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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 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 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

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

Updates:

May 22, 2018

The SNF QRP Table for Reporting Assessment-Based Measures for the FY 2020 SNF QRP APU is now available for download. This table indicates the MDS data elements that are used in determining the APU minimum submission threshold for the FY 2020 SNF QRP determination.

 

SNF Quality Reporting Archives

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