Functional outcomes scores for rehab therapy and quality reporting data reported by skilled nursing facilities (SNF) are now open to the public.
On October 28, 2020 the Centers for Medicare and Medicaid Services (CMS) ‘refreshed’ the SNF Quality Reporting Program (QRP) data reported on Nursing Home Compare (NHC). And on December 9, 2020, CMS refreshed the Inpatient Rehabilitation Facility QRP data. And those weren’t the only updates. CMS also launched its new Care Compare (CCXP), a website on which you can find and compare information on all Medicare providers of care. SNF information can be located by clicking on the “Nursing Homes Including Rehab Services” link on Care Compare.
What this means is that a consumer of post-acute care services or a family member looking for the most appropriate care setting for their loved one could access the scores for your SNF and draw conclusions not only the effectiveness of the rehabilitation care provided to individual persons but also the effectiveness of the SNF community itself. If they are deciding between choosing an Inpatient Rehabilitation Facility (IRF) or a SNF, they can compare the outcomes each achieves. The data for both settings reflects Section GG information collected between 1/1/2019 and 12/31/2019.
Summary of Measures
Here are the four functional outcomes measures that are now available about your SNF:
- Change in Self-Care – the risk-adjusted mean change in score of the Section GG Self-Care items between admission and discharge for SNF Part A residents discharged from a SNF.
- Change in Mobility – the risk-adjusted mean change in score of most of the Section GG Mobility items between admission and discharge for SNF Part A residents discharged from a SNF.
- Discharge Self-Care Score – the estimated percentage of SNF residents who meet or exceed an expected discharge score.
- Discharge Mobility Score is the estimated percentage of SNF residents who meet or exceed an expected discharge score
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What do they say about the rehabilitation program? Due to the Public Health Emergency (PHE), CMS announced it will not be using data collected 1/1/2020 through 6/30/2020 for calculating quality measures. That means, the data publicly reported on CCXP will have to be ‘frozen’ until January 2022 since CMS won’t have enough information to calculate the measures for four quarters. So, hopefully you like your numbers, because they will be visible to the public for a full calendar year. If you don’t like your scores, then here are a few steps you can take now.
- Understand the data elements. Even though SNFs have been collecting Section GG for over 3 years now, there is still a lot of confusion about what is/isn’t included in each data element.
- Understand the rating system. Do all the nurses and therapists in your building use the same terminology and points of reference when scoring GG? How often do you evaluate this?
- Complete an interdisciplinary assessment over the first three days and the last three days of the resident’s stay. That is the CMS requirement. It should not be one discipline completing Section GG at one point in time. There must be collaboration to ensure the ratings accurately reflect the resident’s baseline abilities at admission and as close to discharge as possible.
- Focus on other parts of the MDS. As stated above, there are a lot of risk adjustors to these measures. Ensuring the rest of the MDS reflects a resident’s medical condition and comorbidities is important to the measure calculation.
- Focus on your clinical care. Are your treatment strategies as effective as they can be? Are they patient-centered? Is there an interdisciplinary approach to a resident’s functional performance not just while they are in therapy, but around the clock with all care professionals?
CMS’ goal of all these programs is to collect information on patient characteristics, care processes, care variations, and the short and long-term effects of that care in order to make future policy decisions. Ensuring our data is accurate should also help us to improve the health of the population and the quality of the services we deliver.
Need Help Staying on Top of Compliance?
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