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CMS’s Five-Star Ratings and the Short-Stay Skilled Patient Population

Since 2008, CMS has calculated and published Five-Star ratings on SNFs to help consumers select a provider. With its Five-Star Quality Rating System, CMS has developed a consumer-friendly metric that profiles the quality of a SNF as a whole. However, CMS’s Five-Star rating contains some blind spots for the short-stay patient population. Below we share why, when referring a short-stay patient to post-acute care in a SNF, patients, families, and providers may not want to rely solely upon CMS’s star ratings as an indication of provider quality.

Performance variance

Even among SNFs in the same market that are highly rated (three stars and above), there continues to be significant, unexplained variance in the care provided to patients. For example, a SNF’s registered nurse (RN) hours per resident per day may vary significantly from one three-star facility to another facility with the same rating. The variance in quality from SNF to SNF is the very reason that hospitals and health systems should look beyond the facility’s star rating when building a high-performing SNF collaborative.

Custodial focus

Most metrics within CMS’s Five-Star Quality Rating System are geared toward the patients that SNFs primarily take care of: custodial, long stay patients. For many of these patients, the nursing home is their long-term or permanent home. However, short-stay patients and long stay patients represent two very different patient populations.

The majority (9 of the 15) quality measures (QMs) used to rate SNF quality are based only on the custodial population, and so it doesn’t always make sense to simply choose the highest-rated facilities because that rating isn’t optimized for a short-stay skilled patient population. For example, some short-stay patients only plan to stay at the facility for rehabilitation following surgery before being discharged home to live independently. In this case, CMS’s rating methodology fails to capture short-stay patients’ needs.

Lagged data

Many metrics used in CMS’s Five-Star Quality Ratings System for the short-stay population come from Medicare Fee-for-Service (FFS) claims, which are on average one year old when presented on Care Compare. However, SNF quality can meaningfully change over the course of one year. In just 12 months, the average SNF in the U.S. will have a change in their 30-day rehospitalization rate of more than 20%. For example, a rehospitalization rate of 20% could jump to 24% or dip to 16% in one year. It’s evident that SNF quality can change much more quickly than CMS ratings. If measures information is upwards of a year old, it’s an insufficient indication of SNF performance and can result in poor patient outcomes.

Subjective survey process

There are three domains within the CMS Five-Star Ratings System. The quality domain measures the facility’s outcomes and quality measures but comprises only 18% of a SNF’s rating. The staffing domain determines whether the SNF is adequately staffed and accounts for 19% of the rating. Last, the survey domain makes up 63% of a SNF’s Five-Star rating.

While some survey citation data can be helpful, the majority of a SNF’s overall Five-Star rating is based off of the number of citations surveyors assigned to a SNF upon its annual inspection. While this process is useful and provides data regarding a SNF’s potential quality issues, it counts against the facility for more than 3 years. Also, the citations may be subjective because they’re dependent upon the individual surveyor team and how that team chooses to enforce federal regulations. There can be significant variance amongst surveyor teams in different geographies.

Cost utilization

Average length of stay (ALOS) is one of the most varied metrics in post-acute care and drives cost under the Patient Driven Payment Model (PDPM), but this measure is missing from CMS’s Five-Star Quality Rating System. While most SNFs aim to keep patients for an appropriate amount of time prior to their safe discharge, ALOS differs from facility to facility. For example, some SNFs opt to keep patients for a longer period of time than others; this isn’t always to ensure better patient outcomes, but rather to increase PDPM reimbursement.

Measures freeze

CMS’s already-lagged data is even more lagged due to the ongoing measures freeze. Due to the COVID-19 pandemic, CMS announced a temporary freeze to the Five-Star Quality Rating System in March 2020. CMS made the decision to hold survey data – and freeze measures and ratings across the Five-Star Domain spectrum – to allow nursing homes to focus their full attention on the safety of their residents during the public health crisis. However, time itself is not frozen, and nursing homes continue to admit and discharge new patients while these measures remain at a standstill.

SNF provider ratings will remain frozen until January 2022, which means that Five-Star ratings will be more than two years old before they’re updated, and hospitals will lack critical, up-to-date insights regarding SNF performance if they rely solely upon these CMS data sources.

To ensure patients are discharged to the very best providers in a given market, hospital providers must continuously curate their SNF collaborative with real-time, risk-adjusted metrics. We recently introduced the CarePort Quality Score, which helps ensure providers leveraging the CarePort platform can identify and guide their patients to SNFs in their market that provide the highest quality of care for their short-stay patient population.

For more information regarding the CarePort Quality Score, stay tuned for our next blog post, or watch our recent webinar on demand.

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