Skilled Nursing Facilities (SNFs) are affected by three quality programs established by CMS, all of which include readmission measures:
- Nursing Home Compare Five-Star Quality Rating System
- SNF Quality Reporting Program (QRP)
- SNF Value-based Purchasing (VBP) program
While all three programs measure hospital readmission rates, the measures themselves are different.
There are two claims-based readmission/hospitalization measures in the Nursing Home Compare Five-Star Rating System – one for short-stay residents and one for long-stay residents.
- Percent of short-stay residents who were re-hospitalized after a nursing home admission: Reports the percentage of all new admissions or readmissions to a nursing home from a hospital where the resident was readmitted to a hospital for an inpatient or observation stay within 30 days of entry or reentry (reporting began 10/1/2016).
- Number of hospitalizations per 1,000 resident days: Measures the number of unplanned inpatient admissions or outpatient observation stays that occurred among long-stay residents of a nursing home during a one-year period, expressed as the number of unplanned hospitalizations for every 1,000 days that the long-stay residents were admitted to the nursing home (reporting began 10/1/2018).
A nursing home’s performance on several MDS- and claims-based quality measures (including these hospitalization measures), along with health inspection and staffing ratings, determine the facility’s overall star rating on Nursing Home Compare. Patients, referring providers and payer networks use the information on Nursing Home Compare to determine which facility to utilize or partner with.
The SNF Quality Reporting Program (QRP) established by the IMPACT Act of 2014, included the potentially preventable 30-day Post-Discharge Readmission Measure in FY 2017. This measure assesses potentially preventable readmissions (PPR) within a 30-day window following discharge from the SNF. CMS states that for residents in the 30-day post-acute care discharge period, “a potentially preventable readmission refers to a readmission that should be avoidable with adequately planned, explained, and implemented post discharge instructions,” including establishing appropriate follow-up care.
Currently, a SNF’s performance on the claims-based PPR measure (i.e., the SNF’s readmission rate) does not directly affect reimbursement. Payment penalties began in FY 2018 and are associated with failing to successfully report the MDS assessment-based measures in the program.
The Protecting Access to Medicare Act of 2014 (PAMA) established the SNF Value-based Purchasing (VBP) program. The SNF VBP offers Medicare incentive payments for SNFs paid under the SNF Prospective Payment System (PPS) based on performance on specific readmission measures. Currently, the readmission measure used in the VBP program is the SNF 30-day All Cause Readmission Measure (SNFRM).
The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions within 30 days of discharge from the prior acute hospitalization. Hospital readmissions are identified through Medicare claims, and readmissions within the 30-day window are counted regardless of whether the beneficiary is readmitted to the hospital directly from the SNF or has been discharged from the SNF and is readmitted from the community.
A SNF earns points based on its performance on the measure compared to a national benchmark or the improvement in its own score from the baseline to the performance year. The points awarded determine the facility’s national rank and resulting incentive or penalty payment. The SNF VBP began affecting Medicare Part A payment on October 1, 2018.
Reducing unnecessary unplanned hospital readmissions as defined by each of these quality measures depends on the SNF’s ability to facilitate smooth and effective care transitions (both upstream and downstream) and to skillfully assess and manage the patient’s clinical and functional condition.