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Changes in the Five-Star Quality Ratings

Changes in the Five-Star Quality Ratings

Overview of Changes

Since the creation of Medicare and Medicaid from the Social Security Act of 1965, many changes have occurred in coverage, inspection, benefits, and state involvement in an effort to continue “protecting the health and well-being of millions of American families, saving lives, and improving the economic security of our nation.”1 The Centers for Medicare & Medicaid Services (CMS)­–part of the Department of Health and Human Services (HHS)–was created in 1977 to drive quality and affordability within the Medicare and Medicaid programs.

In an effort to incentivize improvement and continue supplying accurate information about the quality of skilled nursing facilities and nursing homes, CMS recently made substantial changes to their Five-Star Quality Rating System starting in April 2019. This rating system began in 2008 when CMS Nursing Compare needed an easy-to-use metric to compare facilities. Over the years, this rating system has been modified in an effort to provide the public with updated and accurate metrics of the quality of care provided at these facilities. Past changes included: improving design, usability, adding measures of antipsychotic use in the ratings’ calculations, and adjusting the staffing and quality measures.  

There are many components to the nursing facility rating system. Each nursing facility gets an ‘Overall Star Rating’, created from the combined ratings of: health inspections, staffing, and quality measures. The health inspection ratings are comprised of the three most recent health inspections over the last 36 months that focus on the deficiencies and complaints discovered throughout the investigations. The staffing rating is based on “registered nurse (RN) hours per resident day and total nurse staffing (the sum of RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day.”2 The quality measure rating is determined based on a facility’s quality within 17 pre-determined metrics. Each nursing facility will get a rating in quality from 1 star (below average) to 5 stars (above average). According to CMS, the reason there were changes to the rating system was in an effort to “improve the information available to consumers and drive quality improvement amongst nursing homes.”3

While the ratings will continue to focus on quality, many changes were made pertaining to the categories of health inspections, quality measures, and staffing.

A new process was implemented in late 2017 that had different standards and processes for the facilities.  As a result, CMS decided to freeze the health inspections and investigations conducted from February 2018 onwards. The results of these health inspection did not impact ratings but could still be viewed online. After further examination of their inspection methodology, CMS has finally decided to unfreeze these ratings starting in April 2019, which meant all the inspections since November 28, 2017 will now be included in the current star rating. The rating for health inspections will resume back to normal, which involves the combination of the scores between the “complaint inspections that occurred within the most recent 12 months from when the data are uploaded receive a weighting factor of 1/2; those from 13-24 months ago have a weighting factor of 1/3, and those from 25-36 months ago have a weighting factor of 1/6.”4 By unfreezing the health inspections, the ratings will more accurately reflect the current quality of the facilities.

Originally, all nursing homes were also rated using the same methodology regardless of the duration of a patient’s stay. However, because residents within short-term and long-term stays have different needs and goals of rehabilitation, the ratings will now be separate. Both ratings are now separately factored into the overall rating, so consumers can better understand the quality of care to the specific type of nursing home and type of care services they are looking for.

As a way to drive continued quality improvement, CMS has also decided to revise the thresholds for ratings (based on last revisions in February 2015) with the intent of incentivizing nursing homes to improve quality. This improvement includes adding a system for regular updates to the thresholds every six months and weighing and scoring individual Quality Metrics (QMs) differently. This rating was created from “12 Minimum Data Set (MDS)-based QMs and five measures that are created using Medicare claims,”5 that include various factors around health and rehospitalization. The rating system will additionally include: the long-stay hospitalization measure, a measure of long-stay emergency department (ED) transfers, and two short-term stay QMS that will be replacing similar old measures. The QM will now no longer add the factor of long-stay residents who were physically restrained to the rating system. Special Focus Facilities (SFFs), nursing homes that have had a history of serious quality issues, will not have a star rating, but will instead have a warning sign, in an attempt from CMS to stimulate improvement in those providers’ quality of care.

For more than 10 years, CMS has been reminding the nursing homes of the importance of having good facility staffing.  This is based on well-established research that demonstrates a positive relationship between higher staffing ratios and better quality of care. There is a federal requirement to have an RN onsite 8 hours a day, seven days a week, but CMS is increasing the weight of registered nurse staffing in the staffing rating and is changing the quantity of number of days without an RN onsite “that triggers an automatic downgrade to one-star”6 from the old threshold of seven days to four days.

Impact of Changes

These changes to the star ratings are beneficial to everyone– consumers and patients most of all.  They incentivize nursing homes to focus on improving quality of care and staffing ratios. As a result, the ratings are a more accurate tool for patients, their families, and case managers during the discharge planning process. The addition requirements and changes to the rating system are focused on providing quality care to the patient through up-to-date information and increasing the staffing standards. It is also making it easier for people to compare nursing facilities based on rehabilitation specificities. This is an effort from CMS to continue it’s goal of making the healthcare system more patient-facing. With these star ratings, case managers and discharge planners can explain what they are, what the metrics mean, and why it’s important for patients being discharged from the hospital.

CMS noted in its public statement that these changes to the star ratings can vary in impact in comparison to a facility’s old rating. This is due to changes in how CMS is weighing and calculating measures rather than changes in a facilities’ level of care or operations. Since the new star ratings have come out with the additional changes, many nursing facilities have seen a significant change in their ratings. These new star ratings will give a better picture of specificities in quality of a facility and a better way to compare them, specifically within short-term and long-term stays.

How Repisodic Helps You Discuss Ratings with Patients

New IMPACT Act regulations require hospitals to present quality data when discussing post-acute care options with patients and families. We can help you stay compliant.

Repisodic Choice, our hospital discharge solution, helps hospital discharge planners easily identify the best post-acute care options for each patient based on their unique insurance, location, and medical needs. Each post-acute care option is presented alongside its CMS quality data and other information. This information is displayed in a digestible and easy-to-understand format so patients and their family members can quickly and easily evaluate and compare different skilled nursing facilities to make good post-hospital care decisions. Click here to learn more about getting Repisodic Choice at your hospital.

[1] “CMS’ Program History”

[2,4,5] “Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide April 2019″

[3,6] “April 2019 Improvements to Nursing Home Compare and the Five Star Rating System”