MDS Alert

Why you should concentrate on antipsychotic use to regain stars. 

If your skilled nursing facility (SNF) lost a quality star (or more than one star) due to the revamped ranking structure for the Five-Star Quality Rating System, you’re not alone. In fact, nearly one in three SNFs lost a quality star.

The Centers for Medicare & Medicaid Services (CMS) announced the overhaul of its quality rating system in a Feb. 12 SNF/Long Term Care (LTC) Open Door Forum (ODF). CMS officially launched the revised rating system, dubbed “Nursing Home Compare 3.0,” on Feb. 20 (see “Brace Yourself: Your Quality Ratings Could Take a Nosedive,” MDS Alert, Vol. 13, No. 2, page 19).

CMS also added two new antipsychotic medication measures to the Five-Star system, one for short stay and one for long stay, and CMS made minor adjustments to the staffing quality measure dimension.

Bad news: CMS’s rebasing of the Five-Star Quality Rating System will cause an estimated 4,777 out of 15,500 SNFs nationwide to lose one or more stars in their individual quality rankings, even though there are no corresponding reductions in quality, according to a Feb. 20 analysis by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL). 

Overall, 10,362 SNFs will see no change in their star rating, while 4,306 will lose one star and 432 will lose two stars, according to AHCA/NCAL. Approximately 34 SNFs will lose three stars and five will lose four stars. Some SNFs will actually gain a star or more — 335 SNFs gained one star, 20 gained two stars, five gained three stars, and only one SNF gained four stars.

What Industry Heavy-Hitters are Saying

Naturally, industry stakeholders are not happy about these changes and their resulting aftershocks to nursing facilities’ quality scores.

“Any time that nearly a third of an entire sector is impacted by a change of this magnitude, there will be confusion,” said AHCA/NCAL president and CEO Mark Parkinson in a recent statement. “We’re not helping patients and their families get the information they can trust when the star rankings don’t match the quality care being delivered.”

The Five-Star system “is a great idea, but was hastily and prematurely implemented,” lamented Evvie Munley, senior health policy analyst for Washington, D.C.-based Leading Age, in a Feb. 18 analysis. “CMS continues to tweak it without addressing or correcting underlying fundamental flaws.”

“While Leading Age supports the addition of a calculation that measures antipsychotic use and one that revises the current way that staffing levels are determined, we are disappointed overall that CMS has not yet provided more transparency about the recalculations,” Munley continued. “We are concerned about how this might affect and confuse residents and their families.”

Pay Attention to Staffing Measures

And changes to the staffing quality category will also have a negative impact on your overall star rating.

Old way: Before the Feb. 20 rollout of the revised Five-Star system, you could have a rating of three stars for RN and a rating of three stars for Total Staffing, but achieve a rating of four stars overall for staffing, according to Munley.

New way: Now, however, your facility will need to achieve four stars in at least one of the RN or Total Staffing categories to attain a four-star rating for staffing, Munley said. CMS’s rationale is that a four-star overall rating for staffing is not warranted unless the facility achieves four stars in one or both categories.

Sharpen Your Focus on Antipsychotic Use

Additionally, your Five-Star rating in 2015 will now depend upon your facility’s use of antipsychotics. If you’ve lost a star or several stars, a shift in focus toward antipsychotic usage could help you to recapture those lost stars. 

“Nursing homes need to develop strategies to reduce antipsychotic drug use,” according to a March 13 analysis by Amy McCracken, special counsel for Duane Morris LLP in Chicago. “They cannot depend upon physicians to change the drug orders; they need to partner with physicians to develop creative approaches for treatment.”

What to do: Thoroughly evaluate each resident to determine the root cause of behaviors that trigger antipsychotic drug use, McCracken recommended. Once you determine the cause or need — “frequently, the undesirable behaviors are caused by an unmet need” — you can develop individualized, person-centered approaches to prevent or respond to the behaviors.

How to Access Your Preview Report

If you haven’t already, be sure to preview your Five-Star data. CMS posted data in each nursing home’s QIES mailbox — the mailbox you use to submit MDS data and that CMS uses for announcements/pop-ups, Munley said. Each nursing home will have its own password.

Access the Five-Star Preview Report through QIES, on the MDS State Welcome page available on your state server where you submit MDS data, Munley instructed. Select the CASPER Reporting link at the bottom of the page, and then:

1. Select the CASPER Reporting link at the top of your MDS State Welcome page;
2. Click on the “Folders” button; and then
3. Access the Five-Star Report in your “st LTC facid” folder, where “st” is the two-digit postal code of the state in which your facility is located and “facid” is the state-assigned facid of your facility.

Resource: You can read a CMS Fact Sheet on Nursing Home Compare 3.0 at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-02-12-2.html.