5 star rating system webinar final

Best Practice Webinar Series by DartChart, Inc.

Understanding the 5-Star Rating Program for Nursing Home CompareUsing Best Practice Charting to Increase your Facility’s Rating

Presented by: Kevin Miller

Confidential And Proprietary www.dartchart.com

http://www.dartchart.com/Default.aspx

Session Agenda• Welcome and Program Overview• Speaker Credentials• Overview of the 5-Star Rating System• Charting as a best practice• How implementing Best Practices can increase your score• DartChart technology & corporate overview• Session Q&A


"More than three million Americans rely on services provided by a nursing home at some point during the year," said Kerry Weems, CMS acting administrator. "This should help consumers in narrowing their choices, but nothing should substitute for visiting a nursing home when making a decision," Weems added.


Speaker BioMarilyn Burlenski, R.N., B.S.N.• President and CEO – Connecticut Alliance for Long Term Care• Nurse Monitor – State of Connecticut, Department of Public Health• 25 Years RN experience with a focus on SNF/PPS Consultation/MDS Consultation• Medical Record Documentation Consulting• Operations Management Consulting

Session ModeratorKevin Miller, BS Psychology• 16 years medical technology and Healthcare software experience• 5 Years Experience consulting with Hospitals, SNF/LTC and Pharmaceutical MFG with HHS-OIG Healthcare

Compliance Regulations• BS Psychology, Albright College




Overview of CMS’ Rating System• Designed by CMS with 3rd-party feedback

from consulting firms and consumers• Market-driven solution• Activated in December, 2008• Consumer-facing web solution • Overall rating based on 3 metrics for

performance measures– Health Inspections– Staffing (RN broken out)– Quality Measures – based on MDS

• Contains over 200,000 records for health inspection alone



Why is it important…• Public scrutiny is at highest level• Baby Boomers getting ready to retire• Healthcare technology and electronic

information is changing rapidly• On the internet – no one can hide• Creation of a market-driven environment• Competition +regulation + litigation risk makes

it more difficult to provide care and be profitable



Customer Facing – Drives competition at the local level


How the rating system works• Total of 5-stars in rating • Higher scores correlate to lower rating in each of the three

rating categories• Weighted scores based on state and national averages• Health Inspections – Based on state-level inspections

– Deficiencies rated by scope/severity– Need for Repeats visits to validate correction

• Staffing – based on 2 measures; RN Hours and Total Staffing hours (RN, LPN and CNA)– Based on CMS Staff Time Measurement Studies

• Quality Measures – Based on 10 of 19 QM’s posted on Nursing Home Compare– Include 7 long-stay and 3 short-stay metrics


Almost one in four (22%) earned the lowest rating of one star. At the other end of the spectrum, about one in 10 (12%) earned five stars. The remaining 66% of participating facilities were distributed fairly evenly among the two, three and four star rankings.



Rating Methodology – Health Inspection• Based on Federal regulations, national

guidance and federally specified survey process

• Calculated from points assigned to deficiencies

• Variation exists between States• 5-Star System based on relative

performance within a state• Facility performance based on ratings using

the following criteria• Top 10 % receive 5-star• Middle 70 % receive 2-3-4 stars• Bottom 20% receive 1-star rating• Trying to measure facilities at the state

level• An artificial bell curve?



Rating Methodology – Health Inspection• Scoring rules based on health inspection

results and the need for repeat visits• For health inspection result, points based on

scope and severity• If scope/severity impact quality measures,

additional points are assigned• Repeat visits – assigned for 2nd and beyond

based on need for revisit• Most recent health inspections are

weighted higher than previous inspections



Rating Methodology – Staffing Domain• Correlation between RN staffing level and

resident outcomes• Rating for this domain based on 2 measures

• Total nursing hours per resident day• RN Hours per resident day

• Data Source - CMS form CMS-671 (Long Term Care Facility Application for Medicare and Medicaid) entered into OSCAR

• The specific fields that are used in the RN, LPN, and nurse aide hours calculations are• RN hours: Includes registered nurses (tag number

F41 on the CMS-671 form), RN director of nursing (F39), and nurses with administrative duties (F40).

• LPN hours: Includes licensed practical/licensed vocational nurses (F42)

• Nurse aide hours: Includes certified nurse aides (F43), aides in training (F44), and medication aides/technicians (F45)



Scoring Rules– Staffing Domain• 2 Staffing measures are given equal weight • RN Staffing and total staffing• Total staffing score based on the combined

score for each• To receive a five-star rating, facilities must

meet both RN and total nursing thresholds from the CMS Staffing Study.



Rating Methodology – QM Domain• Developed for the MDS-based indicators for

quality of care• Facility rating based on 10 of 19 of the QM’s

posted in nursing home compareLong-Stay Residents: • Percent of residents whose need for help

with daily activities has increased (9.1)• Percent of residents whose ability to move

in and around their room got worse (9.3)• Percent of residents who had a catheter

inserted and left in their bladder (5.2)• Residents with a urinary tract infection (6.1)• Residents who have moderate to severe pain (8.1)• Percent of high risk residents with pressure sores (12.1)• Residents who were physically restrained (11.1)

Post-Acute Care (Short-Stay Residents):• Short-stay residents with delirium (13.1)• Short-stay residents who had moderate to severe pain (13.2)• Short-stay residents with pressure ulcers (13.3)



Scoring Rules– QM Domain• Long stay measures are included if they are

calculated for +30 assessments • Short stay measures are included if they are

calculated for at least 20 assessmentsMissing Data• For facilities that have 4 of 7 QM measures,

statewide averages are used for missing QM measures

• Facilities that receive a QM rating are in one of three categories: • They have points for all of the QMs.• They have points only for the 7 long-stay

QMs (long-stay facilities). • They have points only for the 3 short-stay

QMs (short-stay facilities) • No values are imputed for nursing homes

with data on fewer than 4 long-stay QMs and fewer than 2 short-stay QMs. No QM rating is generated for these nursing homes



Overall Rating – Composite MeasureBased on the five-star rating for the health inspection domain, the direct care

staffing domain and the MDS quality measure domain, the overall five-star rating is assigned in five steps as follows:

Step 1: Start with the health inspection five-star rating.

Step 2: Add one star to the Step 1 result if staffing rating is four or five stars and greater than the health inspection rating; subtract one star if staffing is one star. The overall rating cannot be more than five stars or less than one star.

Step 3: Add one star to the Step 2 result if quality measure rating is five stars; subtract one star if quality measure rating is one star. The overall rating cannot be more than five stars or less than one star.

Step 4: If the Health Inspection rating is one star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings.

Step 5: If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum Overall Quality rating is three stars.



How Charting can impact your rating

Charting Best Practices - Accuracy of data One of the primary drivers for skewed scores is Copy-Cat charting

• Charting is typically manual documentation on a monthly flow sheet

• Data copied from one shift to the next or one day to the next can dramatically impact and skew your CMS data

• Can result in both revenue loss and “bad” data for 5-star rating scores

• Best Practice – eliminate copy-cat charting by “masking” the previous shifts entry


How Charting can impact your ratingCharting Best Practices - Care Plan Compliance• Derived from MDS items• Ensuring data is in the system and accurate• Deficiencies for not adhering to Care Plan• Ensuring care plan adherence through best practices

– 7-day trend reports– Manual data entry eliminated– Managerial intervention– Direct care compliance report provides verification of form

completion in real time.– Compliance report provides management oversight of

compliance/accuracy at any given moment.– Administrative compliance report provides oversight in real time



How Charting can impact your rating

Charting Best Practices – Natural Language Charting Cues• MDS uses verbal cues, not Natural Language• Can be confusing making it difficult for CNAs to understand• DC’s WebForms ADL format makes it easier for CNAs to understand ADL

language• Talk Touch and Take the Weight

– T-T-TW provides language familiar to CNA level staff and readily relates to ADL assistance level tasks. Much easier language for the staff and helps translate what they are doing with the residents

– C.N.A understanding translates into accurate data on ADL assistance levels provided to the resident.



How Charting affects your rating Charting Best Practices – Data Integrity• Garbage in = Garbage out• Direct reflection on MDS• Impact on Finance and Rating; Facility

viability• Best practices can halt problems before

they begin



Dart Chart Supports a Best Practice Model• Designed for Best Practice model• Automates DNS and Administrative oversight• Supports CNA understanding of ADL language • Trend reports spot problems before MDS

submittal• Doesn’t allow for copy-cat charting


78%

12%10%

13%

58%

29%

0%

20%

40%

60%

80%

100%

CMS Study 3YRS

DaRT ChartUsers 3 YRS

5 Stars4 Stars3 Stars and under

DartChart best practice users versus CMS metrics


About DartChart Systems, Inc• Founded in 1997 – HQ, Milwaukee, WI• Electronic charting solution for SNF/LTC• Solution supports the entire MDS charting process• Reimbursement Optimization technology – directly impacts facility revenue• Only charting solution that bases its fees on revenue increases – shared

risk/reward pricing model




74%

14%12%

66%

33%

0%

20%

40%

60%

80%

100%

CMS Study 3YRS

DaRT ChartUsers 3 YRS

5 Stars4 Stars3 Stars and under

Questions & Next Steps• Q&A Session• Copy of today’s materials• Summer Education Series – CEU

Programs beginning soon• Online Demonstration of

DartChart

Thank you for joining us!www.dartchart.com


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