April Five-Star Changes: Impacts and Action Steps

By Caralyn Davis, Staff Writer - May 30, 2019

On April 24, the Centers for Medicare & Medicaid Services (CMS) made a series of changes to the Five-Star Quality Rating System on Nursing Home Compare. Now that directors of nursing services (DNSs) have that update under their belt, they can take the following steps to get a handle on the biggest surprises:

Know which QMs carry the most weight

“The way that the individual QMs are calculated in the updated Five-Star system has taken some DNSs by surprise,” says Carol Hill, MSN, RN, RAC-MT, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL.

“All of the QMs are not created equal, meaning there is a different distribution of the points,” says Hill. “Previously, each of the QMs used in the Five-Star QM domain could have a maximum of 100 points. However, CMS has determined that some QMs are more clinically significant and offer providers a greater opportunity to improve. These nine clinically significant measures now offer a maximum of 150 points each, while the other eight still offer 100 points each.”

Knowing the distribution of points for each measure “can help DNSs identify and prioritize opportunities for improvement,” suggests Hill. The following chart adapted from the section Scoring Rules for the Individual QMs in the Five-Star Quality Rating System: Technical Users’ Guide (April 2019) breaks out the possible point totals for each measure:

Five-Star QM Domain: 9 QMs Can Get 150 Points, 8 Can Get 100 Points

150 possible maximum points each

100 possible maximum points each


  • Percent of Residents Whose Need for Help With Activities of Daily Living Has Increased (Long Stay)

  • Percent of Residents Who Received an Antipsychotic Medication (Long-Stay)

  • Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)

  • Percent of Residents Who Made Improvements in Function (Short Stay)


  • Number of Hospitalizations per 1,000 Long-Stay Resident Days

  • Number of Outpatient Emergency Department (ED) Visits per 1,000 Long-Stay Resident Days

  • Percent of Short-Stay Residents Who Were Re-Hospitalized After a Nursing Home Admission

  • Percent of Short-Stay Residents Who Have Had an Outpatient ED Visit

  • Rate of Successful Return to Home and Community From a SNF (Short-Stay)


  • Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)

  • Percent of High-Risk Residents With Pressure Ulcers (Long Stay)

  • Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)

  • Percent of Residents With a Urinary Tract Infection (Long Stay)

  • Percent of Residents Experiencing One or More Falls With Major Injury (Long Stay)

  • Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay)

  • Percent of SNF Residents With Pressure Ulcers That Are New or Worsened (Short Stay)

  • Percent of Residents Who Newly Received an Antipsychotic Medication (Short Stay)



It’s important to note that CMS removed the restraint QM from Five-Star’s QM domain, says Hill. “For restraint-free facilities, that measure was an automatic 100 points under the previous Five-Star system. Since it is no longer included in the QM rating calculation, facilities no longer have that 100-point safety net.”

Learn how the QM star ratings are calculated

In the previous Five-Star system, the calculation for the QM star ratings was relatively simple, notes Hill. “However, now there is a long-stay rating, a short-stay rating, and an overall rating. The short-stay rating includes an adjustment, so the math isn’t as simple as, for example, adding 150 points for this long-stay QM and 100 points for that short-stay QM for an overall score of 250 points. Understanding how the short-stay calculation impacts the short-stay and overall star ratings will also help DNSs determine areas for improvement.”

The Rating Methodology section of the Five-Star Technical Users’ Guide explains how the short-stay calculation works:

After any needed imputation for individual QMs, points are summed across all of the long-stay QMs, all of short-stay QMs, as well as across all QMs based upon the scoring rules described above to create a long-stay QM score, a short-stay QM score, and a total QM score for each nursing home. The long-stay QM score ranges between 175 and 1,250. Due to differences in number of measures and weights, the unadjusted short-stay QM score has a maximum of 900 points. So that the long- and short-stay measures can count equally in the calculation of the total QM score, an adjustment factor of 1250/900 is applied to the unadjusted total short-stay score. After applying this adjustment, the adjusted short-stay score ranges from 167 to 1,250⁵. The total overall QM score, which sums the total long-stay score and the total adjusted short-stay score, ranges between 342 and 2500.

Look at long-stay ED/hospital use

CMS added two claims-based long-stay measures related to hospitalizations and emergency department (ED) visits to the Five-Star QM domain: Number of Hospitalizations per 1,000 Long-Stay Resident Days and Number of Outpatient ED Visits per 1,000 Long-Stay Resident Days. Many providers have already begun focusing on hospitalizations for Medicare Part A residents since CMS focuses on those residents via multiple programs, including:

  • The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program’s SNF 30-Day All Cause Readmission Measure (SNFRM);

  • The Skilled Nursing Facility Quality Reporting Program (SNF QRP) measures, Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP and Discharge to Community – Post Acute Care (PAC) SNF QRP; and

  • Medicare initiatives for new payment and care coordination models, such as accountable care organizations (ACOs).

“With the addition of the two long-stay QMs for hospitalizations and ED visits to the Five-Star QM domain, many DNSs may want to consider expanding their performance improvement programs for SNF residents to address hospitalizations and ED visits for long-stay residents,” says Hill. “In many facilities, this is a problematic area that DNSs will need to consider.”

Don’t lose focus on MDS section G

The October 1 implementation of the Patient-Driven Payment Model (PDPM) in the Skilled Nursing Facility Prospective Payment System (SNF PPS) will transition fee-for-service Medicare Part A payment to MDS section GG (functional abilities and goals); section G (functional status) will no longer impact SNF PPS payment.

However, DNSs should keep section G on their radar, stresses Hill. “Section G will remain tied into the Nursing Home Compare QMs and the Five-Star QM domain, so you can’t lose focus on section G.”

In fact, three of the 150-point QMs have section G items in their numerator:

  • Percent of Residents Whose Need for Help With Activities of Daily Living Has Increased (Long Stay);

  • Percent of Residents Whose Ability to Move Independently Worsened (Long Stay); and

  • Percent of Residents Who Made Improvements in Function (Short Stay).

And in total, section G can potentially impact seven of the nine 150-point QMs in the Five-Star QM domain via the numerator, denominator, exclusions, or risk-adjustment covariates.

DNSs should ensure that monitoring and auditing of section G documentation remains ongoing, says Hill. “To prepare for PDPM, most providers are reviewing the supporting documentation for each MDS item that will impact PDPM case-mix classification and asking, ‘Where do we document this? How often do we document this? And are we capturing what we need to capture within the look-back period to give us credit for what we do for the resident?’ You may want to do that same type of audit for section G and other QM MDS items. Your staff may be doing great assessments, but those assessments have to fall in the lookback period to serve as supporting documentation.”

Figure out where you stand on survey citations

CMS ended the rating freeze on the Health Inspection domain, says Hill. “So DNSs need to review survey results for the last three years. You always want to have the best survey outcome possible, but it’s a good idea to know where you stand so you realize how the next upcoming survey could impact your Five-Star rating.”

Get in the PBJ loop

DNSs often aren’t involved in submitting staffing data to the Payroll-Based Journal (PBJ), so they don’t realize how big an impact it has on the Staffing domain, says Hill. “However, PBJ is the data source of your Staffing star rating. You should be receiving regular reports from the staff handling the PBJ submissions so you aren’t caught off-guard by, for example, your facility failing to submit any PBJ data at all or submitting it late.”

Staff by acuity established on the facility assessment

The other big issue involving the Staffing domain is acuity, says Hill. “The acuity of patients coming into nursing homes continues to rise. For example, I have seen situations where a resident was admitted into a SNF directly from a hospital intensive care unit.”

With those types of admissions, DNSs have to keep a constant eye on that balance between acuity and staffing, says Hill. “You have to make sure that you have the staff present to care for the residents based on their acuity, which ties back to the facility assessment. Do you have the staff necessary to meet the needs of the resident?”

Review the monthly Five-Star Provider Preview Report

CMS updates data for the MDS-based QMs and the claims-based hospitalization and ED visit measures quarterly, simultaneously updating the QM rating. These updates to Nursing Home Compare usually occur quarterly in January, April, July, and October. Note: Learn about updates to the Staffing and Health Inspection domains in the Change in Nursing Home Rating section of the Five-Star Technical Users’ Guide.

However, the QIES Technical Support Office (QTSO) announces the release of the monthly Five-Star data via the Five-Star Provider Preview Report, which is posted in the News & Updates section here. “DNSs should take the time to review these reports,” says Hill. “You don’t want to be caught off-guard.”



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