One way or another, patient-reported outcome (PRO) measures eventually will come to nursing homes across the country. Meaningful Measures 2.0, the framework that the Centers for Medicare & Medicaid Services (CMS) established to guide quality measure (QM) development, prioritizes outcome- and patient-reported measures, and to help implement that goal, CMS in 2021 announced that it would increase PRO measures across its entire measure portfolio by 50 percent.
CMS defines a PRO as “any report of the status of a patient’s health condition or health behavior that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else,” according to the Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System (SNF PPS) proposed rule. The agency is inching closer to making PRO measures a reality for nursing homes—with some bumps along the way.
CMS initially let providers know that a PRO measure was on its radar in the List of Measures Under Consideration for Dec. 1, 2017 (i.e., the 2017 MUC list), which included the CoreQ: Short-Stay Discharge Measure as a potential QM for the pay-for-reporting Skilled Nursing Facility Quality Reporting Program (SNF QRP). Note: CoreQ (not an acronym) offers a free suite of five National Quality Forum (NQF) endorsed satisfaction measures: three for nursing homes and two for assisted living facilities. The CoreQ: Short-Stay Discharge Measure is the percent of SNF patients, regardless of payer type, who (1) are discharged within 100 days of admission during a six-month period, and (2) are satisfied with their SNF stay upon discharge. The other two nursing home measures in the suite are the CoreQ: Long-Stay Resident Measure and the CoreQ: Long-Stay Family Measure.
CMS waited until the FY 2022 SNF PPS proposed rule to announce its intention in federal rule-making to consider PRO measures in two fee-for-service Medicare Part A programs:
- Table 27, “Future Measures and Measure Concepts Under Consideration for the SNF QRP,” simply listed “patient-reported outcomes” as a future target measure concept.
- Table 31, “Quality Measures Under Consideration for an Expanded Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP),” cited the CoreQ: Short-Stay Discharge Measure as a potential measure of the patient’s experience of care, as well as the Physical measure in the Global Health category of the Patient-Reported Outcomes Measurement Information (PROMIS) system as a potential patient-reported functional outcome measure.
In the FY 2023 SNF PPS proposed rule, CMS followed up with a request for information (RFI) on whether (and how) to make the CoreQ: Short-Stay Discharge Measure a QM in the SNF QRP. This potential move doesn’t hold universal appeal, according to the FY 2023 SNF PPS final rule.
While commenters were “generally supportive” of adding a PRO measure to the SNF QRP, “support for the CoreQ measure specifically was mixed,” the agency notes. “One commenter stated that since the CoreQ has a limited number of questions, it may not fully reflect patient experience at a given facility. Another commenter would not support the CoreQ since it excludes residents who leave a facility against medical advice and residents with guardians, and this commenter stated it would be important to hear from both of these resident populations. Two commenters cautioned CMS to consider the burden associated with contracting with vendors to administer such a measure.”
This somewhat lukewarm reaction isn’t surprising. Back in February 2020, the Center for Medicare Advocacy (CMA) in Washington, D.C., supported the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Nursing Home Surveys from CMS and the Agency for Healthcare Research and Quality (AHRQ) as “the best option” for reporting resident-generated data on Care Compare because they are more clearly focused on resident experience than on resident satisfaction. Alternatively, the CMA wanted CMS to use the survey process to capture resident experience.
In fact, CMS employs CAPHS surveys in multiple settings. For example, CAPHS versions are used in the Home Health Value-Based Purchasing Model, as well as in the Hospice Quality Reporting Program. However, possibly mindful of the increased provider burden in the nursing home setting, CMS hasn’t moved forward with implementing the CAHPS Nursing Home Surveys in any capacity since they were initially tested in 2006 – 2007.
While CMS declined to make a decision in the FY 2023 SNF PPS final rule on whether to add the CoreQ: Short-Stay Discharge Measure to the SNF QRP, the agency clearly views the SNF QRP as a testing ground for the SNF VBP and may still choose to implement the measure despite the mixed comments. In fact, CMS has already initiated a contract to test how to collect the CoreQ data, how to report the scores, and how to regulate vendors.
One factor in the measure’s favor is the Measure Applications Partnership (MAP) Post-Acute Care/Long-Term Care (PACLTC) workgroup’s 2018 support for including the measure in the SNF QRP. It’s also worth noting that the exclusions that worried some commenters are commonly used with other available nursing home satisfaction surveys.
In addition, there is precedent set by state use of other CoreQ nursing home measures in Medicaid VBPs. Twenty states and the District of Columbia now use some type of VBP as part of Medicaid nursing facility payments, according to the August 2022 report, State Use of Value-Based Payment in Nursing Facilities, from the U.S. Department of Health and Human Services. Of those, nine programs incorporate a resident satisfaction measure or measures. States that are using one or more of the long-stay CoreQ measures (some of which are modified) include New Jersey, Tennessee, and Georgia, according to the February 2022 report, A Review of Nursing Home Medicaid Value-Based Payment Programs, from the Center for Health Policy Evaluation in Long-Term Care at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).
How CoreQ works
CoreQ was intentionally designed to be different from other previously developed resident experience surveys, says Nicholas Castle, PhD, MHA, chair and professor for the Department of Health Policy, Management, and Leadership in the School of Public Health at West Virginia University in Morgantown and owner of the CoreQ vendor CoreQ Surveys. Castle developed CoreQ in collaboration with the AHCA/NCAL.
“Most available surveys have a lot of questions. For example, the CAHPS Discharged Resident Survey for short-stay residents has 50 items,” points out Castle. “For nursing homes, that means that the data can be expensive to collect, and the response rates tend to be low. The other limitation of most current surveys is that you don’t get one score that tells you your overall satisfaction. You can use some items in these surveys to compare yourself with others, but the wording and the scales may be slightly different because the items themselves weren’t developed to provide that overall score.”
In contrast to the CAHPS Discharged Resident Survey, the CoreQ: Short-Stay Discharge Measure questionnaire has four items that residents answer using a 5-point Likert Scale: poor (1); average (2); good (3); very good (4); and excellent (5), as the following excerpt shows:
- In recommending this facility to your friends and family, how would you rate it overall?
- Overall, how would you rate the staff?
- How would you rate the care you receive?
- How would you rate how well your discharge needs were met?
“Each CoreQ: Short-Stay Discharge Measure item represents as much satisfaction as you can possibly get from a discharged short-stay resident without overlapping,” says Castle. “Once the four items are put together in an easy-to-comprehend score of 0 – 100, that represents the overall satisfaction of those discharged short-stay residents. Then, you can compare apples to apples—both your own performance over time and your performance in comparison to other facilities that use this measure. All of the CoreQ measures were created specifically to obtain an overall score for comparison, and they all were developed in a similar manner to the short-stay measure.”
While CMS potentially could make some adjustments for the SNF QRP, the short-stay measure currently does have some exclusions, adds Castle. CMS defines these in the FY 2023 SNF PPS proposed rule as follows: “The CoreQ: Short-Stay Discharge Measure excludes certain patients from the denominator, such as patients who die during their SNF stay; patients discharged to another hospital, another SNF, psychiatric facility, IRF [inpatient rehabilitation facility], or LTCH [long-term care hospital]; patients with court-appointed legal guardians for all decisions; patients who have dementia impairing their ability to answer the questionnaire; patients discharged on hospice; and patients who left the SNF against medical advice [AMA].”
“Those exclusions are partly standard operating procedure for survey collection and partly due to the difficulty keeping track of residents who discharge to those types of facilities, which can make response rates low,” explains Castle. “So, the measure typically looks at residents who are discharged to the community or an assisted living facility.”
Providers need a minimum of 20 completed surveys and a response rate of 30 percent to calculate a CoreQ: Short-Stay Discharge Measure score, says Castle. “With most surveys, you would say, ‘the more, the better,’ but CoreQ scores are very stable once you get 20 surveys. And, the response rates tend to be very good because there are only four items. That would make it useful to an organization like CMS because it’s easy—and fairly inexpensive—to create a relative picture of provider performance.”
What CoreQ does—and doesn’t—do
Like all the CoreQ measures, the CoreQ: Short-Stay Discharge Measure gives directors of nursing services (DNSs) and other managers a way to obtain a first read on satisfaction, says Castle. “If you get a low score, you know that your satisfaction is low. However, you don’t know what to improve because the survey wasn’t designed to tell you why your satisfaction is low.”
To find out the why behind the numbers, even high-scoring providers should consider doing a second, extended survey on a routine basis, suggests Castle. “For example, you could do an extended survey quarterly or even annually so that you have data that may help you target where you can make improvements. Essentially, the CoreQ score is like an indicator light of your performance, and then an extended survey can help you do the deep dive of a root-cause analysis to determine why you got that score.”
“CoreQ is that first stop in looking at satisfaction,” agrees Katelyn McCauley, MS, director of senior living research at CoreQ vendor Holleran Community Engagement Research & Consulting in Wrightsville, PA. “If you do a combination of CoreQ and an extended survey, you can get that initial barometer of where you are plus deeper, actionable intelligence.”
Survey help
If CMS chooses to add the CoreQ: Short-Stay Discharge Measure to the SNF QRP, providers that are already using CoreQ will have an existing baseline, points out Castle. “So, there will be no surprises if you have to implement the survey for the SNF QRP or when CMS begins publicly posting the data.”
However, the CoreQ: Short-Stay Discharge Measure has relevance beyond its potential inclusion in the SNF QRP or eventually even in the SNF VBP, suggests Castle. The revised surveyor guidance in Appendix PP of the State Operations Manual that goes into effect on Oct. 24, 2022, includes a heavy focus on staff training under multiple F-tags, ranging from F940 (Training Requirements—General) to F949 (Behavioral Health Training), as well as on Quality Assurance and Performance Improvement (QAPI) under F-tags F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt) to F868 (QAA Committee).
“One potential correlate of satisfaction for all of the CoreQ nursing home measures is staffing,” notes Castle. “These measures can help the DNS and other department leaders be better positioned to identify problems and improve staff training. For example, one of the items on the CoreQ: Short-Stay Discharge Measure questionnaire looks at the resident’s satisfaction with their discharge. So, CoreQ could provide a warning indicator that there may be potential problems with discharge planning, and an extended survey could provide the data to guide changes that will improve and standardize your staff training, as well as facility systems and processes, for discharge planning.”
Finding vendors
The CoreQ website lists about 40 CoreQ vendors along with their e-mail contact information. “If CMS adopts the CoreQ: Short-Stay Discharge Measure for the SNF QRP, there will likely be some vendor changes,” says Castle. “Some vendors will add CoreQ, and some may discontinue it depending on what standards CMS could require. Currently, most vendors attach CoreQ surveys to their own extended survey and do both at the same time, but more could offer CoreQ as a standalone product for the SNF QRP.”
Issues to consider include whether a vendor offers CoreQ by snail mail, telephone, or e-mail, says Castle. “For example, there are more costs associated with administering the survey by mail, but you may have to weigh that against whether you commonly have valid telephone numbers or e-mail addresses for residents.”
Providers that are AHCA/NCAL members can upload their CoreQ data to proprietary AHCA/NCAL software to see a national benchmark for comparison, says Castle. “Nursing homes that don’t have that option should find out whether the vendor will at least provide you with client averages so you can see if you are above or below those averages.”
“One key question to ask is: Is the vendor focused on senior living?” suggests McCauley. “Or, is their attention divided among other sectors? You want to find a vendor that has a full toolbox of resources to provide you with the opportunity to conduct more than a CoreQ survey. The quality of the actionable intelligence that you get from an extended survey is vendor-specific.”
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