The latest refresh of skilled nursing facilities’ quality data includes the initial public reporting of new patient transfer and vaccination measures, reflecting future emphasis for the Centers for Medicare & Medicaid Services.
In the Quality Reporting Program, providers must submit 90% of data or risk a 2% payment loss. However, the most recent federal update of data was more than six weeks late thanks to the government shutdown that started Oct. 1.
Key among the changes is the public reporting of two Transition of Health measures captured in the MDS. They demonstrate how well nursing homes are doing when it comes to providing a reconciled medication list to another provider if a resident is transferred, or to a resident or caregiver when the resident is discharged to home.
CMS had proposed the so-called TOH measures in its fiscal 2020 skilled nursing payment rule, but later delayed implementation until at least two years post-pandemic.
Jessie McGill, RN, senior curriculum development specialist for the American Association of Post-Acute Care Nursing, said CMS had noted that poor communication and inadequate coordination during care transitions results in “patient complications, hospital readmissions, emergency department visits and medication errors.”
She said the agency linked failures in care coordination, including poor communication of information, to an estimated $25 billion or more of wasteful spending in 2011.
But, she added, these two measures — scored based on how often they’re completed — should actually be a boost for many providers.
“The current national average is over 95% for both measures, which shows most facilities have a strong process in place,” McGill told McKnight’s Long-Term Care News on Friday. “Since this measure shows the facility’s ability to communicate key information for care coordination during transfers in care, this may be a key metric that hospitals and other stakeholders look at for preferred providers.”
About bringing clarity
There are some caveats. For facilities with fewer than 20 qualifying cases to calculate each measure, Care Compare will display a “not available” message.
And one element ripe for confusion is that the medication reconciliation process measured by the QRP is “distinctly different” from the medication review the pharmacist completes as required under F756 Drug Regime Review for all residents, McGill said.
“The MDS is only coded for the medication reconciliation process with communication to the subsequent healthcare setting or resident/caregiver for Medicare Part A residents at the end of the Medicare Part A stay,” she said.
In a LinkedIn post about the changes Friday, SMK Medical Consultant Demetrius Kirk, DNP, recommended that nursing home teams audit transition and discharge workflows and data for TOH accuracy to improve compliance and prevent survey surprises.
“These items reflect foundational clinical coordination. If your med rec or discharge workflow is inconsistent, your scores will expose it,” Kirk wrote.
He said it is CMS strategy to make gaps in care planning more visible.
“Poor transitions, missing medication lists, and incomplete discharge documentation do not just affect care,” he added. “They directly influence survey focus and surveyor priority areas, Quality Measure scores, public ratings, hospital and partner referrals, and overall trust in your systems.”
COVID vaccine measurement debuts
Also now in the QRP mix is a measure of the percentage of patients who are “up to date” on their COVID vaccinations.
McGill called it “a simple, yet very confusing measure” because it requires the provider and consumers to understand what CMS means by “up to date.”
While that’s a moving target, CMS has not been keeping up with definition updates since the start of the year. LeadingAge has asked CMS and the Centers for Disease Control & Prevention to update standards, noting that the last CDC version referenced the 2023-2024 COVID shots and expired in September.
The RAI User’s Manual refers the assessor to a CDC web page to determine if the resident is up to date with the COVID-19 vaccine. However, the CDC’s recent change on the Adult Immunization Schedule referencing “shared clinical decision-making” adds more confusion, McGill said.
She said nursing home staff should continue to offer the vaccine with the appropriate risk and benefit conversation to allow residents to make informed choices regarding the vaccine.
“However, until CMS provides urgently needed guidance, the staff must use clinical judgment to determine if this is considered as up to date for MDS coding,” McGill explained. “This measure is also a process measure, so the facility is only penalized under the SNF QRP program if this measure is dashed — indicating the item was not assessed. If the SNF team decided to code as not up to date until further guidance is received, they will not be penalized, but it will be reflected in the publicly reported measure outcomes.”
McGill added that the national average score for the measure is 24.4%. That’s drastically down from averages above 80% after vaccines first became available during the pandemic.
Kimberly Marselas. (2025, November 22). Latest QRP refresh reflects CMS emphasis on better nursing home discharges.
https://www.mcknights.com/news/data/
