Nursing home & post-acute quality
Nursing home quality built on the MDS, the floor and the physician team
Star ratings, quality reporting and value-based purchasing all draw on the same daily work: accurate MDS assessments, safe care, timely physician involvement and good transitions. We help facilities and the physician groups that follow their residents improve that work together.
- Care Compare Five-Star
- MDS quality measures
- SNF QRP and SNF VBP
- QAPI
Who it's for
Built for the teams that run this program
Skilled nursing and long-term care facilities
Administrators, directors of nursing and MDS coordinators who want a clear view of which measures move their ratings and how to improve them.
Physician and NP groups that follow residents
Groups providing attending and medical director coverage who want shared protocols with the facility and better transitions with hospitals and primary care.
ACOs and value-based contract holders
Organizations whose post-acute spending and readmissions affect their benchmark or shared savings.
Design & launch
How we design and launch it
We start with the facility's own data and the people on the floor.
- 1
Quality baseline
Care Compare ratings, MDS quality measure reports, QRP and VBP feedback reports, and survey history, reviewed together.
- 2
Priority measures
Two or three measures with the most room to improve and the clearest link to resident outcomes, chosen with leadership.
- 3
Workflow assessment
We observe admissions, change-of-condition calls, MDS coding, medication review and discharge planning where they happen.
- 4
Shared protocols
Facility and attending practice agree on change-in-condition response, after-hours escalation and hospital transfer decisions.
- 5
Performance improvement project
A QAPI project with a clear aim, measures and test cycles, run with the facility's own team.
Gate: Review results in QAPI before spreading.
- 6
Monitor and sustain
Monthly measure review in the QAPI committee, with ownership by unit and shift.
Operations
How the program runs day to day
Clinical focus areas
Avoidable hospitalizations
Early recognition of change in condition, on-site evaluation, clear escalation to the attending practitioner, and goals-of-care conversations before a crisis.
Care transitions
Complete handoffs on admission from hospital and on discharge home, with medication reconciliation and timely follow-up with the patient's primary care practice.
Antipsychotic stewardship
Gradual dose reduction review, non-drug approaches to behaviors in dementia, and accurate documentation of diagnoses and indications.
Falls
Fall risk assessment, post-fall huddles, medication review and environmental fixes, with attention to falls with major injury.
Pressure ulcers and injuries
Risk assessment on admission, skin checks, repositioning and nutrition, and staging documented accurately.
Infection prevention
Support for the infection prevention and control program, surveillance, antibiotic stewardship and immunization tracking.
Documentation & compliance
Documentation and compliance essentials
The CMS programs that score nursing home and SNF quality, described in general terms.
How CMS measures nursing home quality
Care Compare Five-Star Quality Rating System
- What it is
- Public star ratings for health inspections, staffing and quality measures, combined into an overall rating
- Where the data comes from
- State survey results, Payroll-Based Journal staffing data, MDS assessments and Medicare claims
MDS-based quality measures
- What it is
- Short-stay and long-stay measures such as falls with major injury, pressure ulcers or injuries, antipsychotic use, functional change and hospital or ED use
- Where the data comes from
- Minimum Data Set assessments, with some measures from claims
SNF Quality Reporting Program (QRP)
- What it is
- Required reporting of standardized quality data; facilities that do not meet reporting requirements receive a reduced annual payment update
- Where the data comes from
- MDS, claims and other submitted data
SNF Value-Based Purchasing (VBP)
- What it is
- Adjusts Medicare Part A payments based on performance. Historically a single readmission measure, it is expanding to additional measures over coming program years
- Where the data comes from
- Claims, MDS and staffing data, depending on the measure
Measure lists, scoring methods and program years change through annual SNF payment rules. Verify against the current CMS SNF PPS rule and Care Compare technical guidance.
Documentation and compliance essentials
- Accurate, timely MDS assessments: the source of most quality measures and of payment classification.
- A written QAPI plan, a functioning QAPI committee and performance improvement projects, as required under the long-term care Requirements of Participation.
- Infection prevention and control program with an infection preventionist and an antibiotic stewardship program.
- Psychotropic medication documentation: diagnosis, indication, monitoring and gradual dose reduction attempts.
- Change-in-condition notes, practitioner notification and transfer documentation that travels with the resident.
KPIs we track
What we measure with you
Hospitalizations and ED visits
For short-stay and long-stay residents, trended monthly.
30-day readmissions
From hospital discharge to readmission, including after SNF discharge.
Antipsychotic use
Long-stay residents on antipsychotics, and new starts among short-stay residents.
Falls with major injury
Rate, and post-fall huddle completion.
Pressure ulcers and injuries
New or worsened, with time to identification.
MDS accuracy and timeliness
Assessments completed on time and coded consistently with the record.
Baselines and targets are set from your own data at the start of an engagement. We do not promise specific results.
FAQs
Common questions
Can you raise our star rating?
We do not promise ratings. We help you understand which measures drive your rating and improve the care processes behind them. Health inspection results depend on surveys we do not control.
Do you work with the facility or the physician group?
Either, and ideally both. Many quality measures sit between the two, so the strongest work is done jointly.
Do you provide MDS coding services?
We review MDS accuracy and workflows and train staff. Assessments remain the responsibility of the facility's interdisciplinary team.
Related services
Programs that work alongside this one
Transitional Care Management (TCM)
Two-business-day contact and 7/14-day face-to-face after discharge.
Learn moreComplex Care & High-Utilizer Management
Post-discharge outreach, TCM, readmission and avoidable ED reduction.
Learn moreACO Programs (MSSP, ACO REACH, LEAD)
Quality reporting, benchmarks and participant readiness.
Learn morePractice Transformation & Quality Improvement
HEDIS and Star measures, care gap closure, AWV campaigns and care team redesign.
Learn more
Ready to simplify the complex?
Book a consultation.
A working conversation about your patients, payers, EHR and staffing, and whether this program fits. Please do not send patient information.