In April, the Centers for Medicare and Medicaid Services (CMS) updated the Five Star Rating System Technical User’s Guide . This guide details changes made to the formulas/ calculations to attain the Health Inspection, Staffing and Quality Measure (QM) Domain ratings. CMS made these changes with the intent of improving quality outcomes and to encourage centers to focus QAPI efforts in specific areas.
Regarding the Health Inspection Domain, the formula now uses the three most recent survey cycles (instead of two cycles previously) and terminated the “freeze” on the star rating. Regarding the Staffing Domain, CMS has changed the “Cut Table” with greater emphasis on RN staffing. Additionally, the QM Domain formula has changed significantly. This article will describe the new QM Domain formula used in the Five Star Rating System.
The Five Star Rating system currently uses 17 QMs in the calculation; 10 Long Stay and seven Short Stay QMs. The calculation has removed the Restraint QM and added two new Long Stay QMs. These new QMs are Long Stay Hospitalizations and Emergency Department (ED) visits per 1,000 resident days. Additionally, the new formula places greater weights on specific QMs. QMs with the greatest weighting (up to 150 points each) are as follows:
- Long-stay ADL worsening
- Long-stay antipsychotic medication
- Long-stay mobility decline
- The two claims-based long-stay measures (Hospitalizations and ED visits)
- Short-stay functional improvement
- Three claims-based short-stay measures: Discharge to Community, re-hospitalization and ED visits.
The remaining eight QMs remain with a potential score up to 100 points as follows:
- Long-stay pain
- Long-stay pressure ulcer
- Long-stay catheter
- Long-stay urinary tract infections
- Long-stay falls
- Short-stay pain
- Short-stay pressure ulcer
- Short-stay antipsychotic medication
Additionally, the Short Stay QMs were assigned a weighting factor of 1.39 to balance the Long Stay QMs. The final calculation sums the Long Stay “raw” score with the Short Stay “raw” score (after assigning the weighting factor of 1.39) for a total score, which is then categorized into a star rating based on the new Cut Table. The following graphic displays a sample as an overview.