When the Centers for Medicare & Medicaid Services developed the Quality Measures (QMs) about 20 years ago, the focus was on the resident population that was typical in skilled nursing facilities (SNFs) at the time. These residents were disproportionately receiving long term care, and the QMs reflected the types of quality concerns experienced by long term care residents.

With the dramatic growth of the Medicare post-acute care population over the past two decades and the greater acuity of these residents, the QMs no longer reflect the challenges that SNFs were focused on.
The Quality Reporting Program (QRP) measures apply to Medicare Part A stays only. The eight assessment-based measures use the five-day admission assessment and the discharge assessment, or a matched death in the facility tracking record. Two claims-based QMs are also included in the QRP, as well as a measure of beneficiary cost per stay.

Two of the assessment-based measures were implemented in 2016. One of these, Percent of residents experiencing a fall with major injury, was adapted for the short-stay Medicare population from the long-stay QM. This measure is now reported in Nursing Home Compare (national average of 0.9 percent).

The other measure, Percent of residents with an admission and discharge functional assessment and a care plan that addresses function, including at least one goal, was adapted from long term acute care hospitals (LTACHs). This measure will be used in all post-acute care (PAC) settings, including SNFs, LTACHs, home health agencies, and rehabilitation facilities. For SNFs, this measure is currently reported in Nursing Home Compare (national average of 97.6 percent).

Four functional outcome measures were implemented in October 2018; these will be particularly relevant as the patient-driven payment model is implemented with different incentives for therapy use. Data collection for these measures is underway, as well as preliminary review of results, so these are not currently reported in Nursing Home Compare.

Two of these are functional change scores for Medicare stays during which residents were receiving rehabilitation. They include: Change in self-care score for medical rehabilitation patients and Change in mobility score for medical rehabilitation patients. The self-care score includes seven self-care items (total scores ranging from 7 to 42), and the mobility score includes 15 mobility items (total scores ranging from 15 to 90). Higher scores on both these scales represent greater independence.

These two scores will be risk-adjusted based on resident characteristics to yield a facility average change relative to the expected change for stays meeting inclusion criteria. Two similar scores represent observed discharge scores relative to expected discharge scores for these same two indices, that is, the percentage of residents who met or exceeded expected discharge scores.

Two other assessment-based measures address different aspects of PAC. Change in skin integrity: pressure ulcer injury is currently reported in Nursing Home Compare with a national average rate of 1.6 percent. The measure Drug regimen review conducted with follow-up for identified issues is still undergoing testing.

The two claims-based quality measures are currently available in Nursing Home Compare. These include risk-adjusted rates of potentially preventable readmissions in 30 days (national average 7.3 percent) and community discharge (national average 49.1 percent).

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey.