The Five-Star Challenge: Understanding and Communicating

Contributed by Jennifer Gross, PointRight, THCA Business Member

Spring is a season of change…and Skilled Nursing Facility (SNF) providers are dealing with more change than they expected! Effective April 24^th, CMS released the long-anticipated updates (or as CMS called it in their March 5^th memo, “improvements”) to Five-Star and Nursing Home Compare. These changes impacted all three Five-Star domains, and many SNFs found that their star ratings changed overnight. We have grappled with changes to Five-Star in the past, and with each change comes the challenge of helping residents, families, and referring partners understand why the stars have shifted. Here are some key points to help you meet this challenge:

Health Inspections

As anticipated, the Health Inspection (or Survey) domain was “un-frozen” to include surveys from on or after the November 28, 2017 transition to the new CMS survey protocol. For the last year and a half, SNFs have been in the dark as to how their most recent standard and complaint surveys would impact their star ratings. Have you noticed a difference in the survey process that is affecting scope and severity? You may not be alone.

An unexpected change: Special Focus Facilities (SFF) now have no star ratings for Overall and all three domains. According to CMS’ April SFF list, there are currently five SFFs in Texas, and one facility has graduated from the program. If you are one of those five facilities, unfortunately your star ratings have disappeared from view.

Key points:

The most recent survey cycle (Survey Cycle 1) will continue to hold 50% of the weight of your Health Inspection star rating. Review your most recent standard survey as well as any complaint surveys within the last 12 months, and be prepared to discuss your plan of correction for any deficiencies.
If your facility is an SFF, it’s up to you to keep track of any deficiencies and their scope and severity. Knowing the weighted deficiency points (use the table on page 3 of the Five-Star Technical User’s Guide will help you track your status. Also, this will help you demonstrate your improvement to your families and community, as well as what your star rating is expected to be once you graduate.

Staffing

The changes to the Staffing domain had a significant impact on SNFs that are challenged with their RN staffing levels. With increased staffing thresholds for RNs, as well as lowering the 1-star rating threshold for days with no RN staffing reported from seven days in a quarter to four, we have seen an increase in the number of facilities with 1- or 2-star Staffing ratings.

Key points:

If you have discovered inaccuracies in your Payroll-Based Journal (PBJ) reporting, be prepared to explain the cause (such as inaccurate job codes or under-reporting agency nurses) and your plan to correct this next quarter.
If you have RN staffing challenges, be proactive in communicating your plan, whether it is flexing RN weekend coverage, job postings, or investing in your nurses through LPV/LVN to RN programs. This will show your commitment to providing the best care for your residents, as well as supporting your community’s labor market.

Quality Measures

The change that has had the most unexpected impact was in the Quality Measures (QM) domain. In addition to adding two new claims-based Long Stay QMs, removing Physical Restraints, and reporting separate Short Stay and Long Stay ratings, the point thresholds for each star level were re-calibrated to apply more weight to QMs with what CMS calls the “greatest opportunity for improvement”. What resulted was a significant drop in the number of SNFs with 5-star QM ratings. This also contributed to the drop in many SNFs’ Overall ratings due to losing the “bonus” QM star.

Key points:

Focus your QAPI team on measures with the biggest opportunity for improvement. For example, if your challenge is in the claims-based QMs, focus on your care transitions through collaboration with your home health partners or reducing Long-Stay Emergency Department transfers. Whatever your focus, communicate and celebrate your improvement through your social media and community events.
While CMS has touted the new Short-Stay and Long-Stay ratings as providing better information for consumers, the change may be confusing to your families and community. The important point to communicate is that you haven’t changed the care you provide or the services you offer; the change is because of the change to the rating system itself.

That last point applies to all the changes to Five-Star. Your facility, your residents, and your staff did not change one bit between April 23^rd and April 24^th. While this change may be worrying to some providers, you can use it as an opportunity to find areas to improve, and help your families and referral partners understand the good care you provide – no matter the measuring stick!