Seeing stars: CMS quality ratings in skilled nursing facilities

A History of Reporting on Quality
Launched in 1998, Centers for Medicare & Medicaid Services' (CMS) Nursing Home Compare website was designed to help consumers and their families find nursing homes and to encourage higher quality of care through public reporting of nursing home performance. A decade later, CMS enhanced the website to include a five-star rating system for measuring nursing home performance as designated by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. In early 2015, CMS updated the rating system to address concerns around the data driving the results being self-reported. As of July 1, 2016, the last of this self-reported data (staffing rates) will be filed electronically with CMS.

Star Ratings Calculations
CMS calculates four star ratings for each nursing facility, assuming the minimum data is available. These cover health inspections, staffing levels, quality of care (long- and short-term stays) and an overall composite rating of the previous three measures. In line with value-based initiatives, these measures support patient choice by increasing transparency for patients and families and encouraging skilled nursing facilities (SNF) to improve quality of care to receive referrals among other strong provider networks.

How Will SNF's Star Ratings Be Used?
1. To validate partners for post-acute bundle provider
2. To increase/decrease reimbursement with value-based payment model
3. Score vs. improvement
4. More utilization review of clinical documentation
5. Assessment/MDS
6. To increase standardization in planning
7. To improve discharge planning for transition to next level of care

Recent Regulatory Changes
Over the past year, CMS has not only made changes in how the Nursing Home Compare Star Ratings are calculated, but have also have added new rules around the use of the Star Ratings:

• Under the IMPACT Act, CMS is required to regulate the use of a quality and resource measurement system to inform patients in their selection of a post-acute care provider. CMS has proposed regulations to hospitals, nursing facilities and home health agencies to use a measurement system like the CMS Star ratings to help inform patients.

• Under the Bundled Payment (BPCI) program hospitals can apply a waiver for the 3-day hospital stay required for SNF services post-discharge. In order for a hospital to use this waiver, they must send a list of their identified SNF partners. To qualify, the SNF must have a three-star or better rating during seven of the last 12 months.

• The last rule CMS has recently issued is in relation to the CJR (Comprehensive Care for Joint Replacement) program. Like BPCI, hospitals may use a 3-day stay waiver with SNFs. The SNF must have a three-star or better rating during seven of the last 12months at the time of the patient's episode.

As the healthcare industry continues to shift toward value-based care, initiatives like the star rating system will be imperative. How have the star ratings affected your SNF? Please let us know in the comments!

Jackie Birmingham, RN, MS, vice president, emeritus, of clinical leadership at Curaspan, is a former director of discharge planning, clinical nurse specialist and critical-care instructor.

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