CMS 5-Star Quality Rating. Reviewing How, Why and What are OUR Stars!

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1 CMS 5-Star Quality Rating Reviewing How, Why and What are OUR Stars! FIVE - STAR Fact, Fiction & Strategies Discussion for OCAHF June 25, 2014 By Chris Jung, ehealth Data Solutions

2 What is 5-Star Quality Rating? Established by CMS in December 2008 Enhance Nursing Home Compare with a set of quality ratings for each Medicare & Medicaid Nursing Home To help consumers, families and caregivers compare nursing homes more easily to distinguish between high and low performing SNFs Last Technical Users Guide July 2012 Based on publically reported data on Nursing Home Compare (http://www.medicare.gov/nursinghomecompare/search.aspx) 2

3 What is 5-Star Quality Rating? The ratings are taken from three nursing homes data sources Health Inspections Annual & Complaint Surveys adjusted for Scope and Severity and Revisit Count Staffing Quality measures The 5-Star Quality Ratings were developed with LTC input and CMS Consultant support Developed with assistance from ABT & Associates Consultants and a CMS Technical Expert Panel (TEP) QMs were in a Blackout phase January 2011 to April

4 5- Star TEP & ABT (Technical Expert Panel) TEP Role Input to CMS to Select measures used Develop scoring rules Review methodology for overall rating ABT Role Structure for CMS Input from other public reporting systems Composite measure specification Benchmarks for scoring rules 4

5 Three Rating Dimensions Survey Results Staffing Quality Measures 5

6 What is 5-Star Quality Rating? The system provides up to a 5-star rating for each of three domains which combine to yield an Overall Rating Overall rating Health inspection = past 3 Health Surveys + Revisits & 36 months of Complaint Surveys + Revisits Quality Measures = 9 of 18 QMs (7 Long Stay & 2 Short Stay) Staffing = RN Only & Total Staff Hours 6

7 What is 5-Star Quality Rating? What do the stars mean? Much Above Average Above Average Average Below Average Much Below Average 7

8 California and USA - CMS 5-Star Ratings by Category CMS 5-Stars Overall Health Quality Rating Survey Measures Staffing RN Staffing Average Stars for California SNFs with Star Points CMS 5-Stars Overall Health Quality Rating Survey Measures Staffing RN Staffing Average Stars for USA SNFs with Star Points ACOs are using Stars to pick those providers for their Network Are you prepared to explain your Star calculation? / Do you need to be prepared? As of June 22, 2014 there are 6 Special Focus Facilities in California! 44 SFF in the USA CMS is returning to adding SFFs at a lower rate 8

9 CMS Overall Stars for California and USA USA and State of California Number of Lincensed SNFs counted by CMS Stars as of June 2014 No Stars One Star Two Stars Three Stars Four Stars Five Stars Total CA Overall Stars CA Percent 0.3% 4.1% 19.5% 16.8% 23.7% 35.6% 100.0% USA Overall Stars USA Percent 0.8% 9.4% 20.3% 17.7% 25.5% 26.3% 100.0% Star Data from CMS effective 6/19/2014 9

10 Rating methodology Health Inspections Health inspection domain Health inspection score is calculated based on points assigned to deficiencies identified in Current health inspection survey and two prior surveys Most recent three years of complaints and survey revisits 10

11 Rating methodology Health inspection results Points are assigned to individual health deficiencies according to their scope and severity More points are assigned for more serious, widespread deficiencies Fewer points for less serious, isolated deficiencies If the deficiency generates a finding of substandard quality of care, additional points are assigned 11

12 Rating Methodology Repeat revisits Number of repeat revisits required to confirm correction of deficiencies at level F or greater No points are assigned for the first revisit Points are assigned only for the second, third and fourth revisits If a provider fails to correct major deficiencies by the time of the first revisit, then these additional revisit points are assigned up to a total of 85% for the fourth revisit 12

13 Rating Methodology Recent surveys are weighted more heavily than prior surveys Past Three Standard Surveys (if only 2 Surveys exist I = 60% & II = 40%) Recent survey period = 1/2 Previous survey period = 1/3 Second previous survey period = 1/6 Past non-compliance for J, K or L are assigned G Level points Complaint deficiencies count for 36 months in proportional 12 month increments (1/2, 1/3, 1/6) The weighted time period scores for Standard and Complaint Surveys are summed to create the survey score for the each facility ( Complaints within 15 days of Standard Survey counted once) Life Safety Surveys and Federal Comparative Surveys are not included Facilities with 1 Survey have insufficient data and are set to missing 13

14 Health Inspections Rating Methodology Health & Complaint Inspection Score Points assigned for different types of deficiencies substandard care finding = ( points ) Severity Immediate jeopardy to resident health or safety Actual harm that is not immediate jeopardy No actual harm with potential for more than minimal hard that is not immediate jeopardy No actual harm with potential for min. harm Scope Isolated Pattern Widespread J K L 50 points 100 points 150 points (75 points) (125 points) (175 points) G H I 20 points 35 points 45 points (40 points) (50 points) D E F 4 points 8 points 16 points (20 points) A B C 0 point 0 points 0 points 14

15 Here is what the Best SNF in California on Health Survey Looks like last survey 10/24/2013 as of today One SNF in CA had zero citations over three years Survey Points do not change until another survey! 15

16 Here is what the least best California Health Survey looks like in the CMS 5-Star Scoring System Note: Revisits are more points than the Survey Citations 16

17 Revisits - Health Inspection Rating Methodology Weights for repeat revisits Revisit number Noncompliance points First 0 Second 50 % of Health Inspection Score Third 70 % of Health Inspection Score Fourth 85 % of Health Inspection Score 17

18 Health Inspection Star Rating Methodology Health inspection domain ratings are based on the relative performance of facilities within a state This approach helps control for variation between states In each State 5 Stars are determined by Top 10% in each state receive 5 Stars Middle 70% 23.3% increments receive 4, 3, or 2 Stars Bottom 20% receive 1 Star 5% of sampled State Surveys are checked by Federal Surveyors to assure consistency Health Inspection Stars will not change without a new survey 18

19 Health Inspection Star Change The cut point will be re-calibrated each month so that the distribution of star ratings with states remains fixed over time to reduce the likelihood that the rating process will affect the health inspection process June 2014 CA Health Inspection Cut Points Star Cut Points for Health Inspection Scores (06-01=2013) 1 Star 2 Stars 3 Stars 4 Stars 5 Stars Lower Upper Lower Upper Lower Upper California > <= > <= > <= > <=

20 Estimated California 5-Star Health Inspection Points and Rank Jun USA and State of California Number of Licensed SNFs counted by CMS Stars for Health Inspection as of June 2014 No Stars One Star Two StarsThree StarsFour Stars Five Stars Total CA Overall Stars CA Percent 0.3% 20.4% 22.5% 24.3% 22.0% 10.4% 100.0% USA Overall Stars USA Percent 10.6% 251.4% 291.6% 295.2% 295.7% 137.1% % A given facility Health Inspection Stars are held constant until a new Survey is added Complaints Surveys will change Stars Annual Survey will change Stars Effective June,

21 Staffing Domain Rating Methodology Staffing domain The rating for staffing is based on two case-mix adjusted measures Total nursing hours per resident day (RN + LPN + nurse aide hours) RN hours per resident day Source data is CMS form CMS

22 Staffing Domain Rating Methodology Source data for staffing measures CMS data from Form CMS-671 (Long Tem Care Facility Application for Medicare and Medicaid) Form CMS-672 block F-78 (Resident Census and Conditions of Residents) Measures are adjusted for case-mix differences based on the RUG-III 53 group version of the case-mix system as of the last day of quarter for which staffing data were collected (the survey date) The cut points will be held constant for initial two-year period, after which CMS will review this decision The advantage of fixed cut-points is that it better tracks facility improvement (or decline) over time 22

23 Staffing Domain Rating Methodology Scoring method and cut points for CMS staffing stars effective April 2012 Star Rating 1 Definition <25 th percentile of distribution for freestanding facilities Range (Adjusted hours per resident day) RN Total < < At least 25 th percentile but less than median of the distribution for freestanding facilities > < > < Greater than or equal to the median but less the 75 th percentile of the distribution for freestanding facilities > < > < Great than or equal to the 75 th percentile of the distribution for freestanding facilities but less than the CMS staffing study threshold > < > < At or exceeding the threshold identified in the CMS staffing study >0.710 >

24 Staffing Domain Rating Methodology June 2014 CMS updated Staffing Data Revised Cut Points are expected soon 24

25 Staffing Stars for California and USA USA and State of California Number of Licensed SNFs counted by CMS Stars for Staffing as of June 2014 No Stars One Star Two Stars Three Stars Four Stars Five Stars Total CA Staffing Stars CA Percent 3.4% 3.0% 8.4% 19.4% 52.2% 13.5% 100.0% USA Staffing Stars USA Percent 2.8% 10.9% 14.0% 19.0% 42.3% 11.0% 100.0% USA and State of California Number of Licensed SNFs counted by CMS Stars for RN Staffing as of June 2014 No Stars One Star Two Stars Three Stars Four Stars Five Stars Total CA RN Staffing Stars CA Percent 3.4% 7.7% 12.1% 28.8% 26.7% 21.2% 100.0% USA RN Staffing Stars USA Percent 2.8% 9.5% 15.3% 25.7% 25.7% 21.0% 100.0% Star Data from CMS effective 6/22/

26 Quality Measure Ratings Long-Stay Prevalence Measures: ADL Change High-Risk PU Long-Term Catheter Physical Restraints UTIs Pain Falls with Major Injury Short Stay Prevalence Measures: Pain Pressure Ulcers 26

27 Quality Measure Domain Rating Methodology Quality measure domain Based on 9 of 16 quality measures currently posted on Nursing Home Compare Calculated using the three most recent quarters from which data were available Long Stay measures calculated for at least 30 assessments Short stay measures calculated for at least 20 assessments Each measure assigned between 1 and 100 points best possible score = 100 points poorest score = 0 points 27

28 Quality Measure Domain Rating Methodology All QMs have equal weight Points are summed to create a total score for each facility Percent ranks are national except ADL which is state specific Cut points based on national distribution for second, third and fourth quarters of 2011 and are maintained for 2 years then CMS will review 28

29 Quality Measure Domain Rating Methodology Cut points based on national distribution for second, third and fourth quarters of 2011 and are maintained for 2 years then CMS will review No Values for SNFs with fewer than 4 long-stay measures and fewer than 2 short-stay measures Missing Data has an imputed score Only short-stay measures = score X 900/200 Only long-stay measures = score X 900/700 29

30 Quality Measure Domain Rating Methodology Star rating QM summary point cut-points for Star level based on the MDS Quality Measure Summary Score updated July

31 US and California Quality Measure Stars USA and State of California Number of Licensed SNFs counted by CMS Stars for Quality Measures as of June 2014 No Stars One Star Two Stars Three Stars Four Stars Five Stars Total CA Quality Measures Stars CA Percent 1.1% 1.5% 3.8% 9.0% 26.6% 58.0% 100.0% USA Quality Measures Stars USA Percent 1.1% 2.6% 6.5% 14.8% 35.1% 40.0% 100.0% 84.6% of California SNFs are 4 or 5 Star for Quality Measures versus 72.1% of USA SNFs. 9.0% of USA SNFs are 1 or 2 Star for Quality Measures versus 5.2% of California SNFs 31

32 Overall Nursing Home Star Rating Methodology Overall nursing home rating is assigned in five steps Step 1: Start with the health inspection star rating Step 2: Add one star to the Step 1 result if staffing rating is 4 or 5 stars and greater than the deficiency rating; subtract one star if staffing rating is 1-star. The Overall Rating cannot be more that five stars or less than one star 32

33 Overall Nursing Home Star Rating Methodology Step 3: Add one star to Step 2 result if the quality measure rating is 5- Star; subtract one star if quality measure rating is 1-Star. The Overall Rating cannot be more than five stars or less than one star Step 4: If the Health Inspection rating is 1-Star, then the Overall Rating cannot be upgraded by more than one star based on the staffing and quality measure ratings 33

34 Overall Nursing Home Star Rating Methodology Step 5: If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is 3-star 12 months after SFF graduation a facilities stars may go above 3 34

35 Overall Nursing Home Star Rating Methodology Data is included as soon as it becomes part of the CMS database Citations in IDR are not included until settled Every facility s standing for Staffing is reviewed each month if appropriate RUG data is available staffing score may change Health Inspection Stars can change with more inspections (Annual Health or added substantiated Complaint Survey) Quality Measure ratings are updated mid-month in January, April, July and October and may change the star rating 35

36 5-Star Requires Improvement in Survey, Quality and Staffing Superior management of complaint surveys is important because complaints have significant weighting for 36 months. Use 802 / 672 pages in Operations weekly so that the facility is always close to a 30 minute window to deliver accurate and up-to-date information. When surveys arrive providing accurate reports quickly may help the survey start off in a positive direction 36

37 Staffing- 5 Star More staff for RNs and total nursing increases the level annually. The current staffing formula favors facilities with a rich RN mix and low acuity residents. Applying the time of Administrative RNs to the staffing is allowed. Application of consistent assignment may help with staffing. 37

38 Changing a Staffing Star Correcting or Updating Form 671 Facilities may submit a corrected 671 Part of Plan of Correction update Submit a corrected or updated 671 for past survey period If accepted may require 3 months to appear in the Nursing Home Compare 5-Star information 38 38

39 Famous Mark Twain quotes The coldest winter I ever experienced was summer in San Francisco. There are 3 kinds of lies; lies, damn lies & statistics. (Guess what 5-Star is based off of. STATISTICS) 39

40 Tale of Two Counties Comparison of Ratings of SNFs OC SNFs 5-Star Ratings SD SNFs 5-Star Ratings 1 4% 1 2% 4 26% 5 16% 2 38% 5 50% 2 19% 3 8% 3 16% 4 21% 40

41 OC- Let s Look at Just the Overall Ratings for SNFs Above Average & Much Above Average Overall 4 & 5 Star ratings 33 SNFs Overall 5-Star 13 facilities Overall 4-Star 20 facilities 41

42 OC Survey Ratings- impact on Overall Rating 14 were 2-Star on Survey yet 4-Star Overall 11 were 3-Star on Survey yet 5 earned 4-Star Overall, and 6 earned 5-Star Overall 42

43 OC Staffing Ratings- impact on Overall Rating 6 were 5-Star Staffing, 3 Overall 4-Star & 3 Overall 5-Star 23 were 4-Star Staffing, 15 Overall 4-Star & 7 Overall 5-Star 1 was 3-Star Staffing, & still earned 5-Star Overall 2 were 2-Star Staffing, 1 of the 2 was still 5-Star Overall 43

44 OC Quality Measures Ratings- impact on Overall Rating 28 had 5-Star for QM, with 12 an Overall 5-Star & 16 an Overall 4-Star 2 had 4-Star for QM, & 4-Star for Overall 1 had 3-Star for QM, & 4-Star Overall 1 had 2-Star for QM, & 4-Star Overall 1 was N/A for QM 44

45 Myth-Busting 5-Star 1. Five-Star is a Ratings System & factors in degree-of-difficulty. 2. Five-Star is a formulation of the three fairly equal and important variables of: Health Inspections, All Clinical Staffing & Quality Measures. 3. Five-Star is a current view of what a SNF s Rating is, irrespective of outside factors, while considering all relevant internal metrics. 45

46 Five-Star is a Ratings System & factors in degreeof-difficulty Facilities are graded on a curve, so a portion of facilities in every state must be ranked with one star. In the health inspection category, the Five-Star system predetermines that 20 percent of all nursing facilities will get a failing grade - a one-star rating. Only 10 percent will get the highest grade five stars. That s like telling a class of 100 students that 20 of them will automatically fail. Source: CAHF White Paper 9/13 46

47 Five-Star is a Ratings System & factors in degreeof-difficulty (con t) A facility could see a change in their rating either positively or negatively without having a new survey, based on the results of surveys at other facilities. So it s a Ranking, not Rating System. Under Five-Star, facilities get marked down for accepting the most chronically ill, obese patients, patients with wounds, post-surgical patients and those with pain and diabetes. The scoring is not risk-adjusted for populations like those with Alzheimer s, where a decline is expected and unavoidable. Source: CAHF White Paper 9/13 47

48 Five-Star is a formulation of the three fairly equal and important variables of: Health Inspections, All Clinical Staffing & Quality Measures. The staffing levels count RNs, LVNs and CNAs. Those not counted include nurse practitioners, occupational, respiratory and rehabilitation therapists, social service workers, nurse consultants, activity planners and other staff that provide direct resident care. Survey, according to CMS, was to be the primary driver for overall 5-Star, with the other variables impacting the overall rating not more than one star. However, most recent results seem to indicate CMS is no longer following that methodology. 48

49 Five-Star is a current view of what a SNF s Rating is, irrespective of outside factors, while considering all relevant internal metrics. Health inspection reports reflect past problems over a three year period, not necessarily what is taking place at present. The staffing levels used in the rating are based on facility staffing levels for a two-week period at the time of the most recent standard survey and may be out of date. Fails to include any information on family or resident satisfaction, longevity of staff, success in returning residents to lower levels of care, rehabilitation achievements or community and professional awards. Source: CAHF White Paper 9/13 49

50 CMS s Own Assessment of 5-Star Value The Centers for Medicare & Medicaid Services CMS, calls Five-Star a work in progress and has issued a caution to consumers about relying solely the Five-Star ranking to determine if a facility is the right place for a loved one. Source: CAHF White Paper 9/13 50

51 What has 5-Star Accomplished According to the June 7, 2013 report Nursing Home Compare Five-Star Rating System: Year Three Report Since implementation of the Five-Star Rating System, there have been improvements in nursing facility performance in all three domains of quality that the system utilizes: health inspection surveys, quality measures (QMs) and staffing levels. Certification/CertificationandComplianc/Downloads/FSQRS-Report.pdf Questions? Certification/CertificationandComplianc/Downloads/usersguide.pdf 51

52 Question: How can you raise your 5-star? Surveys, Staffing and QMs Measures Use the data to set up procedures for monitoring and improving the 9 QMs (e.g. Pressure Ulcers, ADL Decline, etc..) Increase staffing, especially RN Hours Have a much better Survey - Improve handling of complaint surveys work to have timely plans of corrections to minimize re-visits and re-visits have significant 5-star penalties. ehds offers a tool to help CareWatch MDS Logic Flags Reports: QM Benchmark, QM SPC and QM Watch Survey Points and Comparisons 52

53 Work to Have an Accurate CMS 671 Form 53

54 Form 671 Staffing Definitions Column A Answer Yes (Y) or No (N) 1 Services provide on site to residents by employees or contractors 2 Services provided onsite to non-residents 3 Refers to those services provided to residents offsite or not routinely provided onsite (corporate staff are contracted) 54

55 Columns B, C & D on CMS Form 671 Column B - Full-time staff, C - Part-time staff, and D - Contract - Record hours worked for each field of full-time staff, part-time staff, and contract staff (do not include meal breaks of a half an hour or more). Full-time is defined as 35 or more hours worked per week. Part-time is anything less than 35 hours per week. Contract includes individuals under contract (e.g., a physical therapist) as well as organizations under contract (e.g., an agency to provide nurses). If an organization is under contract, calculate hours worked for the individuals provided. Lines blocked out (e.g., physician services, clinical labs) do not have hours worked recorded. REMINDER - Use a 2-week period to calculate hours worked. 55

56 The 671 Continued Include regional staff RNs as contracted staff for any time past 2 weeks 56

57 Why 671? Ref: S&C

58 Correcting 671 Staffing Ref: S&C

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