It’s been less than three years since our “Falling Stars” blog post announced that CMS Five-Star ratings were dropping industry-wide. Get ready — it’s about to happen again and at a larger scale.

Read on to learn what CMS just changed and how you can take proactive measures to maximize your Five-Star rating.

So, what’s in the CMS announcement?

Just days ago, CMS announced sweeping new changes to the Five-Star Quality Rating System, which are meant to realign the data and calculations used to assign star ratings to skilled nursing facilities. The changes are significant and will take effect in April, just weeks away.

Although the changes take effect next month, Five-Star quality measures will retrospectively include all MDS assessments submitted since Oct. 1, 2018.

As a reminder, the Five-Star quality rating system covers three domains: healthcare inspections (data from state survey), staffing (data from PBJ and MDS census), and quality measures derived from MDS and claims data.

The April changes will impact all Five-Star domains, but the most significant changes appear to be in the areas of quality measures and staffing.

QMs are changing, big time

Without diving into too much technical detail, the most notable changes to Quality Measures include:

• Changes to QM summary score calculations
• Removal of the long-stay restraint measure
• Expanding claims-based Quality Measures, specifically long-stay hospitalizations and long-stay Emergency Department (ED)
• Cut points calculation changes that affect both PBJ and MDS measures
• Long-stay and short stay pressure ulcer calculation changes

There are a few key takeaways here:

The new CMS changes affect all SNFs in the U.S., and many facilities will lose a QM star based on new cut points. Also, cut point rating adjustments will now occur more frequently (every six months), making it much harder to achieve five stars going forward.

In short, this means that overall Five-Star improvements will no longer be possible simply by improving QMs. The frequency of cut point adjustments means that future star improvements will require improving quality outcomes at a faster rate than your peers.

Staffing: PBJ takes center stage

Staffing rating thresholds are changing, with the staffing level required to receive a Five-Star rating determined based on analyses of the relationship between staffing levels (from PBJ data) and measures of nursing home quality (from MDS data).

Other notable staffing QM domain changes include:

• Overall staffing rating is changing to provide more emphasis on RN staffing
• Ratings are set to one star for nursing homes reporting four or more days in the quarter with no RN onsite
• Staffing ratings are no longer suppressed for nursing homes with five or more days with residents and no nurse staffing hours reported

Given the changes, your PBJ data is more important than ever in terms of its impact on your Five-Star rating. If you have not yet gotten your PBJ house in order, now is the time.

By “in order” I don’t just mean checking the box on your IT to-do list that you are able to compile and submit the PBJ data. While not “easy” by any means (trust us, we know how hard it really is), the mechanics of PBJ submission are the “easier” part. This is just the bare minimum regulatory requirement of CMS.

The real trick is knowing in advance where you stand in relation to Staffing and Five-Star ratings. Facilities that understand the impact of staffing and can properly manage the PBJ process will have a significant advantage in the increasingly competitive five-star ratings game.

The good news about staffing

Throughout 2017 and 2018, we began to see the pain that Payroll-Based Journal compliance was causing our customers. So, in August of last year we acquired a startup company that was laser-focused on the problem: ezPBJ.

Having ezPBJ as part of the SimpleLTC/Briggs suite of software gives us a unique ability to combine MDS analytics with PBJ analytics. The response from customers has been overwhelmingly positive, with the number of facilities using ezPBJ more than doubling in six months.

If you’re not familiar with ezPBJ you can read more about it on our website. Turning on ezPBJ may be the single best decision you make this year in regards to QM improvement.

Don’t forget, we’ve got your back!

I know that these changes may sound scary at first, but rest assured that we are here and on your side.

SimpleLTC is working quickly to update QM views in SimpleAnalyzer™ to adjust for the April changes. Our goal is to have all calculations, cut points and predictive measure changes in place by April 1. We cannot guarantee this date due to a few “unknown unknowns,” but we will let you know when the changes go live.

For SimpleAnalyzer™ users, this means that all back-end calculations and technical details will be automatically adjusted with no need to do anything on your end. Just be aware that the predicted measures you see today will change after we make adjustments.

Given the new changes, especially around claims-based measures, the overall Five-Star rating beyond two quarters will now be harder to predict. We know how powerful and important this QM “crystal ball” feature is to our customers and we will continue to work to give you the most accurate predictions possible.

In the meantime there are still a few details CMS has not made known yet. For example, we do not know the exact schedule of cut point adjustments (CMS has only announced it will be every six months). Also, we do not know the exact date of new QM CASPER reports, but we assume it will be early April.

We at SimpleLTC will conduct a QM/Five-Star training webinar in the near future, so keep an eye out for more info soon. As always, please reach out to us if we can help. Thank you for all that you do provide quality healthcare for our seniors!

Additional resources

• CMS announcement of Five-Star Quality Rating System changes (Mar. 5, 2019)
• CMS Memo #19-08-NH: April 2019 Improvements to Nursing Home Compare and the Five-Star Rating System
• Updated QM User Manual (v12.0)
• Updated Five-Star Technical Guide (April 2019)