Quality Measures (QMs), have set the standards for SNF/LTC QA focus. QM ratings objectively assess the quality of care a skilled nursing facility provides compared to peers and play a key role in the facility selection process for the resident, their family, physicians, social workers, and discharge planners. ACOs, bundled payment providers, and insurance companies also determine if they will refer beneficiaries to your facility largely based on QMs and the 5-Star rating.

A facility’s CMS 5-Star rating is a composite score determined by its ratings for three domains:

      • Health Inspections
      • Staffing
      • Quality Measures

Once all the domain ratings are determined, they are consolidated into a single overall rating. Both the overall rating and the individual measure ratings are available on the CMS Care Compare website.

The last domain, Quality Measures, while arguably the most variable, is based on performance on a subset of 10 MDS-based QMs and five measures that are created using Medicare claims. The measures for Long-Stay residents (defined as residents who are in the nursing facility for greater than 100 days) that are derived from MDS assessments include:

      • Percentage of long-stay residents whose need for help with daily activities has increased
      • Percentage of long-stay residents whose ability to move independently worsened
      • Percentage of long-stay high-risk residents with pressure ulcers
      • Percentage of long-stay residents who have or had a catheter inserted and left in their bladder
      • Percentage of long-stay residents with a urinary tract infection
      • Percentage of long-stay residents experiencing one or more falls with major injury
      • Percentage of long-stay residents who got an antipsychotic medication

The measures for Long-Stay residents that are derived from claims data include:

      • Number of hospitalizations per 1,000 long-stay resident days
      • Number of outpatient emergency department (ED) visits per 1,000 long-stay resident days

The measures for Short-Stay residents that are derived from MDS assessments include:

      • Percentage of short-stay residents who improved in their ability to move around on their own
      • Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened
      • Percentage of short-stay residents who got antipsychotic medication for the first time

The measures for Short-Stay residents that are derived from claims data include:

      • Percentage of short-stay residents who were re-hospitalized after a nursing home admission
      • Percentage of short-stay residents who have had an outpatient emergency department (ED) visit
      • Rate of successful return to home and community from a SNF

These ratings incorporate data from the four most recent quarters for which performance data is available. When considering how to improve these Quality Measures, we turn to our Minimum Data Set (MDS) assessments, which each skilled nursing facility is required to submit as part of a federally mandated process for conducting clinical assessments for all residents in a Medicare or Medicaid certified skilled nursing facility. Monitoring these measures for accuracy and improvement performance is vital for the facility’s star rating.

Strategies for Improving QMs

Focusing on quality measures where the most improvement can be gained in the shortest time period, consider these improvement strategies below for each of the following QM areas:

Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased

This measure reports the percent of long-stay residents whose need for help with late-loss ADLs has increased when compared to the prior assessment. The four late-loss ADL items are bed mobility self-performance (G0110A1), transfer self-performance (G0110B1), eating self-performance (G0110H1), and toileting self-performance (G0110I1). An increase is defined as an increase in two or more coding points in one late-loss ADL item or a one-point increase in coding points in two or more late-loss ADL items. For calculation purposes, codes of 7’s (activity occurred only once or twice) and 8’s (activity did not occur) are recoded to 4’s (total dependence).

      • Ensure coding accuracy. This may include interviewing the direct care staff and the resident themselves. Many facilities rely on nursing assistants to observe and document Section G items. Regardless of who completes Section G documentation in your facility, ongoing education and training is imperative to accuracy and should occur upon hire, annually, and as any gaps in process and/or performance are identified.
      • Education should be based on item and coding definitions provided in the RAI manual. Ideally, training should include coding scenarios, case studies, and real-life observations to promote and evaluate coding competency.
      • Ensure involvement with self-care and mobility functional items as they relate directly to the initial and final three-day period that the patient is in the SNF. Incorporating documentation from both nursing and therapy disciplines is critical.
      • Ensure the resident’s function is assessed and addressed throughout the resident’s admission, and a final functional improvement level is captured on the discharge assessment.

Percent of Residents Whose Ability to Move Independently Worsened

This measure reports the percent of long-stay residents who experienced a decline in independence of locomotion on the unit self-performance (G0110E1) during the target period when comparing the target assessment with the prior assessment. An increase of one or more points at G0110E1 between the target assessment and prior assessment will indicate a decline in ability., For calculation purposes codes of 7’s (activity occurred only once or twice) and 8’s (activity did not occur) are recoded to 4’s (total dependence).

      • Facilitation a process of daily communication between nursing and therapy regarding residents at risk for decline in mobility. Therapy can provide treatments to improve patient mobility or assist with restorative programming to maintain resident’s mobility status. Once coding accuracy has been assured, use consistent Quality Measure data and internal monitoring practices to identify potential or actual individual declines in function.
      • Utilize effective Restorative Nursing and/or Functional Maintenance Programs to promote functional ability and slow decline, and implement internal processes for
      • Encourage therapy referrals and screens to engage rehabilitative services where appropriate.

Percent of Residents Experiencing One or More Falls with Major Injury

This measure reports the percentage of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period. This measure involves a look-back scan.

      • Ensure fall risk assessments are completed for each resident by utilizing standardized assessment tools and thorough clinical assessment to identify components contributing to balance deficits or the reason for falls (multi-sensory, center of gravity control, vestibular, or postural control).
      • Determine and provide appropriate treatment interventions that address balance and strengthening and design exercise progressions/programs to reduce the risk of falls.

Percent of Long-Stay Residents with High-Risk/Unstageable Pressure Ulcers

This measure captures the percentage of long-stay, high-risk residents with Stage II-IV or Unstageable pressure ulcers. If your facility’s pressure ulcer rate is above industry benchmarks or is increasing, initiating a quality improvement plan and monitoring process is imperative. It is necessary to objectively assess current processes and practices related to pressure ulcer prevention and management to identify areas requiring focused improvement.

      • Ensure consistent and thorough assessment of skin integrity, including evaluation of current unhealed pressure ulcers is a key process for preventing and/or healing pressure ulcers/injuries.
      • Head-to-toe skin examinations should be completed at specified frequencies to identify any impairment to skin or potential complications. Best practice dictates that an initial skin assessment is performed within hours of admission as an individual can potentially develop a pressure ulcer/injury within hours of the onset of unrelieved pressure.
      • A weekly clinical “at-risk” meeting can be held and should include a comprehensive review of those residents identified as currently having or are at risk for developing a wound and/or nutritional concern.  For those with an unhealed pressure ulcer/injury, a tracking form or report for each pressure ulcer is needed to evaluate wound healing progress or complication.  The treatment plan should be re-evaluated and revised with any changes and if there is no progression toward healing after two weeks of the current treatment plan.
      • Ensure accuracy of section G. Specific ADLs in Section G, if not reported accurately, may exclude residents from the High-Risk Pressure Ulcer QM denominator and obscure the facility prevalence rate.

We encourage you to review your monthly 5-Star Provider Preview report in your facility CASPER folder to analyze your facility quality measure points compared to the cut points. If you think you can do better with your Quality Measures and want to see how Proactive Medical Review can help you improve your clinical outcomes and quality measure reporting, contact us!



Jessica Cairns, RN, RAC-CT, CMAC Clinical Consultant CPC Clinical Consultant

Learn more about the rest of the Proactive team.