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How To Improve Long-Term Care Quality Measures

Many long-term care administrators are concerned about their facility’s Centers for Medicare and Medicaid Services (CMS) star ratings, and for good reason. CMS ratings measure the quality of care a long-term care facility provides and often play a key role in a potential resident’s facility selection process.

Therefore, the ratings affect a facility’s reputation and ability to stay competitive in the long-term care market. CMS officially began the national Nursing Home Quality Initiative in 2002. That effort currently includes the star ratings listed on the CMS Care Compare website, launched in September 2020 to make Medicare’s comparison data for eight different types of providers available on one site.

Since CMS first implemented its star rating system in 2008, the scores have prompted administrators across the country to assess how to improve their quality measures and staffing ratings on an ongoing basis. Understanding how the five-star rating is calculated can help long-term care facilities improve their scores as well as their residents’ quality of life.

What Is the CMS Rating System?

While no rating system is completely exhaustive, the CMS Five-Star Quality Rating System is considered one of the most comprehensive long-term care facility rating systems. The CMS Rating System was created to help residents, their families, and caregivers more easily compare long-term care facilities and identify questions they may want to ask during the facility selection process. Today, the ratings are also used by regulators, investors, lenders, insurers, and other payer and provider networks to assess the quality of a long-term care facility and help them identify which ones they want to invest in and work with.

As noted, CMS ratings are available through Medicare’s Care Compare website, which displays each facility’s overall rating (from one to five stars) as well as a separate rating for each of the three measures used to calculate a facility’s overall score. These measures are:

Health inspections: During the health inspection process, trained, objective inspectors go onsite to assess the extent to which a long-term care facility has met Medicaid and Medicare’s minimum quality requirements. These inspectors will look for signs of abuse or negligence, evaluate whether food is handled appropriately, assess medication management, and more.

Staffing: The staffing rating encompasses information about the average number of hours of care residents receive each day, taking into account the specific care needs of each facility’s population. That means that a facility with residents who have more severe needs would be expected to have more nursing staff than those that care for individuals whose needs are not as high.

Quality of resident care or quality measures: This rating is based on more than a dozen different measures for evaluating residents’ physical and clinical needs and conditions. In 2016, CMS introduced six more quality measures for nursing homes. The measures, for both short-stay and long-stay residents, expanded the reach of this reporting metric.

How Do You Calculate a Facility’s 5-Star Rating?

Some healthcare professionals are unclear about the terms and quality measures used by CMS. They may wonder, “What is long-term care facility quality, and how is it measured?”

A facility’s CMS rating is a composite score determined by its ratings for the three domains discussed above — health inspections, staffing, and quality measures. The health inspection rating serves as the core of the calculation. The overall score is then adjusted up or down based on the staffing and quality measures ratings. Scores for each of the domains are determined according to the following criteria.

Health Inspection Rating

During the inspection process, inspectors assign points based on the number, scope, and severity of a facility’s deficiencies. Examples of deficiencies are expired food, failure to adhere to proper infection control measures, administering the wrong medication, and inefficient or absent care plans. The more points a facility receives, the lower its star rating will be. If deficiencies persist and multiple visits are needed to ensure that they are addressed, CMS will add points.

A long-term care facility’s CMS health inspection rating is then calculated using the three most recent health inspections as well as any insights garnered from investigations due to complaints. Recent inspections are weighted more heavily than older ones.

According to CMS, “The top 10% of nursing homes get 5 stars, the bottom 20% get 1 star, and the middle 70% of nursing homes receive 2, 3, or 4 stars, with equal proportions (23.33%) in each category.”

Staffing Rating

The staffing rating is calculated using two measures: registered nurse (RN) hours per resident per day and total staffing hours, which combines RN, licensed practical nurse, and nurse aide hours, per resident per day. This data is self-reported by long-term care facilities and is based on the number of hours worked by their nursing staff and the number of residents in their facility.

Both measures — RN hours and total staffing hours — are given equal weight during the calculation process. To receive five stars on the staffing rating, a long-term care facility must meet or exceed CMS staffing study thresholds for both measures.

Quality Measures Rating

This rating is calculated using performance data from Minimum Data Set (MDS) assessments. Each long-term care facility is required to submit MDS assessments as part of a federally mandated process for conducting clinical assessments of all residents in Medicare or Medicaid certified long-term care facilities. Quality measure ratings encompass data from the three most recent quarters for which performance data is available.

Once all the individual quality measure ratings are determined, they are consolidated into one overall rating. Both the overall rating and the individual measure ratings are available on the CMS Care Compare website.

How Can We Improve Our CMS Star Rating?

Improving your CMS rating takes consistent effort, but it is well worth it. Long-term care facilities with higher CMS ratings are more appealing to potential residents and other key stakeholders.

It is possible for a facility to improve across all three domains of the CMS star rating system. Yet many choose to focus on improving their quality measures, given that this rating can be the most variable.

Improving your quality measure calculations begins with creating a quality assurance and performance improvement (QAPI) plan. As part of that plan, facilities should focus on:

Engaging Leadership

Company culture is created from the top down. For front-line employees to engage in quality measure improvements, they must be identified as a priority by senior management and executives. The more leaders demonstrate the importance of quality measures, the more invested their team will be in improving them.

Increasing Staff Participation and Holistic Care

Quality measure reporting involves everyone who works in a long-term care facility — not just the nurses and nursing assistants. Dietary consultants, housekeeping staff, and maintenance technicians all have a part to play in creating a safe, supportive space. By involving a diverse array of employees in the QAPI plan, administrators are better prepared to provide more holistic, patient-centric care that extends beyond residents’ medical diagnoses.

Offering Staff Education

CMS did not pick its quality measures randomly. Agency officials chose the measures because they best reflect the quality of care long-term care facilities provide to their residents. Teaching staff about quality measures and best practices for fulfilling them helps improve residents’ quality of life and boost a facility’s star rating. Employers should consider using employee assessments to better understand their staffs’ existing knowledge of quality measures and how they can work to enhance it.

Improve Your CMS Rating Today

There’s no denying that CMS ratings are important to your facility’s success. While they may not be the only reason a resident chooses a long-term care facility, they play an essential part in the process.

Earning a five-star rating requires collaboration, persistence, and focus. Only when all members of a long-term care facility are engaged and involved in the process — day in and day out — is a five-star rating within reach.


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