Six months have passed since CMS released its new MDS 3.0 based Quality Measures and the updated 5-Star program. What do these data reveal about your organization, and how can you use this information for quality improvement and risk reduction? Specific analytic insights into CMS’ updated QMs and useful tools will reveal key actions to improve organizational performance while mitigating risk.

1. Analytic Insights from CMS’ Five-Star
and New Quality Measures
Jennifer Gross
Jeff Merselis
American Healthcare Association
October 2012
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2. MDS 3.0 Quality Measures
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3. Introduction
• The nursing home Quality Measures (QMs) come from
MDS resident assessment data routinely collected at
specified intervals
– Posted on Nursing Home Compare
– A subset of measures are used for the Five-Star calculation
• Quality Measures on the Nursing Home Compare
website allow consumers, providers, states and
researchers to compare information on nursing homes.
• Many nursing homes use this information to guide
quality improvement efforts and monitor progress
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4. Changes in the MDS 3.0 Quality
Measures
• Although there are many similarities between
the MDS 2.0 and 3.0 QMs, the differences may
affect your facility’s trigger rates
– Resident Selection
– Record Selection
– Resident Assessment Method
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5. Resident Selection
MDS 2.0 MDS 3.0
Post-Acute Care (PAC): PPS 5-day and 14- Short Stay (SS): </=100 cumulative days in
day MDS facility
Chronic Care (CC): OBRA Quarterly, Long-Stay (LS): =/>101 cumulative days in
Annual, Significant Change, Significant facility
Correction
Changes in the resident sample selection affect the denominator size
for Short Stay and Long Stay measures
• Short Stay sample may be larger than PAC due to 100 day time
period
• Long Stay residents remain in LS sample even after reentry from
hospital
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6. Residents on Leave of Absence
• Residents who leave for a temporary home
visit/therapeutic leave
• Residents who have a hospital observation
stay <24 hours and are not admitted
– Discharge assessment is not completed
– These residents can trigger for incidents outside
the facility (e.g. fall w/fracture)
• LOA days still count towards resident’s
Cumulative Days in Facility
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7. Record Selection
• Selection of MDSs used in the QM calculation
no longer based solely on MDS reason for
assessment (RFA)
• Resident’s span of time in the facility dictates
which measures may trigger
– An OBRA assessment may trigger a Short Stay
measure if the resident has </=100 CDIF
– A PPS assessment may trigger a Long Stay
measure if =/> 101 CDIF
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8. Record Selection (cont.)
• Look-Back Scan: used to capture triggering
conditions within the episode
– May not be the most recent MDS
• Three measures with look-back scans
– New/Worsening Pressure Ulcers (SS)
• Looks back up to the beginning of the episode
– Falls (LS)
– Falls with Major Injury (LS)
• Look back up to a year (275 + 93 days)
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9. Resident Assessment Method
• Resident interview only for Pain assessment
– Residents who were not interviewed excluded
from SS and LS measures
– Reduces denominator size
• New/Worsening Pressure Ulcers
– Stage 2-4 only
– Section M0800 not completed on first assessment
since most recent entry/reentry
• Excludes hospital acquired/worsened ulcers
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10. Resident Assessment Method (cont.)
• Symptoms of Depression
– Uses either the PHQ-9© resident interview or staff
assessment
• Little interest/pleasure in doing things or feeling
down/depressed/hopeless: half or more days
AND
• Total severity score =/>10
• Influenza Vaccine (SS/LS)
– If vaccine given for current flu season, carry forward
code on future assessments until next flu season
begins
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11. New Antipsychotic Measures
• Different from the antipsychotic “surveyor
measure” on CASPER
– Fewer exclusions
• Incidence of Psychoactive Medication Use (SS)
– Short-stay residents who did not receive antipsychotic
on initial assessment and do receive it on target
assessment
• Prevalence of Psychoactive Medication Use (LS)
– Long-stay residents who receive antipsychotic
• Both measures only exclude residents with
Schizophrenia, Tourette’s or Huntington’s
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12. Average QM Rates 2.0-3.0
• The differences in data collection and record
selection have resulted in different QM rates
for measures that had “similar” MDS 2.0
counterparts
• Even though the actual QMs can’t be
compared from MDS 2.0 to MDS 3.0, how the
public sees your facility’s rates doesn’t change
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13. QM Rates 2.0-3.0: ADL
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14. QM Rates 2.0-3.0: Pain
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15. QM Rates 2.0-3.0: Pressure Ulcers
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16. Five-Star Quality Domain
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17. “The primary goal of this rating system is to
provide residents and their families with an
easy way to understand assessment of
nursing home quality, making meaningful
distinctions between high and low performing
nursing homes.”
CMS’s Five-Star Technical Users’ Guide
July 2012
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18. CMS’ Five-Star Program
• The rating system features an overall
Five-Star rating based on facility performance
for three types of performance measures:
– Health Inspection (CASPER)
– Staffing (CASPER)
– Quality (Public Quality Measures)
• The rating system has been available to the
public on Nursing Home Compare since
December 18, 2008
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19. Quality Measures Domain
• Facility ratings for the quality measures are
based on performance on 9 of the 18 QMs
that are currently posted on the Nursing
Home Compare web site
– Based on MDS 3.0 assessments
• Include 7 Long-Stay (LS) measures and 2
Short-Stay (SS) measures
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20. Long-Stay Residents
• Percent of residents whose need for help with activities
of daily living has increased
• Percent of high risk residents with pressure sores
• Percent of residents who have/had a catheter inserted
and left in their bladder
• Percent of residents who were physically restrained
• Percent of residents with a urinary tract infection
• Percent of residents who self-report moderate to
severe pain
• Percent of residents experiencing one or more falls
with major injury
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21. Short Stay Residents
• Percent of residents with pressure ulcers
(sores) that are new or worsened
• Percent of residents who self-report moderate
to severe pain
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22. Included Assessments
• Long Stay measures are included in the score if
the measure can be calculated for at least 30
assessments (summed across three quarters of
data)
• Short Stay measures are included in the score
only if data are available for at least 20
assessments
• Ratings are calculated using the three most
recent quarters for which data are available
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23. Five-Star Quality Score Calculation
MDS 2.0 MDS 3.0
ADL measure weighted higher than other ADL measure weighted equally with other
measures measures
ADL measure ranked in percentiles based ADL measure ranked in deciles based on
on State distribution State distribution
All non-ADL measures ranked in quintiles All non-ADL measures ranked in
based on National distribution percentiles based on National distribution
Points assigned according to quintiles Points assigned according to percentiles
Total possible score ranges from 0-136 Total possible score ranges from 9-900
points points
Changes in the Five-Star Quality Domain calculation from MDS 2.0 to MDS 3.0
requires attention from providers
• The basic premise is the same: lower QM rates=higher point values
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24. Star Cut-points for MDS Quality Measure
Summary Score
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25. Quality Measure Score Thresholds
• Cut points for the QMs were set based on the QM
distributions averaged across Q2-Q4 of 2011
– will be maintained for a period of at least two years,
after which CMS will review
• These thresholds were set so that the overall
proportion of nursing homes in each rating category in
July 2012 (when the QM rating based on MDS 3.0 is
first reported) would be similar to what it was when
the MDS 2.0 QM rating was frozen in March 2011.
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26. Comparison of Five-Star Quality
Domain 2.0-3.0
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27. Facility Star Rating Changes 2.0-3.0
New Quality Rating –
Number of Facilities Percent of Facilities
Old Quality Rating
-4 44 <1%
-3 445 3%
-2 1418 9%
-1 3205 21%
0 4967 33%
1 3251 21%
2 1435 9%
3 406 3%
4 62 <1%
Although the national distribution of star ratings remains the same, individual
facilities will see changes in their own Quality ratings
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28. CMS August Update to Nursing Home
Compare
• Shifted QM 3-quarter time period from
March-December 2011 to July 2011-March
2012
• Facilities saw a resulting change in their
publicly reported QM rates and star ratings
• Note the potential for changes with each
quarterly update to NHC
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29. Facility Star Rating Changes July-
August 2012
August 2012 Quality
Rating– Number of Facilities Percent of Facilities
July 2012 Quality Rating
-4 0 0%
-3 2 <1%
-2 60 <1%
-1 1857 12%
0 10425 68%
1 2939 19%
2 122 1%
3 10 <1%
4 0 0%
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30. Five-Star Changes and Your Facility
• Changes in the QMs can have an effect on
your facility’s Quality and Overall Five-Star
ratings
– Keep on top of CMS updates to Five-Star
• The challenge: to understand these changes to
put your facility’s rating in context and
communicate with residents, families and the
public
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31. Five-Star/QMs and Your
Ability to Compete
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32. How was the Five-Star Quality Rating
System designed to be used?
1. Help educate consumers about nursing home quality
2. Help improve provider quality
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33. How are Five-Star and MDS 3.0 QMs
actually being used?
 SNF’s marketing departments
 Hospital Discharge planners
 HUD lending/re-financing
 Plaintiff attorneys
 Insurance brokers
 ACOs/ “Bundles”
 Medicare Advantage Plans
 Media
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34. 1. Does the SNF that you work for have
a marketing strategy?
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35. 2. Does the SNF that you work for use
Five Star rating in marketing efforts?
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36. 3. Does the SNF that you work for use
Quality Measures (QMs) in marketing
efforts?
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37. 4. Does the SNF that you work for
sometimes lose referrals to other SNFs
with a higher Overall Five Star rating?
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38. 5. Does the SNF that you work for use
the Overall Five Star rating in their
marketing efforts to hospitals?
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39. 6. Does the SNF that you work for use
the Overall Five Star rating in their
marketing efforts to ACOs?
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40. 7. Does the SNF that you work for market
your Five Star components (i.e. Survey,
Quality, Staffing, etc.) separately?
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41. 8. Was the SNF that you work for “surprised”
by your 3.0 Quality Measure (QM) rating
compared to your 2.0 QM rating?
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42. 9. Do you find that the Quality Measures
(QMs) enhance your overall marketing
strategy?
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43. Strategies for Success
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44. Five Data-Driven Strategies for Using Five-Star and
QMs to Market your Facilities More Effectively
1. Remember the who and why
2. Turn blunt instruments into sharp tools
3. Augment Five Star and QMs with other
key metrics
4. Don’t rely solely on yesterday’s news
5. Turn weaknesses into strengths
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45. How is Your Data Quality?
Proportion of MDS Assessments with Issues (>5,000,000
assessments)
17%
With Issues
Without Issues
83%
Of the 83% of assessments with issues, on average each
assessment had 2.41 issues.
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46. QM Strategies for Success
• Review MDS Data for accuracy
– Correct errors before CMS submission
– Identify processes that impact accurate MDS coding
• Supporting documentation
• Staff education
• Make Five-Star QMs part of facility quality
improvement process
– Trends and benchmarks
• Root Cause Analysis
– Review other CASPER QMs and related care processes
– Monitor positive outcomes to ensure good processes
are maintained
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47. Nursing Home Quality Assurance &
Performance Improvement (QAPI)
• Being rolled out by CMS in 2012
• Provides tools and resources to help facilities
meet existing QAA requirements
– Based on best practices
– Continuously identify and correct quality deficiencies
– Sustain performance improvement
• QAPI Element 3: Feedback, Data Systems and
Monitoring
– QMs can be incorporated into QAPI monitoring
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48. For More Information
• QM Users’ Manual
– www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/MDS30QM-
Manual.pdf
• Five-Star User’s Guide
– www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/usersguide.
pdf
• CMS’ QAPI Page
– www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/QAPI.html
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49. Thank You!
• Jennifer Gross Senior Healthcare Specialist
– jennifer.gross@pointright.com
• Jeff Merselis VP Business Development
– jeff.merselis@pointright.com
• http://www.pointright.com
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