Percent of Residents Who Made Improvements in Function – My facility generally performs very well in this Quality Measure but we have recently seen fewer residents triggering and a decline in our percentage. Most of our short-term residents are discharging to the community and therapy reports that residents are improving. What should I be monitoring to ensure accuracy for this measure?
This measure reports the percentage of short-stay residents who were discharged from the nursing home that gained more independence in G0110B1: transfer, G0110E1: locomotion on unit, and G0110D1: walk in corridor during their episodes of care. There may be several things to consider when reviewing this measure.
- Where is the documentation for the MDS coming from – CNAs, Therapy, both? Oftentimes, therapy may report an improvement but the MDS is coded based on CNA documentation that may not reflect an improvement (based on a misunderstanding of the Section G items, or differences in the resident’s ability for nursing vs. therapy).
- Is Section G coding accurate? It’s important to review each assessment used in the measure calculation. It’s possible that coding on the admission/5-day OR discharge may not accurately reflect the resident’s ability, either of which can affect the outcome.
- Is all other MDS coding accurate? There are certain exclusions and covariates for this measure that need to be accurately reported. For example, if the discharge was unplanned (A0310G = ) the resident will be excluded from the measure.
- What is the length of stay? If the stay is short (for example, 5-day assessment date 9/15 and discharge assessment date 9/17) the observation periods may overlap and leave no room for a documented improvement. You may consider scheduling the 5-Day assessment earlier for short stays to capture an improvement by discharge and/or if scheduling requirements permit, combining the 5-Day with the discharge as this combined assessment will not be included in the QM.
- If MDS coding is verified to be accurate and there is truly no improvement, consider reviewing other facility processes that may need attention (staffing, therapy, restorative nursing, etc.)