Five-Star System Shines Light on CMDs

Abstract

PHOENIX — The Five-Star Quality Rating System that is tightening networks and driving referrals and reimbursement is also giving certified medical directors the opportunity to “shine” and to meaningfully influence the quality of care in their facilities, Sabine von Preyss-Friedman, MD, CMD, said at the Annual Conference of AMDA – the Society for Post-Acute and Long-Term Care. “We’re at a happy place where quality and reimbursement are meeting each other,” she said. “All of a sudden administrators have skin in the game, and that’s where you as medical directors can really influence quality.” Dr. von Preyss-Friedman, the chief medical officer for Avalon Health Care, a provider of skilled nursing and assisted living facilities, encouraged directors who are just stepping up their quality improvement efforts to concentrate first on rehospitalization. Beginning in January of this year, five new quality measures were fully integrated into the calculation of the Five-Star Quality Rating System’s quality measure (QM) ratings. A measure of the percentage of short-stay residents who were rehospitalized after a nursing home admission is one of four new measures (out of the five) that are short-stay measures, and one of three that are based on Medicare claims rather than the Minimum Data Set (MDS). Each of the claims-based measures applies only to fee-for-service Medicare patients, which is “good news for us,” she said. The short-stay rehospitalization measure covers unplanned readmission to the hospital within 30 days of admission to the skilled nursing facility and includes discharged patients. Other new measures cover the percentage of short-stay residents who have an outpatient emergency department visit, and the percentage of residents who are successfully discharged to the community. As of last year, the national short-stay rehospitalization rate was 21%, according to data from the Centers for Medicare & Medicaid Services, and “at this point, many [hospitals and insurance networks] want it below 12%,” she said. “I think you should make this your goal.” (Avalon’s national short-stay rehospitalization rate now stands at 17%, she noted.) Dr. von Preyss-Friedman, also a clinical associate professor at the University of Washington, encouraged use of the INTERACT (Interventions to Reduce Acute Care Transfers) program. “Maybe just focus on the SBAR [Situation, Background, Assessment, Recommendation] communication form ... do something that focuses on early recognition of changes in condition,” she advised, adding that she had learned so much about the trends leading to hospital transfers in her facilities by using INTERACT’s Quality Improvement Tool for Review of Acute Care Transfers. (Dr. von Preyss-Friedman does not have any financial interest in the INTERACT program.) “If you have a high rehospitalization rate, I also really encourage you to form a rehospitalization committee,” she said. The committee should meet monthly and include the medical director, director of nursing, administrator, and charge nurse. Among other considerations, she highlighted the following: •MDS accuracy is still key. Even though the short-stay rehospitalization measure is claims-based (as are the measures for emergency department visits and successful discharge), the MDS-based covariates for functional status and conditions or diagnoses are part of a complex risk adjustment system that adjusts for facility risk. “It’s really important that your MDS coordinator is really good at what they do, because [their work] can affect your quality measures in a big way,” she said.•Hospice and end-of-life discussions should be integrated as early as necessary. This is because hospice-enrolled patients are excluded from the rehospitalization measure (as well as the other two claims-based short-stay measures). “If patients are entitled to a hospice benefit, bring up the conversation — don’t short-change them, because you’re short-changing [your facility] as well,” she said.•Time is of the essence. The data framing the new claims-based short-stay QMs are based on a rolling 12-month period, so they will not be up to date, she said. “You have to work on these things right now because it will take some time for your work to be reflected in updated measures.” Moreover, she added, only a Five-Star rating on the quality domain of the Five-Star system will affect a facility’s overall Five-Star rating. “You should fight for every single quality measure, every single point,” she emphasized. For more details on the Five-Star system and how ratings are calculated, see “The Fault in Our Stars: Does the Five-Star System Fall Short?” in the March 2017 issue of Caring. Christine Kilgore is a freelance writer in Falls Church, VA. •Start with Health Inspection rating•Add one star to the Step 1 result if staff rating is four or five stars and greater than the health inspection rating•Subtract one star if staffing is one star•Add one star to the Step 2 result if quality measure rating is five stars•Subtract one star if quality measure rating is one star