Quality Measures

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What's New

September 21, 2023

Public Reporting Timeline for NHQI Measures Impacted by the MDS 3.0 G-GG Transition

Effective October 1, 2023, MDS Section G: Functional Status will be replaced with Section GG: Functional Abilities and Goals. This transition will significantly impact the specifications of the following Nursing Home Quality Initiative (NHQI) quality measures (QMs):

• Percentage of Residents Who Made Improvements in Function (Short Stay)
• Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay)
• Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)
• Percent of High-Risk Residents with Pressure Ulcers (Long Stay)
• Percent of Low-Risk Residents Who Lose Control of Their Bowel and Bladder (Long Stay)

To address the impact of this Section G to GG transition on the 2024 Nursing Home Care Compare public reporting schedule, CMS will freeze (hold constant) the aforementioned QMs on Nursing Home Care Compare in April 2024. In October 2024, CMS will replace the Percentage of Residents Who Made Improvements in Function (Short Stay) measure with the new Discharge Function Score measure which was finalized in the FY2024 SNF PPS Final Rule for use in the SNF Quality Reporting Program (QRP) and the SNF Value Based Purchasing (VBP) program. [NR(1] [A2] The remaining four measures will continue to be frozen until January 2025 while the data for the equivalent measures are collected.  

Please see the Updates to Nursing Home Care Compare Staffing and Quality Measures QSO memo for more information.

September 20, 2023

MDS 3.0 QM User’s Manual Version 16.0– Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V16.0 is now available. The MDS 3.0 QM User’s Manual V16.0 contains detailed specifications for the MDS 3.0 quality measures and includes a Notable Changes section that summarizes the major changes from MDS 3.0 QM User’s Manual V15.0.

Major changes to the manual involve the re-specification and replacement of QMs that use items impacted by the MDS transition from version 1.17.2 to version 1.18.11, effective October 1, 2023 (i.e., Section G items are replaced by Section GG items).

The MDS 3.0 QM User’s Manual V16.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V15.0 has been moved to the Quality Measures Archive webpage.

One file related to the MDS 3.0 QM User’s Manual has been posted:

1. MDS-3.0-QM-USER'S-MANUAL-v16.0.pdf contains detailed specifications for the MDS 3.0 quality measures, as well as the Quality Measure Reporting Module Table that documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. MDS-3.0-QM-USER'S-MANUAL-v16.0.pdf is available under the Downloads section of this webpage.

The current nursing home quality measures are:

Short Stay Quality Measures

• Percent of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
• Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
• Percent of Residents Who Newly Received an Antipsychotic Medication
• Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
• Percent of Residents Who Made Improvements in Function
• Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
• Percent of Residents Who Received the Seasonal Influenza Vaccine*
• Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
• Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
• Percent of Residents Who Received the Pneumococcal Vaccine*
• Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*

* These measures are not publicly reported but available for provider preview.

Long Stay Quality Measures

• Number of Hospitalizations per 1,000 Long-Stay Resident Days
• Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
• Percent of Residents Who Received an Antipsychotic Medication
• Percent of Residents Experiencing One or More Falls with Major Injury
• Percent of High-Risk Residents with Pressure Ulcers
• Percent of Residents with a Urinary Tract Infection
• Percent of Residents who Have or Had a Catheter Inserted and Left in Their Bladder
• Percent of Residents Whose Ability to Move Independently Worsened
• Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
• Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
• Percent of Residents Who Received the Seasonal Influenza Vaccine*
• Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
• Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
• Percent of Residents Who Received the Pneumococcal Vaccine*
• Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
• Percent of Residents Who Were Physically Restrained
• Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
• Percent of Residents Who Lose Too Much Weight
• Percent of Residents Who Have Symptoms of Depression
• Percent of Residents Who Used Antianxiety or Hypnotic Medication

* These measures are not publicly reported but available for provider preview.

Quality measure specifications are available in the QM Users’ Manual download file, which can be found under the Downloads section below. A sub-group of quality measures are incorporated into the Five-Star Quality Rating System and used to determine scoring for the quality measures domain on Nursing Home Compare.