Understanding the Purpose and Function of Quality Measures
Nursing home quality measures (QMs) are a cornerstone of transparency in the long-term care industry. They are data-driven tools designed to provide a snapshot of a facility's performance in key areas, helping to inform consumers and hold facilities accountable. These QMs are collected from the Minimum Data Set (MDS), a comprehensive, standardized resident assessment tool that all Medicare and Medicaid certified nursing homes must use. The collected data is then aggregated and analyzed to produce facility-level performance scores, which are publicly available through the CMS website and other resources.
The system is designed to provide comparable information, which is critical for families navigating the complex process of choosing a nursing home for a loved one. By comparing scores on metrics like hospital readmissions, fall rates, and vaccination status, prospective residents and their families can gain insight into the quality of care provided. It is important to remember that these measures represent the average performance of a facility and should be considered alongside other factors, such as personal visits and resident interviews, when making a final decision.
Short-Stay vs. Long-Stay Quality Measures
CMS categorizes quality measures into two main groups, reflecting the different needs and expected outcomes for residents based on their length of stay. This distinction is vital for accurate evaluation and comparison.
Short-Stay Resident Quality Measures
These measures apply to residents who are in a facility for 100 days or less, often for post-acute care and rehabilitation following a hospital stay. The focus is on metrics related to a resident's transition and recovery. Examples include:
- Percent of residents who were re-hospitalized after a nursing home admission
- Percent of residents who had an outpatient emergency department visit
- Percent of residents who newly received an antipsychotic medication
- Changes in skin integrity (e.g., pressure ulcers/injuries)
- Percent of residents who received recommended vaccines (influenza and pneumococcal)
Long-Stay Resident Quality Measures
These measures cover residents who have been in the facility for 101 days or more and typically have more serious, long-term health needs. The QMs focus on the sustained health and quality of life over time. Examples include:
- Percentage of long-stay residents who have or had a catheter inserted and left in their bladder
- Percentage of long-stay residents experiencing one or more falls with major injury
- Percentage of long-stay residents with a urinary tract infection
- Percentage of long-stay residents whose need for help with daily activities has increased
- Percentage of long-stay residents with new or worsened bowel or bladder incontinence
- Percentage of long-stay residents who lose too much weight
- Percentage of long-stay residents who were physically restrained
The Role of QMs in the CMS Five-Star Quality Rating System
The Centers for Medicare & Medicaid Services (CMS) uses nursing home QMs as one of three key components to calculate the publicly reported Five-Star Quality Rating System. This widely used system helps consumers compare facilities on the Medicare Care Compare website. The three domains are:
- Health Inspections: Based on state health survey results over the past three years, including regular annual inspections and complaint investigations.
- Staffing: Measures the number of nursing staff hours per resident per day, adjusted for the complexity of resident needs (case-mix adjusted).
- Quality Measures (QMs): This domain contributes significantly to the overall star rating and is calculated using the short-stay and long-stay measures derived from resident assessment data.
The overall star rating is a composite score, meaning a high rating in one area cannot completely offset a low rating in another. This encourages facilities to strive for improvement across all domains to achieve a better score.
A Comparison of Key Quality Measure Areas
To illustrate the difference in focus, consider this comparison of how quality measures assess different aspects of care:
| Assessment Area | Short-Stay Measure | Long-Stay Measure |
|---|---|---|
| Hospitalization | Focuses on re-hospitalization rates, indicating effectiveness of short-term care and discharge planning. | Tracks hospitalization rates per 1,000 resident days, reflecting management of long-term and chronic conditions. |
| Functional Ability | Measures functional discharge score, reflecting a resident's ability to return home or to the community after rehabilitation. | Tracks the percentage of residents whose ability to move independently has worsened, indicating decline over time. |
| Medication Management | Records new use of antipsychotic medication, highlighting potentially unnecessary use during acute treatment. | Measures chronic use of antipsychotic medication, monitoring long-term pharmacological management of residents. |
| Infections | Focuses on healthcare-associated infections resulting in hospitalizations, a critical short-term safety issue. | Tracks the percentage of residents with urinary tract infections, indicating facility-wide infection control protocols. |
Using and Interpreting Quality Measures
For families and residents, understanding how to use and interpret QMs is crucial for making an informed decision. While a low percentage is typically better for negative outcome measures (like falls or infections), some measures are interpreted differently. Here are some steps to follow:
- Look beyond the stars: While the overall star rating is a good starting point, always look at the individual ratings for health inspections, staffing, and QMs. A facility with a high overall rating but a low staffing rating may raise a red flag.
- Understand the context: QMs are averages and do not represent a single resident's experience. Talk to the staff, residents, and family members to get a more complete picture of the facility's culture and daily operations.
- Focus on improvement: Some QMs are problem-based, where a low score indicates better performance. For example, a lower rate of falls with major injury is a sign of effective fall prevention protocols. Conversely, a higher rate of residents receiving recommended vaccines shows proactive health management.
- Engage with QAPI programs: Facilities are encouraged to participate in Quality Assurance and Performance Improvement (QAPI) programs. Asking about these programs and how the facility uses QM data to drive continuous improvement can provide a deeper understanding of their commitment to quality. Facilities with a culture of quality are more likely to have processes in place to address deficiencies identified by the QMs.
- Utilize CMS resources: The Medicare website provides detailed information and reports on nursing homes. For comprehensive, publicly reported data, explore the CMS Care Compare website: https://www.medicare.gov/care-compare.
Conclusion
Nursing home quality measures are a vital resource for anyone seeking to evaluate a long-term care facility. By providing standardized, public data on health outcomes, safety, and care processes, they help to create a transparent and accountable healthcare environment. While the CMS Five-Star Quality Rating System is a useful tool, a comprehensive evaluation requires looking at the individual QM data, understanding the differences between short-stay and long-stay measures, and combining this information with personal observations and feedback from the facility community. This multifaceted approach empowers individuals and families to make the best possible choice for their loved ones' care.
