Thursday, June 27, 2019

Quality Initiative Achievements Linked to Performance in New Five-Star Ratings

Kiran Sreenivas

The AHCA/NCAL Quality Initiative is championed to be in alignment with CMS’s Five-Star Quality Rating System and prepare skilled nursing centers for future policy and regulatory changes. The recent April 2019 changes to Five-Star, which included adding new quality measures, changing RN staffing thresholds, and lifting of the survey freeze, puts this notion to a test. Based on a preliminary analysis, the theory follows true to form.

Currently, there are 7,798 (50%) skilled nursing centers in the nation that have achieved a goal in at least two of the four domains of the AHCA/NCAL Quality Initiative, which are hospitalizations, antipsychotics, customer satisfaction, and functional improvement.

Those nursing centers succeeding in the Quality Initiative by having achieved at least one goal in 2 or more domains are more likely to have an overall Five-Star rating of 4 or 5 stars compared to the rest of the nation (47% vs 37%). A similar relationship exists for each of the other components of Five-Star (Survey: 36% vs 31%, Staffing: 32% vs 29%, Quality: 59% vs 41%). Figure 1 shows the full Five-Star distribution breakdown between the two comparison groups.


When looking at the percentage of centers who lost, gained, or had no change in stars after the April 2019 Five-Star changes, there is additional evidence supporting the positive association between the Quality Initiative and Five-Star performance. Under this analysis, those centers achieving 2 or more of the Quality Initiative goals were more likely to have no change in their Five-Star Quality Rating, whereas the rest of the nation were more likely to lose stars (See Figure 2).


While none of these analyses prove causation, they do support an association between success on the Quality Initiative and performance on Five-Star.

From a theoretical perspective, the association between the Quality Initiative and Five-Star is logical. For example, the Quality Initiative and the April 2019 Five-Star changes both emphasize reducing short- and long-stay hospitalizations and long-stay off-label use of antipsychotics. Also, the customer satisfaction domain of the Quality Initiative reflects performance on key aspects of Five-Star, such as staffing and processes to prevent adverse events. This association between the CoreQ customer satisfaction measures used in the Quality Initiative and improvement in quality outcomes has been shown in prior work.

It is likely Five-Star will continue to evolve and change in the coming years. Thankfully, the AHCA/NCAL Quality Initiative appears to be a successful approach for being ready and succeeding under Five-Star changes.

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