DOH Finalizes 2022 Nursing Home Quality Initiative Measure Set
The Department of Health (DOH) Office of Quality and Patient Safety has finalized the set of measures that will be used to calculate the 2022 State Nursing Home Quality Initiative (NHQI). The 2022 NHQI is based on 2021 quality measures that will be scored individually, then combined into a composite facility score. DOH is likely to perform the calculations in late 2023. Members may recall that DOH released the final scores of the 2021 NHQI in December 2022, although related payment adjustments have not yet been made pending executive review.
The 2022 NHQI, commonly referred to as the Quality Pool, will be comprised of 18 measures across three realms: quality, compliance, and efficiency. While there is overlap with the measures used in the federal Five-Star methodology, NHQI measures focus more on long-stay residents whose care is more likely to be funded by Medicaid. Consistent with prior years, points will be awarded based on performance, and in some cases, improvement, on the individual measures. Facilities will then be categorized into quintiles based on their total score. Because the NHQI is self-funded (i.e., redistributes existing Medicaid funding), those in the top three quintiles receive a tiered net gain, while those in the bottom two quintiles see a uniform negative adjustment approximating 0.8 percent of their annual Medicaid revenue.
The 2022 measure set will debut two new measures, drop one, and reintroduce four that were suspended in last year’s NHQI due to COVID-19 considerations.
New Measures
The measures being added to the 2022 NHQI are nursing staff turnover and the percentage of current residents up to date with COVID-19 vaccination. Both are currently calculated by the Centers for Medicare and Medicaid Services (CMS), with facility performance reported publicly on the federal Nursing Home Compare website.
Total nursing staff turnover will be calculated by CMS using the same methodology that is currently part of the Five-Star staffing measure. It will measure the percentage of Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Aide staff who left the home (i.e., had a 60-day or longer separation) in the last 12 months based on Payroll-Based Journal (PBJ) data. While the turnover rates will be calculated by CMS, DOH will assign points based on regional comparisons, as is done with the health inspection measure, to help ensure that regional variation does not skew the results. The measure will be scored on a quintile basis in the same way that other quintiled measures are scored, with five points awarded to the top quintile, three to the second, one to the third, and zero to the fourth and fifth quintiles.
The turnover calculation encompasses the following employed and contracted staff: RN director of nursing (PBJ job code 5), RN with administrative duties (job code 6), RN (job code 7), LPN with administrative duties (job code 8), LPN (job code 9), certified nurse aide (job code 10), aide in training (job code 11), and medication aide (job code 12). Facilities that fail to report PBJ data may be subject to zero points.
Percentage of current residents up to date with COVID-19 vaccination calculations will exclude those residents with medical contraindications and will be modeled on the measure as it is currently displayed on Medicare Care Compare. The data will be sourced from the CMS compilation of data that facilities submit weekly through the National Healthcare Safety Network (NHSN). Display of resident (and staff) COVID-19 vaccination rates on Care Compare began in the fall of 2021, with data regarding boosters added in February 2022.
Unlike most of the measures that would be based on 2021 performance, the data source for this measure will be one of the weekly NHSN reports submitted in Quarter 4 of Calendar Year (CY) 2022. This measure also differs from other resident-based quality measures in that it counts all, not just long-stay, residents. We did express our concern to DOH that this methodology may disadvantage homes with a large share of subacute residents whose short-stay status may have an impact on vaccination decisions. The measure will be worth five points and be scored on the 5-3-1-0-0 quintile scoring.
Reinstated Measures and Other Changes
For the 2022 payment year (2021 measurement year), four measures that had been suppressed in 2021 due to COVID-19 will return to the NHQI. The measures being reinstated after a one-year absence, using the same parameters and scoring conventions used previously, are:
- Percent of Long Stay High Risk Residents with Pressure Ulcers (five-point measure)
- Percent of Long Stay Residents Who have Depressive Symptoms (five-point measure)
- Percent of Long Stay Residents Who Lose Too Much Weight (five-point measure)
- Potentially avoidable Hospitalizations (10-point measure)
In addition, the scoring convention for the quality measure Percent of employees vaccinated for influenza will be shifted from threshold scoring, which awarded five points for homes with a rate of 85 percent or higher and zero points to those below 85 percent, to the 5-3-1-0-0 quintile scoring methodology. This change was precipitated by a significant drop in the staff immunization rate from the 2018-19 flu season to the 2020-21 flu season. The measure was suppressed in 2019-20.
Finally, the compliance measure Timely submission of nursing home certified cost report will be removed as a measure based on near universal (i.e., 99 percent) compliance.
Other dynamics of the methodology remain the same, including the potential to earn improvement points, although those can only be earned on the six measures that were used in the 2021 NHQI and that were scored on a quintile basis:
- Percent of Long Stay Residents Who Received the Pneumococcal Vaccine
- Percent of Long Stay Residents Who Received the Seasonal Influenza Vaccine
- Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
- Percent of Long Stay Residents with Dementia Who Received an Antipsychotic Medication
- Percent of Long Stay Residents Whose Need for Help with Daily Activities Has Increased
- Rate of Staffing Hours per Resident per Day
Facilities that receive a J/K/L deficiency between July 1, 2021 and June 30, 2022 (based on Oct. 1, 2022 data to allow a three-month window for a potential Informal Dispute Resolution process) will be excluded from receiving NHQI funding. Additionally, specialty facilities and Continuing Care Retirement Communities (CCRCs) are categorically excluded from the NHQI and are not part of the scoring. We congratulate LeadingAge NY members who continue to lead the state in quality care, with 75 percent scoring in the top three quintiles.
We remain wary of the potential of the COVID-19 vaccination measure to be skewed by regional variation while disadvantaging homes with higher proportions of post-acute residents. We are also uncertain of the advisability of incorporating a staffing measure (i.e., turnover) during a staffing crisis and will review the results and urge DOH to monitor the impact going forward. The Dear Administrator Letter (DAL) with the 2022 methodology is available here. Member observations and questions are welcome.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841