April 20, 2022
Several Updates to SNF Quality Reporting Program in Proposed PPS Rule
On April 20, 2023 by Julie Apold
The Center for Medicare and Medicaid Services (CMS) recently released its 2024 Skilled Nursing Facility Prospective Payment System Proposed Rule. It includes several proposed SNF Quality Reporting Program (QRP) changes.
Notable proposed changes to the SNF QRP program include adopting, removing, or modifying several measures and changes to the data completion thresholds.
New measures proposed for adoption
- Discharge Function Score: This measure would replace the current SNF QRP measure “Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function” beginning FY 2025. The collection of MDS data for this measure would begin Oct. 1, 2023, with reporting on Care Compare starting with the Oct. 2024 refresh.
- CoreQ - Short Stay Satisfaction: The CoreQ is a resident-reported outcome measure involving surveying short-stay residents discharged within a six-month period and calculating the percent of satisfied residents. SNFs would be responsible for contracting with a CMS-approved CoreQ survey vendor to administer the survey and report results to CMS. SNFs would begin sending resident information files to vendors in FY 2024 and must meet data completeness thresholds of at least 90% of required data fields submitted for at least 75% of the reporting weeks.
- Patient/Resident COVID-19 Vaccine: For FY 2026, CMS proposes adopting the measure “COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date.” Data would be based on a new item on the MDS assessments for SNF patients discharged during the reporting period. SNFs would begin reporting MDS data for residents discharged beginning Oct. 1, 2024, with reporting on Care Compare starting with the Oct. 2025 refresh.
Measures proposed for removal
- Application of Functional Assessment/Care Plan: The “Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and Care Plan that Addresses Function” measure would be removed from SNF QRP beginning FY 2025. CMS’ rationale for removing this measure points to the current high level of performance on this measure, not allowing for the meaningful distinction between providers. In addition, the “Discharge Function Score” measure proposed for adoption is more strongly associated with the resident functional outcomes being targeted. SNFs would not be required to report Self-Care Discharge Goals or Mobility Discharge Goals for residents admitted on or after Oct. 1, 2023, and these items would be removed from the MDS in the next release.
- Changes in Self-Care and Mobility Score: The two “Application of IRF Functional Outcome Measures” – “Change in Self-Care Score” and “Change in Mobility Score” would be removed beginning FY 2025. The rationale for removal is that the costs for SNFs and CMS associated with the measure outweigh the benefits of the information obtained. According to CMS, the measures are highly correlated with the “Discharge Self-Care Score” and “Discharge Mobility Score” measures and do not appear to measure unique concepts. Reporting on Care Compare for these measures would end by the Oct. 2024 refresh.
Measure modification
- HCP COVID-19 Vaccine Measure: The COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure requires reporting the percentage of healthcare personnel who have completed a SARS-CoV-2 vaccination course. The proposed modifications for FY 2025 replace the completed vaccination course language with HCP who are “up to date” based on the CDC’s definition of up to date. The modifications also specify the time frames within which HCPs are considered up to date.
Increases to data completion thresholds
- An increase is being proposed in data completion thresholds for SNF QRP MDS items to 100% submission of the required data on 90% of MDSs vs. the current completion threshold of 100% complete data for 80% of submitted MDSs.