Nursing Intervention List

welcome to this mln connects video on the skilled nursing facility quality reporting program. this presentation was recorded at the mln connects webcast on wednesday, september 14, 2016. i am leah nguyen from the provider communications group here at cms, and i am your moderator today. i would like to welcome you to this mln connects event on the skilled nursing facility or snf quality reporting program. mln connects events are part of the medicare learning network . during this webcast, learn about the reporting requirements for the new snf quality reporting program, effective october 1st, 2016. the

improving medicare post-acute care transformation act of 2014, or impact act, established the program and requires the submission of standardize data. at this time i would like to turn the call over to our first presenter, sharon lash, from the division of chronic and post-acute care of the center for clinical standards and quality. sharon lash: hi, good afternoon everybody and thank you for joining us today with this first webcast for the skilled nursing facility quality reporting program training

okay, i'm so sorry for that technical difficulty there everyone. we are new to webcasting, and so you're going to have to bear with us while we get used to the technology here. this is my first webcast. and again, i want to thank you. we have around 550-some attendees, and we are getting ready for qrp implementation on october 1st. and i want to give you some additional information with this presentation. there will be laura smith, who is our contractor with research triangle institute, who is very key in developing the quality measures and has been with the nursing home world for some years now. and i have been

working with the division since last october to stand up this new program for skilled nursing facilities. so as leah mentioned, i'm just going to go through the impact act very briefly. but we have legislative basis for these programs in the impact act of 2014, which was passed almost 2 years ago. so this has been moving rapidly. it requires the standardized patient assessment data across post-acute care settings. and these include long-term care facility long-term care hospitals, intermediate i'm sorry, in-patient rehab facilities, skilled nursing facilities, and home health

agencies and hospice. so we want to standardize our assessment items and quality reporting endeavors as much as possible across post-acute care setting. obviously, all the initiatives that cms implements is designed with an eye on improvement of medicare beneficiary outcomes. we also want to give providers access to their own longitudinal information to facilitate their own coordination of care, their own, you know, quality of assurance, performance improvement activities, to enable hospital discharge planning more effectively and to conduct research to enable

payment models based on patient characteristics. so, the quality reporting programs are very much structured like the in-patient quality reporting programs in hospitals and acute care providers. the transformation, if you will, using the impact act terminology, is now where it's applied to post-acute care providers. and this is very new and, i think, a very important development. so why is there such emphasis on post-acute care well, we know that there are increasing numbers of the beneficiaries accessing post-acute care providers. and along with that is an escalating cost associated with post-acute care.

we don't have a very good set of data standards and interoperability across the pac settings to allow us to trace that beneficiary to our post-acute care provider settings. and the last item on that slide states that the goal of establishing payment rates according to the individual characteristics of the patient and not the care setting. and obviously we need to optimize our payment schedules and payment outlays. so we're trying to improve all things for the beneficiary and for the tax payer. so these are the applicable pac settings, as i mentioned before. we have long-term care, intermediate rehab facilities, home

health agencies, and nursing homes. i did mention hospice, and that's not in the impact act, but we are engaged in quality reporting programs for hospice within our division as well as part of a post-acute care provider community. again, i want to just high-level summary of the impact act, which is standardizing patient assessment data. the dates i want to point out to you include the home health agencies when data collection beginning for qrp this for standardized assessment data will begin january 1, 20 i'm sorry the reporting will be begin as of january 1, 2019. the

skilled nursing facility quality reporting program annual payment update and public reporting will be effective october 1, 2018, as well as the inpatient rehab facilities and long-term care hospitals. the quality measure domains, as specified in the act, contain the following: there's the functional status, cognitive function, and changes in function and cognitive function. they're also specifying skin integrity and changes in skin integrity, medication reconciliation, incidence of major falls, and communicating the existence of and providing for the transfer of health information and care preferences.

so these are the impact act quality measure domains, and this is why you will see the quality measures developed along these lines. and that's what we are going to be presenting today are the three quality measures, the assessment measures that we will be implementing this fall, on october 1, for the assessment-based measures. and laura is going to introduce the three claims-based measures that will be collected as of october 1. the resource measures, which i just mentioned that laura will be introducing, and they were finalized in our 2017 pps snf pps, with

resource use and other measures will be specified for reporting, which may include standardized assessment data in addition to claims-based data. so that's what this is all about. so we're using both sources of the assessment as well as administrative claims data. the resource use and other measure domains include the total estimated medicare spending per beneficiary, discharge to community, and various measures to reflect all conditions, risk-adjusted potentially preventable hospital readmission rates. in response to the reporting require so that is the overall i'm sorry, let me just restate. that

is the overall review of the impact act. i know we've had many, many outreach opportunities for the impact act over the last year, and they have been rather intensive. we've been trying to reach out to all stakeholders to educate people about the impact act, how it's going to be implemented and those timelines, and what providers are going to be affected. and this is the last time i 'm going to prevent to present an impact act you know information in advance of the quality reporting program implementation. afterwards, it will be very, very specific and very

focused and targeted on the specific aspects of the skilled nursing facility quality reporting program. next, i'm going to give yet another high-level overview of the policy policies that were finalized in the 2016 snf pps rule that introduced most of you to this skilled nursing facility quality reporting program. so, again, this will be the last time that i provide this overview because the training materials that we're posting to our website, the snf qrp website, which we will discuss later at the end of this powerpoint, will contain all of this information. and again, going

forward, we will be very specific on the program specific requirements of the quality reporting program. i just wanted to make sure that everybody had an opportunity to hear these high-level policy requirements and try to understand the source of them. so, in response to the reporting requirements under the impact act, cms established the skilled nursing facility quality reporting program and its quality reporting requirements in fiscal year 2016 snf prospective payment system final rule. so for the statute, facilities that do not submit the required quality measures data may receive a

2-percent 2 percentage point reduction to their annual payment update for the applicable payment year. this is very consistent with the other programs across the post-acute care providers, long-term care hospitals, inpatient rehab facilities, and hospice. this program is effective, as i mentioned, october 1st, 2016, and for more information regarding this snf qrp, please visit our webpage. it can be accessed from the nursing home quality initiative page, and it will take you to an entire new newly constructed snf qrp page that contains numerous menu options on the left for you to select.

right now, the skilled nursing facilities currently submit mds 3.0 data to the cms through the quality improvement and evaluation system, otherwise known as qies, asap system. the october 1st, 2016, implementation of the snf qrp will not change the process of mds 3.0 data submission through qies. so what we're talking about right now are the measures that will be used to determine the 2018 payment determination of the 2-percent annual payment update. so, the payment determine the payment year determination for the 2-percent annual payment update for fiscal year

2018 is dependent on data that's collected from october 1st, 2016, through december 31st, 2016. the data submission deadline, that is the last opportunity you have to review and correct any data mistakes and to just do your own internal qa on your data, is may 15th, 2017. so you have 4 months from the end of the quarter to review and correct any of your data in qies asap. so that's all my presentation for today for this section. i'll be joining you again to discuss our website. so right now i'd like to turn this over to laura smith from rti international, and laura, please take

it away. laura smith: thank you sharon. thank you for that introduction. so in this section of presentation we'll be reviewing the quality measures that have been finalized in the fiscal year 2016 and the fiscal year 2017 pps final rules. this first segment will focus on the claim the assessment-based measures that were finalized in the fiscal year 2016 final rule, which will affect the fiscal year 2018 payment determination. i just want to preface the next set of slides, just that, these will be

fairly high-level descriptions of the measures. throughout we'll be naming places where you can go and get additional resources. sharon already mentioned one website link, and then when sharon returns she'll walk you through some more of those resources that are available online. and so, again, this the section here with the assessment-based measures that were finalized in fiscal year 2016, you can go specifically to this pdf file to get details that were released with that rule about the specifications of the measures and details about their development.

so, moving on to the first measure that we're talking about today, on slide 17, is this is the application of the percent of residents experiencing one or more falls with major injury. before i get into details about the measure i just want to pause to talk a little bit about those first few words in the title, which may or may not be may seem a little bit strange to folks. and so it's this "application of." and so many of you may be familiar with the long-stay measure, which is currently publicly reported on nursing home compare. that applies to nursing home residents who've stayed in the nursing home for 101 or more

days. that long-stay measure, which captures the percent of long-stay residents experiencing one or more falls with major injury during their episode of nursing home care has been endorsed by the national quality forum. the snf qrp measure is a modification of that long-stay measure where the specifications have been modified to apply to the snf's medicare part a population. so you can just stay on slide 17; i'll let you know when the next one goes, and just so folks know i'm doing this presentation remotely, and

thanks, leah, for advancing the slides. oh, actually okay, sorry, it's slide 18. as sharon said, we're this is our first webinar, and so we apologize for the hiccups. so, to resume what i was saying, the snf qrp measure is a modification of that long-stay measure and applied to the snf medicare part a population. so therefore we're calling this snf qrp measure an application of that percent of residents experiencing one or more falls with major injury long-stay measure. okay. so then in the subsequent slides i will talk some more about the details in the measure, including its purpose and how we define a

medicare part a stay, and the population for the snf qrp measure. so moving on to the next slide. this cross-setting measure is intended to meet the requirements of the impact act domain of major falls. and it reports the percentage of medicare part a stays where one or more falls with major injury occurred during the snf stay. major injury is defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma. so, as i promised, with the next slide, i am going to talk i'm now going to talk about the definition of medicare part a stay. so, the

medicare part a stay is defined as the period of time between a start the start of a resident's medicare part a covered stay and the corresponding end date for that stay. the start and end date for a medicare part a stay are identified by a 5-day pps assessment and an associated discharge. and that may be a standalone part a pps discharge or a part a pps discharge combined with an obra discharge. the start date for a medicare part a stay is derived from the item a2400b, which is labeled as the start date of the most recent medicare stay.

as for the end date, for a resident who is not discharged from the nursing home at the end of their medicare-covered services, they will have a standalone part a pps discharge. and the end date for their medicare part a stay will be derived from a2400c. for residents who are physically discharged on the same day or the day after the end of their medicare-covered services, the end date of their medicare part a stay will be the same as the discharge date obtained from their obra discharge or the item a2000. note that there is an important difference from the nursing home

episodes that are used as the unit of analysis for the nursing home quality initiative measures. for the measures reported currently on nursing home compare, if a resident's initial pps stay ends with a discharge with return anticipated to the nursing home, that resident's episode will continue if the resident reenters the same facility within 30 days. so for this example i'm describing, if a resident discharge with return anticipated reenters the facility and is still eligible for their snf benefit, this would be counted as a single episode. but, it would be

counted as two medicare part a stays, because the discharge with return anticipated would mark the end of the first medicare part a stay, and the 5-day pps completed at reentry would mark the beginning of a new medicare part a stay. moving on to more details about the falls measure, this slide gives an overview of the construction of that measure, and it takes the form of a proportion with a numerator and a denominator. i'm going to read through the equation, and then we'll walk back through to explain more thoroughly what it means.

so the numerator is defined as the number of resident medicare part a stays with one or more look-back scan assessments that indicate one or more falls that resulted in major injury. the denominator is defined as the number of resident medicare part a stays with one or more assessments that are eligible for a look-back scan, except those with exclusions. so stated more simply, the numerator of the measure is the number of medicare part a stays where a resident experienced at least one fall that resulted in major injury. and i'll talk about what we even mean by

a look-back scan in just a moment. so the denominator of this measure is the number of completed medicare part a stays with the end date occurring during that same time period as the numerator and excludes selected stays based on our exclusion criteria that i'll describe shortly. so note that the unit of analysis for this measure is the resident medicare part a stay rather than the resident. and i'm making this distinction because a resident could actually be counted more than once in this measure if they have more than one completed medicare part a

stay during the 12-month measure time period. this also means that a resident could be counted more than once in the numerator. so, for example, if a resident had two completed medicare part a stays and an injurious fall happened in each of those stays so i'm talking about two separate injurious falls, one occurring in each stay that resident would be counted twice in a numerator, one for each stay that had an injurious fall occurring during it. okay, so then returning to that term i used in the denominator that you see on the slide, that look-back scan. so what that is is that all

assessments completed during a resident's medicare part a stay will get reviewed for information about whether or not there was an injurious fall. a look-back scan of all assessments completed for the resident's medicare part a stay is necessary in order to get a picture of that full stay, because if a resident has an interim assessment between their 5 day pps assessment and the end of their medicare part a stay, that item on the discharge will only look-back to the interim assessment. so that would mean, if we only look back to the interim assessment we'd be

blind to what happened between that 5 day assessment and the interim. so by doing a look-back scan where we look at all of the assessments during that stay, we would be able to capture any injurious falls that might have occurred between the 5 day and the interim assessment. okay, and that this next slide shows the assessments that are eligible for inclusion in the look-back scan. i won't go into detail on that. and we'll move along to the next slide where we have a description of the measure exclusion. so a resident medicare part a stay would be excluded if none of the assessments that are included in the look-back

scan has a useable response for the items that indicate the presence of a fall with major injury during the selected time window. in other words, the stay will be excluded if information on falls with major injury, which is j1900c, is missing on all assessments used during a resident's stay during the selected time period. so, put this another way, a resident must have at least one assessment in their medicare part a stay with a valid response to the item reporting information on falls with major injury. and also note that this measure is not risk-adjusted or stratified.

okay. so, now we'll move on to the second measure that we'll be discussing today on the next slide. this is the percent of patients or residents with pressure ulcers that are new or worsened. and i'll give you a similar review of the measure purpose and calculation. so on the next slide, this is a cross setting quality measure that's been adopted to meet the requirements of the impact act domain, skin integrity and changes in skin integrity. and it's intended to encourage pac providers to prevent pressure ulcer development or worsening and to closely monitor and appropriately treat existing pressure ulcers.

so we have an important note on slide 25 slide, sorry, slide 26, excuse me, but we have recently updated the specifications for this measure, and so i encourage you to follow through to the link here for more information, the download section about the modifications to this measure. in short, we did make modifications to address and eliminate some features of the specification that specifically the use of episodes and look-back scans that could result in a systemically higher set of scores for snf relative to other pac settings calculated for the same

measure because inpatient rehab facilities and long-term care hospitals are not using interim assessments in their calculations. moving on to the next slide, again, we're giving you an overview of the measure, and this reflects the revisions to the construction of this particular measure. it is also a proportion with the numerator and denominator. the numerator is the number of medicare part a stays that end during the selected time window that indicate that the resident had a stage 2, 3, or 4 pressure ulcer that was new or worsened since admission to the facility. and the denominator is the count of medicare

part a stays that end during the selected time window except those who meet exclusion criteria. and so, on the next slide, i'm just going to note a little bit about the difference with the new specification. so, where previously all assessments in a resident's episode were reviewed for reports of stage 2 through 4 pressure ulcers that were not present on a or were at a lesser stage on admission, using the look-back scan, so that's the description that you see here in the slide. that process no longer actually applies.

and so, i will go through this next little bit just to a little bit more slowly just to make it clear. so, the new specification is based on admission and discharge information. so we're not reviewing all of the assessments in a resident's episode, as it states here in the slide. because we're using the admission and discharge information, and we don't require a look-back scan of assessments in a resident's stay. the new specification uses the mo 300 items that are coded on the discharge assessment to calculate the measure. so, the new specification looks at the count of pressure ulcers present at discharge by each stage

and uses the present on admission mo 3 items to determine if any of the ulcers counted at discharge were not also present at admission at the same stage. so this is accomplished by, for each pressure ulcer stage subtracting the count of ulcers at discharge that were present on admission from the total count of pressure ulcers at that stage that are present at discharge. if this difference is non-zero, then the resident counted in the numerator is counted in the numerator as having a newer or worsened pressure ulcer.

and this measure only has a couple of exclusions, and this is basically based on data availability. we show them on the next slide. so if data is missing on the items used to calculate the measure or if the resident has only one assessment so there's no separate initial assessment available to derive data for risk adjustment, we exclude that stay. moving on to the next couple of slides, we will talk about risk adjustment. so, risk adjustment is used to account for variation from facility to facility and the medical and functional complexity of snf resident populations. this is in recognition that some residents may be

at higher risk than others for poor outcomes due to their clinical status, independent from the quality of care provided by the facility. risk adjustment is based on resident characteristics. these characteristics, which we call covariates when they're used in risk adjustment, were selected because they are known to put residents at increased risk for skin breakdown or to impact the ability to heal. so, moving to the next slide, we list the specific four resident characteristics or covariates for this measure. and they are limited or more assistance in bed mobility self performance; bowel incontinence, at

least occasionally on the initial assessment; the presence of a diagnosis of diabetes or peripheral vascular disease; and low body mass index on the initial assessment. so moving on to the next slide. i'll talk about the third assessment-based measure that we'll be talking about today. this is the application of percent of long-term care hospital patients with an admission and discharge functional assessment and a care plan that addresses function. this nqf endorsed long-term care hospital measure has been modified for application to the snf medicare part a stay

population. so, therefore you're seeing that same phrase, "application of," in the title of this snf qrp measure. so to the next slide. cms has adopted this measure to satisfy the impact act requirements for cms to specify qms and pac providers to report standardized data regarding functional status, cognitive function, and changes in function and cognitive function. the measure reports the percent of residents with an admission and a discharge functional assessment and at least one goal that addresses function. similar to the last two measures, we have the next slide shows the

construction of the measure, which is also a proportion with a numerator and denominator. shown on slide 34, the numerator is the number of medicare part a covered resident stays with functional assessment data for each self-care and mobility activity and at least one self care or mobility goal. the denominator of the measure is the number of medicare part a stays and then during the same time period as the numerator. for this measure, it's 12 months. so, on the next slide, we're going to talk a little bit about the definition of an incomplete stay. and so, for this measure the design

recognizes that when a resident has what we are calling an incomplete stay, it may be difficult to collect discharge functional status. it may just simply not be feasible. so we'll go into more detail in just a moment about that. but, in the case of residents who have incomplete stay the requirements for the measure are slightly different. so, for a resident with incomplete stays, admission functional status data and at least one treatment goal would be required. but discharge functional status data is not required to be reported.

and so, on this next slide, we talk about in more detail about incomplete stays. and so, residents who have incomplete stays are defined as those residents who have an incomplete stay due to a medical emergency or leave the snf against medical advice or and this is not written on the slide, but you may if you've written them out you printed them out you may want to make a note which is that or any other unplanned discharge. so basically these first two criteria here, the incomplete stays due to a medical emergency or due to a resident leaving against medical advice, those basically get encapsulated into

the category of unplanned discharges. so that essentially we don't the measure does not capture the specific reasons for incomplete stays, but rather the calculation is based on the ao310g type of discharge item, in the cases here listed, if there is a 2 indicating an unplanned discharge, then that resident would be considered as having an incomplete stay. we also add that an incomplete stay is also defined as having a pps part a stay that's less than 3 days. and a resident who dies during their medicare part a stay or the day after the end of their medicare

part a stay will also be considered to have an incomplete stay. and this measure is not risk-adjusted. so moving on to slide 38. this is where we get into the claims based measures that were finalized during the fiscal year 2017 final rule. and so, we can advance to slide 39. so, we can go ahead and i've discussed the contents on this particular slide, so why don't we move on to slide 39, where we'll be talking about the first of the three ... leah nguyen: yes, we're having some technical difficulties, but we're

working on advancing the slides. laura smith: okay. all right, well i'll give you i'll start talking just about the background. i think for at least the first slide in this section you don't need to see it for it to be effective. so, there were three claims-based measures that were finalized in the fiscal year 2017 snf pps final rule. and these three claims-based measures will affect the fiscal year 2018 payment determination as well. i'll note that there was one additional measure which was assessment-based that was also finalized in the fiscal year 2017 rule

this summer, but that measure will be impacting the fiscal year 2020 payment determination. and so we'll not be reviewing that measure in detail during this presentation. oh great, thanks leah. okay, so then we'll move on to the next slide. so, this next slide shows briefly the reporting and payment timelines that i just alluded to for the new measures that were finalized in the fiscal year 2017 rule. the first three measures listed here are those claims-based measures that i was referencing. and they are discharged community, potentially preventable 30-day post-discharge readmissions,

total estimated medicare and total estimated medicare spending per beneficiary. and so initial reporting has not been listed for these three since they're based on claims. so there's no additional new data collection being required of providers for these three measures, but the forth measure that i alluded to earlier, which is the drug regimen review conducted with follow up for identified issues, that is assessment-based, and the initial reporting will start in october of 2018. and that'll impact the fiscal year 2020 payment determination.

okay. so moving to the next slide. here again are some links, this you'll see is the fiscal year '17 specifications, and you can click through for more details using these links. so then the first measure that we're going to talk about is the discharge to community measure. and we can move on to slide 43. so this measure was developed to meet the impact act requirements for resource use and other measures. this claims-based outcome measure assesses the successful discharge to the community from a snf, the successful discharge including no unplanned

re-hospitalizations and no deaths in the 31 days following discharge. so on this next slide we'll pause for just a moment to talk a little bit about the definition of community. so discharge community is determined using discharge status codes on the medicare fee-for-service claim for this measure. and community discharge is defined as discharged to home or self-care with or without home health services. and you can see the specific status codes that are found on the claim that correspond to that discharge to community. and moving to the next slide, as i stated, meeting this claims-based

outcome measure assesses successful discharge to the community. in the next couple of slides i will describe the numerator and denominator definitions for this measure, but i'll just note these are complicated measures, so i do encourage you to consult the specification documents that are linked on slides 10 and 40 for more details. so before i dive into the different components, at the conceptual level the discharge community measure looks at the observed and expected counts of discharges to community for a given snf and shows whether a given snf has a higher rate of discharge to community than expected

based on the characteristics of the residents receiving services from that snf and what we know about the average rates of discharge to community for residents with the same specific clinical characteristics. moving into more specific terms, the denominator for the measure is the risk adjusted expected number of discharges to community for a given snf. this this expected number is the number of community discharges predicted for a set of residents with the same characteristics as that snf that we're looking at, but calculated as though these residents were receiving services from the averageness, rather than the specificness

that we're looking at. then the numerator is the risk-adjusted oh and that's the next slide. the numerator is the risk-adjusted estimate of the number of stays ending with discharge to community which do not have an unplanned readmission to an acute care hospital or ltac in the 31 days post-discharge observation window, and who remain alive during that observation window. so to get that numerator number, we start with observed community discharges for that specific snf we're looking at and adjust those observed discharges based on the resident characteristics

for that facility and controlling for the general effect of the provider independent of any case mix. so then we can take that numerator, which is the risk adjusted observed discharges to community, and then we divide that numerator by the denominator or the expected number of discharges to community for a population. and we basically look to see whether or not that specific snf has higher or lower rates of discharge to community than we expected. so that value that i described, the taking the observed discharges over the expected discharges is a ratio.

and so if the observed community discharges is the same as the expected discharges, the value would be one. if the observed discharges are actually lower than the expected ratio for than expected excuse me that ratio would be less than one. and then logically if the observed discharges for that snf are higher than the expected value then the ratio would be greater than one. so lastly this ratio that i just described is multiplied by the national discharge to community rate to get a standardized rate of discharges to community, which ranges from 0 to 100 percent and that standardized rate of discharges allows for

comparisons across facilities. and then the last slide for this measure, which is note that there are some more details available regarding specific measure exclusions as well as the risk adjustment that i referenced, you can look at the slides, the links that are found on slides 10 and oh, excuse me 11 and 14. thank you. okay. so then moving to slide 48, we move on the second claims-based measure, and this is the potentially preventable 30-day post-discharge readmission measure for snf qrp, and it is another measure that was

adopted to satisfy the impact act requirement for resource use and other measures. so this measure reflects the rates of residents who are readmitted to a short-stay acute care hospital or an ltac with a principle diagnosis considered to be unplanned and potentially preventable. so we'll talk briefly on this next slide, 50, about the definition of the potentially preventable readmission. so this potentially preventable readmission, and based on the principle diagnosis on the readmission claims, with some exceptions, the measure specifications that are posted

publicly include more detail regarding the process of developing this definition as well as lists the specific conditions. but generally, just to give you a feel for our process, the measure was built in part on prior research, including the agency for healthcare research quality as prevention quality indicators or pqi as maintained in the text in the slide. at a high-level, the final set of potentially preventable conditions included in this measure were identified and grouped on the following clinical rationale, which are inadequate management of chronic conditions, inadequate management of infections,

inadequate management of other unplanned events, and inadequate injury prevention. excuse me, let me say that last one. i sort of swallowed the last word. that last one was inadequate injury prevention. moving to the next slide. we'll talk briefly about the construction of the measure that's conceptually similar to the discharge community measure that i just talked about where we're basically looking at observed and expected outcomes. in this case, we're looking at observed and expected counts of readmissions for a snf. and, looking at whether

or not a snf has a higher rate of readmissions than expected based on the characteristics of the residents receiving services in that specific snf than what we know about the average risk for readmissions for residence with snf clinical characteristics. moving to more specific terms again. the denominator is the risk-adjusted expected number of readmissions for a given snf. this number is the number of readmissions predicted for a set of residents with the same characteristics as the snf we're looking, at but calculated as though these residents were receiving services from the

average snf rather than the specific snf we're looking at. and you can stay on the same slide that you've got up. so moving to talk about the numerator. that numerator is the that numerator is the risk-adjusted estimate of the number of unplanned readmissions that occur within 30 days of pac discharge. and so, to get that number, we have a similar procedure as i described for the discharge community, so we start with an observed count of readmissions for the specific snf and then we adjust those observed readmissions based on the resident characteristics and we control for the general effect of the provider.

and then the next step is, is we take the observed count of readmissions, which is the numerator. we divide that by the denominator, which is the expected number of readmissions, and look at that ratio to determine whether or not a particular snf has higher or lower rates of readmissions than expected. so the and this is a ratio as as described in the next, in the discharge community section. and similar to the discharge community measure, the ratio is multiplied by the national readmission rate to get a standardized rate of readmissions ranging from 0 to 100 percent.

okay. so lastly, i'll give an overview of the third claims-based measure, the medicare spending per beneficiary pac snf resource use measure. moving to slide 54. cms has adopted this measure to satisfy the impact act requirements for resource use and other measures like the similar to the other two claims-based measures. and this measure evaluates snf providers' resource use relative to the resource use as a national median for snf. it has a similar general structure to the discharge community and

potentially preventable readmissions measures. in this case we're looking at whether or not the we're looking at the observed and expected medicare spending per beneficiary for a snf, and whether or not that snf has a higher rate of spending than expected or a lower based on the characteristics of the residence receiving services from that snf and what we know about average spending for residents with specific clinical characteristics. so, the denominator for this measure is the episode-weighted national median of spending across all snf providers.

and moving to slide 56. the numerator is the average risk-adjusted stay per-episode spending across all episodes for the provider. excuse me, all stays for the provider, this, too, should be a stay-based measure for snf. and this measure is also standardized using the national average spending for all snf providers. at this point, i will hand the floor back over to sharon lash. sharon lash: okay. thank you, laura. i really appreciate your in-depth coverage of the quality measures and how they're structured. so what i'm going to do now is present, just briefly, the snf qrp resources

available to the providers so that you know where to go to find information when you need it. and we can advance to the next slide, number 58. the snf qrp webpage, as i mentioned, can be accessed from the nursing home quality initiative page at the bottom link that indicates the snf quality reporting program and with parenthesis impact act of 2014. so, the training materials, fact sheets, and other resources for providers are all located in the various menus in this page. next slide please. what i'm going to do is just go through briefly the

screenshots that we have of the quality reporting program pages. and just give you an idea of how we structured it. but at the top this particular slide breaks out the general information. and you can see the different links to this. so i'm not going to go into this in great detail. you can review these slides yourselves in your own time. but this is just to give you a high level kind of introduction to our webpage. next slide please. so the spotlights and announcements page is probably where you should frequently check in to check whether we're updating any

specifications, any manuals, trainings, open door fora any kind of announcements that are relative to the quality reporting program. next. this one is a very important link to the measures and technical information. we are going to break this out next year into measures and we're going and then technical information because there is going to more technical information associated with public reporting and other matters. so but right now, the this section is very important that it identifies all the quality measure. we need to update it, obviously, to

include the new measures that have been finalized in the 2017 rule. next. training is another place you can go to retrieve the various training slides that were produced in our onsite provider trainings, and these trainings as well. so, come to this site to retrieve the training powerpoint productions that you can adapt and use for your own purposes for training your own staff and facilities. next. faqs are under construction, and these are being compiled, and we're doing some quality assurance to make sure that we are answering all of your questions consistently and thoroughly. so, for example, we

are doing our final review of the questions that we received in our atlanta training. i apologize for the delay, but we have numerous sources of questions and answers coming in, and we want to make sure that we are answering to really meet your needs. so, we do have a help desk as well. and so we're trying to cross-reference questions there with the questions that come in in our training. so please bear with us. but watch this site for questions and answers that have been received on in the provider trainings, on the onsite provider trainings, and during some of these calls.

next. the data submissions deadlines will be developed as well. but i think that's currently is available on the quality reporting program measures and technical information site as well. next please. and so the reconsiderations and exception extension will be developed. but we just want to let you know that we are going to be developing the information and refining that. so certainly when you have a reconsideration of a decision that was made based on a calculation of your measures that you object to or you feel doesn't represent what your data really represents, implies, you can go to the reconsideration

process. then exemptions are if you have any kind of natural disaster or data submission interruption due to natural causes. and those will be identified more clearly. those procedures and policies will be identified more clearly on this page in the future. next please. and so, the help the quality reporting help is where you can find the various help desk items and numbers, phone numbers and websites. next please. so this is the primary help desk,

snfqualityquestions@cms.hhs.gov, for general questions about the snf qrp reporting requirements, reporting deadlines, and snf qrp quality measures. i would like to thank our presenters and also thank you for participating in today's mln connects event on the snf quality reporting program. have a great day everyone. thank you for viewing this presentation. the information presented was correct as of the date it was recorded. this presentation is not a legal document. official medicare program legal guidance is contained in the

relevant statutes, regulations, and rulings.