Using CASPER Reports for Quality Measure Monitoring with Recommended Run Schedule
This is part 1 or a 2 part blog on the effective using of CASPER reports.
Certification and Survey Provider Enhanced Reports, better known as CASPER, offer an assortment of real-time data that allows skilled nursing facilities (SNFs) the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance. CMS developed these publicly reported Quality Measures (QMs) with the intention to publicize the differences in quality among nursing facilities, thus giving the consumer helpful information for determining which facility to select. Based on data submitted by the provider, these reports can be essential in identifying outliers, which can assist your facility in having better patient outcomes as evidenced by optimal QM scores.
While all the reports within CASPER contain information that can be extremely helpful to your facility, the two reports you may want to focus on are the Quality Measures Report and the Five Star rating report. To receive the most out of every CASPER report, your facility should be running these reports as often as they are updated. Effective April 2019, 32 QMs were posted on the Nursing Home Compare website. Quality Measures and Five Star ratings have new data calculated at different times throughout the year. Nursing Home Compare is updated each quarter in January, April, July, and October. Facility reports for Quality Measures are updated weekly, however, the comparison percentages with other facilities nationally and in your state are deferred by two months. Starting in April 2020, every six months the QM thresholds will increase by half of the average rate of improvement in QM scores. The intent of this is to incentivize continuous quality improvement and reduce the need to have larger adjustments to the thresholds in the future.
Quality Measures scores comprise the third domain of the Five-Star Quality Rating System. It is calculated using the four most recent quarters for which data is available. Facility ratings for the quality measures are based on performance in 15 of the QMs that CMS currently posts on the Nursing Home Compare website. These include nine long-stay measures and six short-stay measures. QM ratings are based on performance on a subset of ten MDS-based QMs and five measures that are monitored using Medicare claims.
Measures for Long-Stay residents (defined as residents who are in the nursing home for greater than 100 days) that are derived from MDS assessments:
- Percent of residents whose need for help with activities of daily living has increased
- Percent of residents whose ability to move independently worsened
- Percent of high-risk residents with pressure ulcers
- Percent of residents who have/had a catheter inserted and left in their bladder
- Percent of residents with a urinary tract infection
- Percent of residents experiencing one or more falls with major injury
- Percent of residents who received an antipsychotic medication
Measures for Long-Stay residents that are derived from claims data:
- Number of hospitalizations per 1,000 long-stay resident days
- Number of outpatient emergency department (ED) visits per 1,000 long-stay resident days
Measures for Short-Stay residents that are derived from MDS assessments:
- Percent of residents who made improvement in function
- Percent of SNF residents with pressure ulcers that are new or worsened
- Percent of residents who newly received an antipsychotic medication
Measures for Short-Stay residents that are derived from claims data:
- Percent of short-stay residents who were re-hospitalized after a nursing home admission
- Percent of short-stay residents who have had an outpatient emergency department (ED) visit
- Rate of successful return to home and community from a SN
The 5 claims-based measures are updated every 6 months (in April and October), which sums the previous 12 months’ worth of data. Once the data becomes public, it is 9 months old. For example, April 2019 claims-based measure information has a look-back of July 1, 2017, through June 30, 2018.
Consider what practices your facility has in place to monitor your QM’s on a routine basis. Below is a recommended run schedule for QM and Five Star CASPER Reports.
Best practices include:
- Understanding the details of each quality measure and what information is included
- Reviewing the accuracy of your MDS coding
- Developing your QAPI around root cause analysis
- Using CASPER monthly comparison reports to monitor changes
- Routinely monitoring key aspects of resident care systems and care delivery
- Monitoring, developing and implementing maintainable solutions
References:
- Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide, October 2019, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf Accessed 5 November 2019.
- Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide State-Level Health Inspection Cut Point Table, October 2019, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/cutpointstable.pdf Accessed 5 November 2019
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Blog by Jessica Cairns, RN, RAC-CT, CMAC, Clinical Consultant, Proactive Medical Review
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