percentile cut points (data boundaries between star categories) were determinedusing the data available as of March 2018. First update of cut points since December 2011 Changes in expected staffing due to transition to RUG-IV Cut points set so that changes due to RUG-IV would not impact overall distributionof the five-star ratings So proportion of nursing homes in each rating category would initially (April2018) be the same as it was in March 2018. CMS will evaluate whether further rebasing is needed on a quarterly basis.JudyWilhide.com (c)15
And you shall rise and show respect to theaged.11/10/18Census using MDS Data Select reporting period: Q4 2017 Extract MDS assessment data for all residents of a facility beginning 1 year priorto the reporting period to identify all residents that may resident in the facility. For Q4 17, scan Oct 1 2016 – Dec 31, 2017 looking for submitted records Identify discharged residents: If there is a discharge assessment, use that discharge date. If there is an MDS assessment followed by at least 150 days with nosubsequent MDS record, assume discharge on day 150. Everyone with an MDS assessment and an interval shorter than 150 days will beassumed to be a resident for that particular day. All MDS data extractions will be after required completion and submissiondeadlines have passed.Take home message: All MDS records must be completed and submittedtimely. Once the staffing data is calculated, it will not be recalculated forsubsequent MDS submissions. The larger your census artificially appears, themore short-staffed you will appear.Five StarQuality MeasuresJudyWilhide.com (c)16
And you shall rise and show respect to theaged.11/10/18QM Star Rating Unchanged in April 2018 UpdatesMDSBased134 Short Stay9 Long StayNot based on pay sourceCalculated once per resident, per quarterAdd overallstarIf QM Rating is Five StarsClaimsBased3Short Stay Original Part A onlyCalculated per stayCould be more than once per residentSubtractoverall starIf QM Rating is One StarOverview: 16 Five Star Quality MeasuresCumulative Days in the Facility CDIF:Does not count temporary absences 100 CDIFLong Stay 100 CDIFShort StayTemporary absence: Time between DCRA & ReentryJudyWilhide.com (c)17
And you shall rise and show respect to theaged.11/10/18Short Stay MDS Based Measures: Include a rolling 6 month target rAprMayJunAprMayJunJulAugSepLong Stay MDS Based Measures: Include a three month target periodOctNovDecJanFebMarAprMayJunJulAugSepResident Level Preview Report has names of all SS and LS residents in MDSbased QM computationJudyWilhide.com (c)18
And you shall rise and show respect to theaged.11/10/18LS High-risk pressure ulcersSS new/worse pressure ulcersLS moderate to severe painSS moderate to severe painLS antipsychotic useSS newly received antipsychoticLS ADL declineSS improvements in functionLS ability to move worsenedLS fall with major injuryLS physically restrainedLS UTILS indwelling catheterSS residents emergency department visitSS residents re-hospitalizationSS residents successfully community dischargeClaims basedmeasuresOct 2018: July 1 2017 – June 30 2018Original Medicare A OnlyPer stay, not per residentFour quarters of dataRecalculated every 6 monthsApril and OctoberMJudyWilhide.com (c)UKIDI19
And you shall rise and show respect to theaged.11/10/18Provider 12345672015Q2 2015Q3 2015Q4MDS 3.0 Long-Stay MeasuresLower percentages are better.Percentage of residents experiencingone or more falls with major injuryPercentage of residents who self-report2moderate to severe painPercentage of high-risk residents withpressure ulcersState2016Q1 4Q avgRating1PointsNational4Q avg 4Q 8%Quality MeasurePointsLS Falls w/majorinjury10080604020LowHighAverage 80.035110520.050359731.000000000.02280Each QM has it’s own cutpoint tableCutpoint table from QM ManualUnchanged in April 20181 star2 stars3 stars4 stars5 starsJudyWilhide.com (c)325 - 789790-889890-969970-10541055-160087020
And you shall rise and show respect to theaged.11/10/18“Low Prevalence”Must have four quarter average of zero to get 100 pointsSS new/worsened pressure ulcersSS newly received antipsychoticLS physically restrainedLS RestraintsSS New/worsenedpressure ulcerSS Newly dMeasuresHospitalReadmission 1211.0000000019.660MJudyWilhide.com (c)UKIDI21
And you shall rise and show respect to theaged.11/10/18TechnicalSpecificationsDeeper DiveTarget Records uses for both Long and Short StayMDS Based MeasuresOBRA AdmissionQuarterlyAnnualSignificantchange SignificantCorrectionJudyWilhide.com (c) ScheduledPPS5 Day14 Day30 Day60 Day90 DayOBRADischarge Returnanticipated Return notanticipated22
And you shall rise and show respect to theaged.11/10/18May be done any time in 5 day lookbackIf more than one interview in lookback, RAI manual silent on which one to use.Short Stay & LongStayModerate toSevere PainINTERVIEW ONLYAlmost Constantlyor FrequentlyAlmost ConstantFrequentlyOccasionallyRarely5-9Moderate orSevere10Very Severe,horribleShort Stay: New or Worsened Pressure Ulcers SS Look Back Scan is entire SS episode Covariates M0800 ONLY if A0310E 0Any number 0 for any MDS in lookback scan***Not on MDS 3.0 beginning Oct 1, 2018JudyWilhide.com (c)23
And you shall rise and show respect to theaged.11/10/18Long stay high risk pressure ulcerBed Mobility 3,4,7,8High Risk ifany one presentTransfer 3,4,7,8Comatoseororand St 2,3 or 4 PU in M0300Malnutrition I5600Percent of Short-Stay Residents Who Newly Received anAntipsychotic Medication (look back scan)Initial AssessmentExclusions:Schizophrenia (I6000)Tourette’s Syndrome (I5350)Huntington’s Disease (I5250)Any subsequent assessment 0JudyWilhide.com (c)24
And you shall rise and show respect to theaged.11/10/18Long Stay AntipsychoticsExclusionsUTILong Stay UTIJudyWilhide.com (c)TargetAssessment25
And you shall rise and show respect to theaged.11/10/18Long Stay Catheter“urinary retention” is a “signs and symptoms” diagnosisSymptoms and signs are acceptable for reporting when the providerhas not established a related, definitive (confirmed) diagnosis.Catheter tiveuropathyexcludedLong Stay Restraint UseTrunkrestraintLimb restraintChairpreventsrisingUsed DailyBed rails & Other Restraints do not trigger this QMJudyWilhide.com (c)26
And you shall rise and show respect to theaged.11/10/18Fall withMajor InjuryQ1: Jan 1 –Mar 31ARD 1/5/17QuarterlyNo Major injury FallWhen MajorInjury happens,set ARD to getclock runningARD 7/5/16AnnualFall Major InjuryTarget AssessmentNo Major Injury FallARD 10/5/16QuarterlyNo Major Injury FallARD 6/4/16Fall happened Mar 10, 2016275 Day lookback scan from ARD oftarget Assessment: June 5, 2016ExclusionsADL Quality MeasuresLS ADL declineLS ability to move worsenedSS improvements in function300 pointsJudyWilhide.com (c)27
And you shall rise and show respect to theaged.11/10/18ExclusionsO0100K: Hospice while residentJ1400: PrognosisSS improvements in functionLS ADL declineLS ability to move worsenedSS improvements in functionLS ADL declineLS ability to move worsenedJudyWilhide.com (c)28
And you shall rise and show respect to theaged.11/10/18Long Stay ADL DeclineSelf PerformanceTwo declineby one pointBed MobilityTransferEatingToiletingOne declinesby twopointsLS ability to move worsenedSS improvements in functionBoth risk adjusted in new ways:Covariates:Move worsened: age, gender, vision, oxygen use,Assistance in other ADLs, severe cognitive impairmentFxl improvements; age, gender, severe cognitiveimpairment, Assistance in other ADLs, heart failure, CVA,Hip fracture, Other fracture,JudyWilhide.com (c)29
And you shall rise and show respect to theaged.11/10/18Short-stay improvements in functionTransfersLocomotionon UnitWalking inCorridor onunitTotal5 Day orAdmit33810DischargeReturn NotAnticipated2316G0110 Self PerformanceMid-lossADL (MADL)Note: 7 or 8 added as “4”If total on DCRNA lower: ImprovedImprovements in FunctionExclusions1.Residents satisfying any of the following conditions:1.1. Comatose (B0100 [1]) on the 5-day or admissionassessment, whicheverwas used in the QM.1.2. Life expectancy of less than 6 months (J1400 [1]) on the 5-day oradmission assessment, whichever was used in the QM.1.3. Hospice (O0100K2 [1]) on the 5-day or admission assessment, whicheverwas used in the QM.1.4. Residents with G0110B1, G0110D1, or G0110E1 missing on any of theassessments used to calculate the QM (i.e., discharge assessment, and 5-day oradmission assessment, whichever was used in the QM).1.5. Residents with no impairment (sum of G0110B1, G0110D1 and G0110E1 [0]) on the 5-day or admission assessment, whichever was used in the QM.1.6. Residents with an unplanned discharge on any assessment during the careepisode (A0310G [2])JudyWilhide.com (c)30
And you shall rise and show respect to theaged.11/10/18Percentage of long-stay residents whose ability to move independentlyworsenedAssessmentLocomotionon UnitTarget1PriorClaims basedmeasures0G0110 Self PerformanceIf score on target is higher thanprior: worsenedNote: 7 or 8 added as “4” Prior must be 45 to 165 daysbefore targetDetailsSS residents emergency department visitSS residents re-hospitalizationSS residents successfully community dischargeMJudyWilhide.com (c)UKIDI31
And you shall rise and show respect to theaged.11/10/18Items used in risk adjustment for the three claims basedmeasures: Obtained from hospital claimsAge and SexESRDhospital LOS prior to SNF admitNumber of inpatient hospital stays inyear preceding SNF stayTime in ICU prior to SNF admitPrincipal diagnosis (ICD code)Ever got Medicare due to disabilityCo-morbidities (ICD codes)Claims-based MeasuresIncludedPart A stay that begainwithin one day of hospitaldischarge(IRF/LTCH excluded)Risk AdjustmentsNone are simple fractions. Actualnumberator & denominator are riskadjusted based on characteristicspresent around the start of SNFstayExcluded Stays JudyWilhide.com (c)Not enrolled in Medicare for risk periodMissing dataHospice any time in risk periodComatose on 1st MDSNo 1st MDS32
And you shall rise and show respect to theaged.11/10/18Percentage of short-stay residents who were rehospitalized after a nursing home admissionPart A Stays in which resident had: Unplanned hospital inpatient or outpatientobservation stay Within 30 days of entering SNF Regardless of whether they were dischargedfrom SNF prior to hospital readmissionJudyW ilhide.comMDS items used in riskadjustment: unplannedreadmissionFoot infectionRadiationSeizure disorderWalk in roomDiabetic footulcerTrachUlcerative colitisIV MedWound infectionHeart failureIV FluidWalk in corridor Internal bleedingWandersTwo personassistDehydratedVentUTIDementia (all)Feeding tubeDaily painTransfusionsChemoRejected failureViral hepatitisCancerOstomy carePrognosisCognitive statusSurgical woundnot intactAcute change inmental statusTotal bowelincontinenceAnemiaVenous/ ArterialulcersRarelyunderstoodShortness ofbreathSepticemiaOxygenEntered from: Acute hospitalJudyWilhide.com (c)Cough duringFell in last monthmealsFell in 2-6DialysismonthsEatingCVA1st MDS since entry is SignificantChange33
And you shall rise and show respect to theaged.11/10/18Percentage of short-stay residents who have had anoutpatient emergency department visitPart A Stays in which resident had: Unplanned ED stay without acute admit orinpatient observation stay Within 30 days of entering SNF Regardless of whether they were dischargedfrom SNF prior to hospital readmissionJudyW ilhide.comMDS items used in riskadjustment: ED VisitIsolationAnticoagulantRadiationSeizure disorderDialysisFell in last monthWalk in roomInternal bleedingTrachRespiratorytherapyHeart failureFell in 2-6 monthsCOPDRejected careIV FluidWandersDaily painOrthostatichypotensionVentUTIInsulinFeeding tubeTwo person assistSurgical woundTransfusionsPneumoniaViral hepatitisRespiratory failureCognitive statusnot intactSpeech TherapyAntibioticsVenous/ ArterialulcersOstomy careCancerAcute change inmental statusShortness ofbreathAnemiaOxygenRarelyUnderstoodPrognosisWalk in corridorDehydrated1st MDS since entry is SignificantChangeJudyWilhide.com (c)34
And you shall rise and show respect to theaged.11/10/18Percentage of short-stay residents who weresuccessfully discharged to the communityBeneficiary stay that: Had an MDS discharge assessment indicating discharge to ‘community’within 100 calendar days of the start of the episode; AND within 30 days ofthis discharge the beneficiary: Was not admitted to a nursing home Did not have an unplanned inpatient hospital stay Did not dieMDS items used in riskadjustment: SuccessfulDischargePsychotic DisorderSchizophreniaMarriedInterpreter neededResidentexpectations (Q)MalnutritionHTNHyperkalemiaHip/other fxCVAAnxiety disorderManic DepressionADL DependenceFoot infectionRadiationSeizure disorderDepressionWeight lossBalance problemDiabetic foot ulcerUnderstands othersParaplegiaDialysisFell in 2-6 monthsHemiplegiaSwallowing disorder(K0100)IV MedWound infectionHeart failureIV Fluids/s deliriumSuctioningVentUTIDementia (all)Feeding tubeMedicare RUGVision ImpairmentTransfusionsChemoMSDiabetesCognitive ImpairmentSurgical ��sAcute change inmental statusIncontinenceAnemiaID/DD or relatedconditionViral hepatitisCancerMakes selfunderstoodShortness of breathSepticemiaOxygeninjectionsAntipsychoticsMech Alt dietCOPDEntered from:Psych hospitalJudyWilhide.com (c)Any behavior, wander, reject care,hallucination, delusion35
And you shall rise and show respect to theaged.11/10/18Other MDS Based Quality Measures, notpart of Five Star11/10/18judywilhide.com71Antianxiety or hypnotic medication: Two separate measures NH Compare & Casper Casper Prevalence of Antianxiety/Hypnotic Use(Long Stay) N033.1 Percent of Residents Who UsedAntianxiety or Hypnotic Medication(Long Stay) N036.1Exclusions: Schizophrenia (I6000 [1]). Psychotic disorder (I5950 [1]). Manic depression (bipolar disease)(I5900 [1]). Tourette’s syndrome (I5350 [1]). Huntington’s disease (I5250 [1]). Hallucinations (E0100A [1]). Delusions (E0100B [1]). Anxiety disorder (I5700 [1]). Post-traumatic stress disorder(I6100 [1]).Exclusions:JudyWilhide.com (c) Life expectancy of less than 6months (J1400 [1]). Hospice care while a resident(O0100K2 [1]).36
And you shall rise and show respect to theaged.11/10/18 Long Stay Prevalence of Falls: All falls on any assessment in the LS lookback scan11/10/18judywilhide.com73Long Stay Behavior Symptoms Affecting Others:Anything more thanzero in any of theseboxes11/10/18JudyWilhide.com (c)judywilhide.com7437
And you shall rise and show respect to theaged.11/10/18Long Stay Low Risk BedMobility4,7,8HighRiskTransfer4,7,8Locomotionon unit4,7,811/10/18Everyone deemedlow risk codedfrequently/alwaysincontinent ofbowel or bladderExclusions: Ostomy, catheterjudywilhide.com75Long Stay weight LossSubtitle text here You can replacethis textYou can replacethis textYou can replacethis text11/10/18JudyWilhide.com (c)On TargetAssessmentSubtitle text hereNon-physicianprescribedweight lossjudywilhide.com7638
And you shall rise and show respect to theaged.11/10/18Long Stay Depressive SymptomsDown, depressed,hopeless7-14 daysORLittle interest orpleasure7-14 daysScore 10And11/10/18UsesInterview orStaffAssessmentjudywilhide.com77The Vaccine Quality Measures: Short & LongStaySNFStateNationNot on Casper Reports, Not Five Star7811/10/18JudyWilhide.com (c)judywilhide.com39
And you shall rise and show respect to theaged.11/10/18Assessed andAppropriatelyGiven thePneumococcalVaccineUp to l rules for influenza vaccination measures Flu vaccination measures are calculated once per year. In anormal year where the influenza season begins on October 1and ends of March 31, the target period will coincide with thesedates End-of-episode date will be March 31 for an episode that isongoing at the end of the influenza season and that March 31should be used as the end date when computing CDIF and forclassifying stays as long or short for the influenza vaccinationmeasures.8011/10/18JudyWilhide.com (c)judywilhide.com40
And you shall rise and show respect to theaged.11/10/18Percentage of Appropriate VaccinesPercent of Residents Assessed and AppropriatelyGiven the Seasonal Influenza Vaccine (Long Stay)NumeratorOrCode 2, Received outside of this facilityCode 3, Not eligible—medical contraindicationCode 4, Offered and declined8111/10/18judywilhide.comPercentage of Appropriate VaccinesDenominatorAll long-stay residents with a selected influenza vaccination assessment,except those with exclusions.ExclusionsResident’s age on target date of selected influenza vaccination assessmentis 179 days or less. {pediatric NH}NO other exclusions!8211/10/18JudyWilhide.com (c)judywilhide.com41
And you shall rise and show respect to theaged.11/10/18Percentage of Appropriate Vaccines Measure calculated once a year with target period October 1 ofthe prior year to June 30 of the current year and reports for theOctober 1 through March 31 influenza season. Scan all assessments with target dates on or after October 1 ofthe most recently completed influenza season. Select the record with the latest target date with: Qualifying reason for assessment OBRA, scheduled PPS or discharge Target date on/after October 1st of the most recently completed influenzaseason, and A1600 entry date is on or before March 31st of the mostrecently completed influenza season.8311/10/18judywilhide.comLong Stay Claims Based Measure: Number of hospitalizations per 1,000 LS DaysThis claims-based quality measure will be reported on Nursing Home Comparestarting in October 2018, and integrated into the Five-Star Quality Rating Systemin April 2019. It reports the ratio of unplanned hospitalizations per 1,000 long-stayresident days for non-Medicare A Long Stay residentsJudyWilhide.com (c)42
And you shall rise and show respect to theaged.11/10/18SNF VBP: One Measure onlyFirst year:Skilled Nursing Facility 30-Day All-CauseReadmission Measure (SNFRM NQF #2510)To be replaced by:FY 17 Proposed Measure:SNF 30-Day Potentially Preventable ReadmissionMeasure (SNFPPR)Changes/additions/deletions to VBP measures would come in future rule-makingJudyW ilhide.comTwo ways to earn points:Achievement ScoreRate thresholdRate benchmark0 points100 pointsRate between the two1 to 99 pointsAchievementThreshold25th percentile ofnational SNFperformance duringCY 2015BenchmarkMean of top decile ofnational SNFperformance (10thpercentile) duringCY 2015Achievement Performance: Happy Valley SNF’s rate of all-cause readmissions(SNFRM) in CY 2017 compared to the national rate in CY 2015JudyWilhide.com (c)43
And you shall rise and show respect to theaged.11/10/18Two ways to earn points:Improvement ScoreRate thresholdRate benchmark0 points100 pointsRate between the two1 to 89 pointsImprovementThresholdBenchmarkYour SNF’sperformance duringCY 2015Mean of top decile ofnational SNF performance(10th percentile) duringCY 2015Improvement Performance: Happy Valley SNF’s rate of all-cause readmissions(SNFRM) in CY 2017 compared to it’s own rate in CY 2015Calculating Performance:Higher numbers will be betterCMS thinks this is easier for public to understandIf actual readmission rate is 20%i.e.: 20% of residents included in measure were rehospitalizedYour rate would be 80%i.e.: 80%of residents included in measure were not rehospitalizedCMS is required to pay the better of Achievement or ImprovementJudyW ilhide.comJudyWilhide.com (c)44
And you shall rise and show respect to m (c)45
QCP, CPC, DNS -CT judy@judywilhide.com 909-800-9124 www.JudyWilhide.com November 2018 Overview Quality Measures MDS Based Five Star Survey SNF QRP Claims Based Five Star SNF QRP SNF VBP. And you shall rise and show respect to the aged. 11/10/18 JudyWilhide.com (c) 2 Five Star Rating System
