Jessie McGill, RN​There are over 40 different quality measures (QMs) that affect skilled nursing facilities (SNFs) across several programs. MDS 3.0 Quality Measures, SNF Quality Reporting Program (QRP) measures, SNF Value-Based Purchasing (VBP) Program measures, Nursing Home Compare (NHC) claims-based measures, and the Five-Star Quality Rating System are just a few of the quality measures nurse leaders must keep track of.

To add to the confusion, some measures are used in more than one program, like the Changes in Skin Integrity Post-Acute Care (PAC): Pressure Ulcer/Injury SNF QRP measure that also factors in the MDS 3.0 Quality Measures. The cross-over between programs may become even more complex if the Centers for Medicare & Medicaid Services (CMS) finalizes changes to the SNF VBP and SNF QRP programs as proposed in the fiscal year (FY) 2023 SNF Prospective Payment System (PPS) proposed rule. SNF leadership will need to recognize the key differences among each of the programs to understand how the measures will impact their facilities.

MDS 3.0 Quality Measures

The MDS 3.0 Quality Measures are the foundation of quality measurement for both short-stay and long-stay residents of all payer types. Facilities use these measures for quality improvement, while surveyors use them to identify potential problems. The MDS 3.0 measures are facility-reported using MDS assessment data submitted to the national database. The specifications for these measures can be found in the MDS 3.0 Quality Measures User’s Manual.

Five-Star Quality Rating System Measures and NHC Claims-Based Quality Measures

The Five-Star Quality Rating System publicly reports quality ratings for facilities’ health inspections, staffing, quality measures, and an overall star rating. The quality measure domain compiles ratings from MDS 3.0 measures, SNF QRP measures, and NHC claims-based measures to calculate a star rating for short-stay measures, long-stay measures, and an overall quality measure rating. Additionally, the staffing domain has recently developed two staffing measures, which are expected to be incorporated into the staffing star methodology in July 2022.

The Five-Star quality measures are publicly reported on the Care Compare website, along with outcomes from several other measures from both the MDS 3.0 and SNF QRP measures that are not used in the Five-Star QM domain methodology. Consumers use the Five-Star ratings when comparing nursing homes, and hospitals consider them when making referrals. Additionally, the Five-Star rating may impact the facility’s ability to obtain contracts with some managed care plans, or to participate in an Accountable Care Organization (ACO).

SNF QRP Measures

The SNF QRP is a reporting program. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act requires SNFs and other post-acute settings to report standardized data elements on Medicare beneficiaries to enable comparison of outcomes across the different settings. Specifications and reporting requirements for each fiscal year are available on CMS’s SNF QRP Measures and Technical Information website. This program penalizes facilities only if they fail to report the data needed to calculate the SNF QRP measures. Facilities are not penalized based on the outcomes of these measures. For the SNF QRP program, facilities must submit at least 80 percent of MDS assessments with 100 percent of the required MDS data as well as 100 percent of the data submitted to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Failure to submit the required data results in a 2 percent reduction to the annual payment update for the SNF QRP program year. While facilities are only penalized if they fail to comply with the reporting requirements, it is important to note that the measure outcomes are publicly reported on Care Compare.

SNF VBP Measures

The SNF VBP program is a result of the Protecting Access to Medicare Act (PAMA) and connects Medicare reimbursement to quality outcomes. This program withholds 2 percent of Medicare funds for the program year and redistributes 50 percent to 70 percent back to the SNFs as an incentive payment. Facilities are scored based on the higher of either an achievement score (facility compared to all facilities) or an improvement score (facility compared to its own baseline score). Since the inception of this program, it has been based on one Medicare beneficiary readmission measure; however, the Consolidated Appropriations Act of 2021 allows for up to nine additional measures to be added to the program. The poorest performing facilities may receive no incentive payment and lose the full 2 percent that was withheld, while the best-performing facilities can earn incentive payments that could exceed the 2 percent withholding.

Understanding Measures in Multiple Programs

CMS has proposed adopting two existing SNF QRP measures into the SNF VBP program: the Healthcare-Associated Infection (HAI) Requiring Hospitalizations measure for the FY 2026 program year and the Discharge to the Community measure for the FY 2027 program year. These two measures are both 100 percent claims-based measures, meaning the data comes solely from hospital Medicare claims and not from the MDS assessments. This also means that facilities are not penalized in the SNF QRP program since the facility is not reporting the data. However, these measures are both publicly reported on Care Compare. Furthermore, the Discharge to Community measure also applies in the Five-Star quality star rating but uses the name “Rate of Successful Return to Home and Community from a SNF.” Currently, facilities face no direct penalty related to the reporting or outcomes of these measures. However, if the proposal is finalized, the outcomes of these measures would affect the incentive payments received under the VBP program.

Additionally, CMS has proposed a new measure for the FY 2026 VBP program year: the Total Nursing Hours Per Resident Day Staffing measure. In the proposed rule, this measure references the methodology for total nursing hours per resident day in the Five-Star staffing domain. However, this measure is different than the weekend staffing and turnover measures, which are also expected to impact the staffing domain starting in July 2022. While staffing hours and the star rating are publicly reported and historically may have impacted referrals and consumer perspective, if finalized, the staffing measure scores will also impact the SNF VBP incentive payments.

Overall, when an existing measure is adopted into another program, the measure specifications remain the same, but the data is used in a new way. This allows facilities to continue the quality improvement efforts currently in place for the measure, even if the measure’s impact on the facility has expanded. When the focus is on overall quality improvement, the facility and residents will benefit, regardless of which program the measure belongs to.

Jessie McGill, RN, RAC-MT, RAC-MTA, is Curriculum Development Specialist for the American Association of Post-Acute Care Nursing (AAPACN).