A webinar detailing how the Centers for Medicare & Medicaid Services (CMS) runs its five-star rating system for nursing homes provides insights into how nursing homes can improve the care they provide to their residents and earn higher star ratings in the process.

McKesson Medical-Surgical, a business unit of McKesson, sponsored the webinar, “Five Star Rating—How to Improve Your Rating Through Data and Quality Processes.” Karolee Alexander, director of clinical and reimbursement consulting for Pathway Health, a Minnesota-based long-term care consulting firm, hosted the hour-long session.

CMS launched its five-star rating system for Medicare and Medicaid certified nursing homes in December 2008. The system awards stars in three subcategories to determine an overall composite star rating for each nursing home. The three subcategories are onsite health inspections, staffing and quality measures. The process starts with awarding stars in the health inspection category. Then the number of health inspection stars can be adjusted up or down based on the number of stars awarded for staffing and quality measures to determine the final rating. CMS awards stars relative to a facility’s performance against other nursing homes within its own state. In each state, 10 percent of nursing homes receive five stars—the highest rating. Some 20 percent receive one star—the lowest rating. The remaining 70 percent are evenly distributed among two, three and four stars.

As Alexander demonstrated during the webinar, the challenge for nursing homes is threefold:

  • Knowing what performance measures CMS is using to calculate the number of stars in each subcategory.
  • Knowing how to collect, analyze and report those performance measures internally and externally.
  • Knowing how to use that information to improve clinical performance and the facility’s overall star rating.
How to Improve Nursing Home Star Ratings

With those challenges in mind, she identified opportunities or strategies in each subcategory to improve performance and ideally, notch more stars to push a nursing home’s overall rating even higher.

Strategies to improve health inspection scores and stars

Health inspection stars are determined by onsite inspection scores, and onsite inspection scores are determined by adverse events that can harm nursing home residents. Low scores are better than high scores. For example, adverse events that affected one or two residents and caused no harm are worth zero points. On the other end of the scale are adverse events that affected all residents and posed an immediate risk to resident health or safety. They can be worth as many as 175 points.

Alexander recommended three steps nursing homes can take to avoid a high health inspection score or push a high health inspection score lower.

  • Understand all state nursing home health regulations and educate all staff on those regulations.
  • Use the Quality Assurance and Performance Improvement process to identify, mitigate and improve areas of poor quality and safety performance.
  • Roll out the performance-improvement changes to the entire nursing home.
  • Implement the changes before the next nursing home inspection.

“The number of revisits that it takes to clear a deficiency really has a big impact on the overall calculation for that health inspection rating,” Alexander said. “Make sure the plan of correction is thoroughly implemented by the time you’re ready for a revisit.”

Opportunities to improve staffing scores and stars

Staffing stars are determined by nursing home staffing levels, staff-to-resident ratios and the licensing mix of staff. Higher staffing levels, higher ratios and higher percentage of registered nurses all push the staffing star needle in the right direction. The CMS equates higher numbers in those three areas with higher quality and safer care for nursing home residents.

Alexander recommended three steps nursing homes can take to know where those numbers are and keep them in the desired range. Nursing homes should:

  • Accurately complete the staffing section on CMS Form 671, which is the application for Medicare and Medicaid certification.
  • Follow the new federal regulations on competency-based nursing home staffing.
  • Focus on staff retention as well as recruitment.

“Staffing is the number one challenge in nursing homes across the country,” Alexander said. “Keeping the good staff that you have is very important because there may not be other staff out there readily available to recruit.”

Ways to improve quality measure scores and stars

Quality measure stars are determined by how well nursing homes score on 16 performance metrics. In 2016, CMS added five metrics to the original 11. The data source for the original 11—which include such measures as percentage of high-risk residents with pressure ulcers and percentage of residents with physical restraints—is the Minimum Data Set 3.0. The MDS is the data set all Medicare and Medicaid certified nursing homes are required to report to CMS.

Data for two of the five new metrics also come from the MDS. But data for the other three come from Medicare and Medicaid claims, including percentage of residents who had emergency department visits within 30 days of nursing home admission and percentage of residents who were still at home within 30 days after nursing home discharge.

Alexander recommended three steps nursing homes can take to conquer this key piece of the five-star rating formula:

  • Know and collect the data elements required for each quality measure.
  • Review and improve MDS coding accuracy.
  • Review and improve all clinical care and systems that affect quality and safety outcomes.

Automating quality measure collection, analysis and reporting functions can improve the efficiency and accuracy of this component of the five-star rating system as well as allow nursing homes to compare their performance with industry benchmarks, according to Alexander. This produces actionable insights to improve resident care and documentation to achieve more stars.

Improving care and earning more stars are crucial to the future success of nursing homes as consumers increasingly are using star ratings to choose nursing homes, payments to nursing homes increasingly are based on outcomes and other providers increasingly are looking for effective nursing homes partners as part of their value-based reimbursement strategies.

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