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The Stars Are Changing: Nursing Home Compare and Five-Star Quality Rating Updates
In April 2019, the Centers for Medicare & Medicaid Services (CMS) will release an update to both the Nursing Home Compare tool and the Five-Star Quality Rating System.1,2 The Nursing Home Compare website and Five-Star Quality Rating System were created to help consumers, their families, and caregivers compare long-term care facilities (LTCFs), helping them to identify elements they may want to ask about when looking at nursing care, even though this information is utilized more often by health systems developing preferred skilled nursing facility (SNF) networks to improve clinical and financial outcomes.2,3
Nursing Home Compare has a quality rating system that gives each facility a rating between 1 and 5 stars. Those with 5 stars are considered to have above-average care quality, and those with 1 star are considered to have below-average care quality. There is one overall 5-star rating for each facility and also a separate star rating for each of the following 3 factors:
Health Inspections. Inspections include the findings on compliance to Medicare and Medicaid health and safety requirements from onsite surveys conducted by state survey agencies at LTCFs.
Staffing Levels. The staffing levels are the numbers of nurses available to care for patients in an LTCF at any given time.
Quality Measures. The quality of resident care measures is based on resident assessment and Medicare claims data.
CMS has periodically made improvements to the website and ratings system. These new updates follow a
history of similar efforts by CMS to improve outcomes (Table 1). Each update has been part of CMS’ ongoing effort to increase the accuracy of information available to consumers and to drive quality improvement at LTCFs across the country. The April 2019 changes include revisions to the inspection process, enhancement of new staffing information, and implementation of new
quality measures.
Summary of Updates Within Categories
Health Inspection
CMS is lifting the “freeze” on the health inspection ratings that was instituted in February 2018. This freeze on the health inspection category was enacted after CMS implemented a new survey process for LTCFs. Because facilities receive surveys at different times, some facilities would have been surveyed under the old process and others under the new process. Without placing a freeze on health inspection star ratings, facilities would have been scored using 2 different evaluation processes, making the outcomes misaligned and the data inaccurate. The freeze stayed in place until all facilities were surveyed at least once under the new survey process for LTCFs. Ending the freeze is critical for consumers, as they will now be able to see the most up-to-date status of a facility’s compliance, which is a very strong reflection of a facility’s ability to improve and protect each resident’s health and safety.
Staffing Levels
Additionally, CMS is setting higher thresholds and evidence-based standards for facility staffing levels. Nurse staffing has the greatest impact on the quality of care LTCFs deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic 1-star rating when a facility reports “no registered nurse [RN] is onsite.” Currently, facilities that report 7 or more days in a quarter with no RN onsite are automatically assigned a 1-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to 1-star will be reduced from 7 days to 4 days. CMS is also making changes to the quality component on Nursing Home Compare that would make it easier to identify differences in quality among facilities, raise expectations for quality, and incentivize continuous quality improvement.
Quality Measures
To provide further value and remain consistent with CMS’sMeaningful Measures initiative,4 the April 2019 Nursing Home Compare update includes adding measures of long-stay hospitalizations and emergency room transfers and removing duplicative and less meaningful measures. CMS is also establishing separate quality ratings for short-and long-stay residents and revising the rating thresholds, again, to help users identify the differences in quality among LTCFs so they can make more informed decisions.
Implications for Facilities
Beyond being used by patients and their families as well as health systems in determining which SNF to prefer for use, getting to an overall rating of 3 stars or better is required to be part of the SNF 3-Day Rule Waiver to receive Medicare Part A subacute services. As described in a previous LTC GPS column, this will enable those SNFs that qualify to receive direct admissions to increase the use of their facility.5 This program is available under the Shared Savings Program and involves CMS entering into a participation agreement with each participating accountable care organization (ACO).6 Improving utilization of hospital and SNF services is critical, as CMS will reward eligible ACOs when they lower growth in Medicare Parts A and B fee-for-service costs (relative to their ACO-specific benchmark) while they meet performance standards on quality of care at the same time. The SNF 3-Day Rule Waiver waives the requirement for a 3-day inpatient hospital stay prior to a Medicare-covered, post-hospital, extended-care service for eligible beneficiaries. Again, this is only available to 3-star designated or better facilities as a means to increase the utilization of their facility and value as a preferred SNF partner.
Conclusion
Beyond increasing referrals from patients, families, and health systems looking for higher performing SNFs, there may potentially be more benefits based on star rating. Theoretically, the star rating will lead to more admissions, but it will also be used to direct reimbursement whereby higher performing SNFs are paid more. This extra funding will come from penalties on lower performing SNFs, so a facility’s star rating will become a great advantage for those SNFs that perform best. The stars are truly changing. For some, these changes will be great opportunities, for others, they will create challenges.
References
1. CMS improving nursing home compare in April 2019 [press release]. Baltimore, MD: Centers for Medicare & Medicaid Services; March 5, 2019. https://www.cms.gov/newsroom/press-releases/cms-improving-nursing-home-compare-april-2019. Accessed March 25, 2019.
2. Centers for Medicare & Medicaid Services. Five-star quality rating system. cms.gov website. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs.html. Updated March 5, 2019. Accessed March 25, 2019.
3. Centers for Medicare & Medicaid Services. Nursing Home Compare. medicare.gov website. https://www.medicare.gov/nursinghomecompare/search.html. Accessed March 25, 2019.
4. Centers for Medicare & Medicaid Services. Meaningful measures hub. cms.gov website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/General-info-Sub-Page.html. Updated October 25, 2018. Accessed March 25, 2019.
5. Stefanacci RG. Direct admissions to skilled nursing facilities—are you ready? Ann Longterm Care. 2018;26(7):10-11. doi:10.25270/altc.2018.12.00049
6. Centers for Medicare & Medicaid Services. Medicare Shared Savings Program Skilled Nursing Facility 3-Day Rule Waiver. https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/snf-waiver-guidance.pdf. Published January 2019. Accessed March 25, 2019.
