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Dementia and the Five Star rating system

Nursing homes are seeing a lot of changes related to compliance and dementia this year. Starting with the change in five star ratings that now incorporates dementia related quality measures, more change is on its way that might increase risk for providers.

CMS rates nursing homes on three categories: results from onsite inspections by trained surveyors, performance on certain quality measures and levels of staffing. CMS uses these three categories to offer an overall star rating, but consumers can see and focus on any of the three individual categories.

Nursing home star ratings now:

  • Include use of antipsychotics in calculation of the star ratings. These medications are often used for diagnoses that do not warrant them. The two existing quality measures – for short stay and long stay patients – will now be part of the calculation for the quality measures star rating. CMS first launched the National Partnership to Improve Dementia Care in Nursing Homes in 2012. One of its primary goals was to improve and expand the use of non-pharmacological approaches to care and reduce antipsychotic medication use in long-stay nursing facility residents. CMS documented a 19.4 percent reduction in antipsychotic drug use in United States nursing facilities by the end of 2014; its goal by the end of 2016 is a 30 percent reduction.

  • Have improved calculations for staffing levels.  This includes adjustments to ratings associated with staffing levels for registered nurses, licensed practical nurses and certified nursing assistants. Facilities are now expected to reach at least 3-stars on certain aspects of those dimensions. Ensuring adequate staffing levels has been shown to reduce medication errors and decrease patient complications and mortality, according to the American Nurses Association. This has a direct impact on dementia care as the need for more person centered attention increases with cognitive loss.

  • Reflect higher standards for nursing homes to achieve a high rating on the quality measure dimension on the website. Showing more person centered metrics increases visibility on quality of care and dementia related areas.

The facility star rating is based on a comparison to other homes in the state.  Facilities are awarded stars as follows:

  • Five-Star – top 10 percent of homes (those with the best inspections in the state)

  • Four-Star – next lower 23.33 percent

  • Three-Star – next lower 23.33 percent

  • Two-Star – next lower 23.33 percent

  • One-Star – lowest 20 percent (those homes with the worst inspections in the state)

The impact is great on many homes: Some of the new payment model initiatives require homes have a three, four or five-star rating to participate.  Overnight, some homes lost their qualification.  Accountable care organizations (ACO’s) may choose to set star rating parameters on skilled nursing facility (SNF) membership.  Referral sources often use the Five-Star Rating when choosing a discharge location.  There will be some fallout, and homes must be prepared to respond to negative perceptions.

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