Skilled Nursing Facility (SNF) Quality Reporting Program Measures and Technical Information

The IMPACT Act of 2014 requires the Secretary to implement specified clinical assessment domains using standardized (uniform) data elements to be nested within the assessment instruments currently required for submission by LTCH, IRF, SNF, and HHA providers. The Act further requires that CMS develop and implement quality measures from five quality measure domains using standardized assessment data.  In addition, the Act requires the development and reporting of measures pertaining to resource use, hospitalization, and discharge to the community. Through the use of standardized quality measures and standardized data, the intent of the Act, among other obligations, is to enable interoperability and access to longitudinal information for such providers to facilitate coordinated care, improved outcomes, and overall quality comparisons.  

What are the SNF quality reporting measures?

Measures currently adopted and finalized for the SNF QRP are listed below. Data for the SNF QRP measures are collected and submitted through two methods:

  • Minimum Data Set (MDS) 3.0
  • Medicare Fee-For-Service Claims

The following measures are submitted using the MDS 3.0 unless noted otherwise: 

SNF QRP Measure #1: Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)

This measure was finalized in the FY 2016 SNF PPS Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46440). Data collection for this measure began 10/1/2016.

SNF QRP Measure #2: Application of Percent of LTCH Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631)

This measure was finalized in the FY 2016 SNF PPS Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46444). Data collection for this measure began 10/1/2016.

SNF QRP Measure #3: Medicare Spending Per Beneficiary-PAC SNF QRP

This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52014). This is a claims-based measure and no additional data need to be submitted by the SNF.  

SNF QRP Measure #4: Discharge to Community-PAC SNF QRP 

This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52021). This is a claims-based measure and no additional data need to be submitted by the SNF.   

SNF QRP Measure #5: Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP

This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52030). This is a claims-based measure and no additional data need to be submitted by the SNF. 

SNF QRP Measure #6: Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP

This measure was finalized in the FY 2017 SNF Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52034). Data collection for this measure began 10/1/2018. 

SNF QRP Measure #7: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36572). Data collection for this measure began 10/1/2018.

SNF QRP Measure #8: Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36578). Data collection for this measure began 10/1/2018.

SNF QRP Measure #9: Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36580). Data collection for this measure began 10/1/2018.

SNF QRP Measure #10: Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36583). Data collection for this measure began 10/1/2018.

SNF QRP Measure #11: Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36584). Data collection for this measure began 10/1/2018.

Measures Removed from SNF  

  1.  Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)

This measure was finalized in the FY 2016 SNF PPS Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46433). Data collection for this measure began 10/1/2016.  As finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on 08/04/2017 (82 FR 36572), this measure was replaced in the QRP by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 SNF QRP.

For more detailed information on data collection and submission deadlines, please refer to the SNF Quality Reporting Program Data Submission webpage. For more information on the SNF QRP Quality Measure specifications, please reference the Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual on the Skilled Nursing Facility (SNF) Quality Reporting Program Measures and Technical Information webpage. For detailed information on MDS 3.0 Item sets and coding guidance, please reference the MDS 3.0 RAI Manual webpage on the Nursing Home Quality Initiative website.

SNF QRP Future Measure Development:

Project Title: Development and Maintenance of Quality Measures for Skilled Nursing Facility Quality Reporting Program (SNF QRP)

Dates:

The Call for TEP nomination period closed on February 15, 2019.

The TEP met on May 9, 2019.

Documents:

The TEP Summary Report and the TEP Membership List are posted below in the download section.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop and maintain quality measures for the SNF QRP. The contract name is Development and Maintenance of Symptom Management Measures. The contract number is HHSM-500-2013-13015I. As part of its measure development process, RTI International convenes groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

Project Objectives:

Healthcare-associated infections are an important public health and patient safety issue. Under the Quality Priority of “Making Care Safer by Reducing Harm Caused in the Delivery of Care” is the Meaningful Measure Area of Healthcare Associated Infections. To focus on the high priority domain and fill an important gap of quality measurement in this area, this project is aimed to develop a claims-based measure of healthcare-associated infections in skilled nursing facilities.

The purpose of this TEP is to inform the direction and development of a claims-based measure of healthcare-associated infections in skilled nursing facilities.

SNF QRP Measures and Technical Information Additional Resources:

Please also visit the CMS Post-Acute Care Quality Initiative website for more information related to cross setting quality measures and quality initiatives:

CMS Post-Acute Care Quality Initiative website

 

Information on the IMPACT Act of 2014 can be found at:

http://www.gpo.gov/fdsys/pkg/BILLS-113hr4994enr/pdf/BILLS-113hr4994enr.pdf

https://www.govtrack.us/congress/bills/113/hr4994

/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality- (PDF)

Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-Measures.html.

For SNF Quality Reporting Program comments or questions:  SNFQualityQuestions@cms.hhs.gov 

Updates:

March 05, 2019

CMS is updating the Quality Improvement and Evaluation System

Starting in March, the Quality Improvement and Evaluation System (QIES), Certification and Survey Provider Enhanced Reports (CASPER) and Automated Survey Processing Environment (ASPEN) will undergo a series of modernizing enhancements. Once updated, the system will be called the Internet Quality Improvement and Evaluation System (iQIES). The iQIES system will not change how providers currently submit data to CMS.

The new enhancements in iQIES are based on user research and testing and feature a human-centered design and agile development practices. CMS is phasing in the iQIES system beginning with Long Term Care Hospitals (LTCH). Several updates to the QIES- Assessment Submission and Processing (ASAP) system are also planned. The Cloud-based solutions will also make it easier for users to receive support and use the system.

iQIES Details:

  • Users will no longer need a virtual private network (VPN) or CMSNet to access the system. iQIES is Internet-facing and maintains the latest system architecture and security standards.
  • System enhancements support flexible and user-friendly data reports for providers, allowing them to use real-time data for care planning as well as quality monitoring and improvement.
  • Users can access important information for work anywhere, at any time, on mobile devices, laptops, and tablets.

CMS will be sharing more information about iQIES such as onboarding, stakeholder engagement opportunities, training, and general updates soon!

If you have questions, please contact our service desk at: help@qtso.com or by phone: 800-339-9313.

 

SNF Quality Reporting Archives

Page Last Modified:
12/06/2019 02:43 PM