The Discharge Function Score is an incredibly complicated quality measure (QM), notes Joel VanEaton, BSN, RN, RAC-MT, RAC-CTA, RAC-CT, executive vice president of post-acute care regulatory affairs and education for Broad River Rehab in Asheville, NC. “Its technical specifications are as close to rocket science as we have ever seen in nursing home quality measurement.”
Nevertheless, it’s more important than ever that the nurse assessment coordinator (NAC) and other nurse leaders understand how this QM works—and what to do with it, says VanEaton, who will present the April 24 session “Do You Know Your Discharge Function Score?” during the April 22 – 25 AAPACN 2025 Conference in Louisville, KY.
Keys to understanding why the Discharge Function Score should be prioritized include the following:
SNF QRP, Five-Star, and SNF VBP impacts
“SNFs must navigate what essentially amounts to three ‘value-focused’ quality programs: the pay-for-reporting Skilled Nursing Facility Quality Reporting Program (SNF QRP), the public-facing Five-Star Quality Rating System, and the pay-for-performance Skilled Nursing Facility Value-Based Purchasing program (SNF VBP),” says VanEaton.“The Discharge Function Score measure affects each leg of this three-legged stool of value-focused quality measurement. It is one of just three current QMs that impact all three programs. These programs drive the outward reflection of the quality that you are providing in your facility. So, you need to pay attention to the Discharge Function Score measure.”
VanEaton offers the following summary of how this measure can impact each QM program:
- The SNF QRP. “The section GG (Functional Abilities) items that contribute to this measure, as well as other section GG items, are required reporting as part of the SNF QRP’s MDS-based data submission threshold,” says VanEaton. “Achieving that annual threshold can help you prevent CMS from applying a 2 percent penalty to your FFS Part A payment rates in the corresponding program year.”
Since Jan. 1, 2024, SNFs need to report 100 percent of the required MDS data on at least 90 percent of the required assessments for the MDS-based data submission threshold. For more information on the fiscal year (FY) 2027 (which uses calendar year 2025 data) reporting requirements, see the Data Collection & Final Submission Deadlines for the FY 2027 SNF QRP and the SNF QRP Overview of Data Elements Used for Reporting Assessment-Based Quality Measures and Standardized Patient Assessment Data Elements Affecting FY 2027 Annual Payment Update (APU) Determination. - Five-Star. “As of the January 2025 refresh of Care Compare, the Discharge Function Score has replaced Percentage of Residents Who Made Improvements in Function as a short-stay Nursing Home Quality Initiative (NHQI) QM in Five-Star’s QM domain,” says VanEaton. “So, your Five-Star ratings will be affected by this measure going forward, which in turn can impact referrals due to how the public perceives your organization and how certain payers will work with you.”
In Five-Star, the Discharge Function Score measure will be called Percentage of SNF Residents Who Are at or Above an Expected Ability to Care for Themselves and Move Around at Discharge (Short-Stay). The January 2025 Nursing Home Five-Star Quality Rating System: Technical Users’ Guide specifically identifies this measure as the Discharge Function Score, and the MDS 3.0 Quality Measures User’s Manual version 17 confirms that the NHQI Discharge Function Score is calculated using the SNF QRP’s technical specifications for the measure. - The SNF VBP. “Starting in FY 2027 (Oct. 1, 2026 – Sept. 30, 2027), the Discharge Function Score measure will be one of eight QMs that feed into the SNF VBP incentive multiplier that determines your level of financial success in the program each year,” explains VanEaton. “Success with QMs like this is exactly what CMS is looking for in terms of obtaining value for the money that the Medicare program spends.”
While the payment impact of the Discharge Function Score measure is still a few years away, the performance period that will determine FY 2027 payment is currently ongoing. The measure’s FY 2027 performance period is FY 2025 (Oct. 1, 2024 – Sept. 30, 2025), and the baseline period is FY 2023 (Oct. 1, 2022 – Sept. 30, 2023).
The following graphic highlights the Discharge Function Score measure’s connections to these three programs:
SNFs vs. HHAs, IRFs, and LTCHs
The expansion of Medicare Advantage is not the only payment shift impacting SNFs. More than half (53.4 percent) of Medicare beneficiaries who have traditional fee-for-service (FFS) Part A and/or Part B are receiving care from some type of accountable care organization (ACO) or other Innovation Center model, says the Centers for Medicare & Medicaid Services (CMS). However, ACOs that have preferred SNF networks commonly report that finding high-quality SNFs is a challenge, according to “Characteristics of Accountable Care Organizations’ Preferred Skilled Nursing Facility Networks” in the Dec. 12, 2024 The American Journal of Managed Care.
“Certainly, SNFs want to shine as a sector compared to the rest of the post-acute care settings in relationship to the outcomes that we generate,” says VanEaton. “We collectively need to be able to demonstrate the value of referrals to a SNF.”
The Discharge Function Score measure is now the standard for discharge therapy outcomes across post-acute care, points out VanEaton. “Using cross-setting section GG assessment items, CMS has implemented the Discharge Function Score not just in SNFs, but also in home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs). The Quality Reporting Programs created the environment to allow equal comparison across post-acute care settings.”
Keys to creating an action plan
Once nurse leaders understand why the Discharge Function Score is important, the next step is to learn some basics that will assist the team to create a viable action plan, says VanEaton. These include the following:
Understand what goes into this QM
The Discharge Function Score measure estimates the percentage of Medicare Part A SNF stays that meet or exceed an expected discharge function score,” says VanEaton. “This is one QM where triggering is a positive occurrence. You want as many residents as possible to trigger because it indicates an improvement from admission to discharge (i.e., the observed discharge function score met or exceeded the expected discharge function score).”
Ten section GG items pulled from the Part A PPS Discharge assessment are used to calculate the resident’s observed discharge function score for this measure, says VanEaton. The following chart adapted from Table 8-8 in the SNF QRP Measure Calculations and Reporting User’s Manual lists these items:
The function assessment items used for Discharge Function Score calculations are:
* Count Wheel 50 feet with 2 turns (GG0170R) value twice to calculate the total observed discharge function score for stays where (i) Walk 10 feet (GG0170I) has an activity not attempted (ANA) code at both admission and discharge and (ii) either Wheel 50 feet with 2 turns (GG0170R) or Wheel 150 feet (GG0170S) has a code between 01 and 06 either at admission or at discharge. The remaining stays use Walk 10 feet (GG0170I) + Walk 50 feet with 2 turns (GG0170J) to calculate the total observed discharge function score. In either case, 10 items are used to calculate a resident’s total observed discharge score and scores range from 10 – 60. Note: The admission function values are included in the covariates and calculated using the same procedure as the observed discharge function score, including the replacement of NA codes with imputed values. |
“This measure also relies heavily on the use of a complicated list of 23 admission covariates or risk adjusters from the PPS 5-Day assessment to calculate the resident’s expected discharge function score,” says VanEaton. “These covariates include the same section GG items from column 1 (Admission Performance), such as GG0130A1 (Eating Self-Care Admission Performance) to pair with GG0130A3 (Eating Self-Care Discharge Performance). They also include, for example, certain primary medical condition categories captured in item I0020 (Indicate the Resident’s Primary Medical Condition Category).”
The following chart adapted from Table 8-8 in the SNF QRP Measure Calculations and Reporting User’s Manual defines the 23 covariates:
| Data for each covariate are derived from the admission assessment included in the target Medicare Part A SNF Stays. 1. Age group 2. Admission function – continuous form65 3. Admission function – squared form66 4. Primary medical condition category 5. Interaction between admission function and primary medical condition category 6. Prior surgery 7. Prior functioning: self-care 8. Prior functioning: indoor mobility (ambulation) 9. Prior functioning: stairs 10. Prior functioning: functional cognition 11. Prior mobility device use 12. Stage 2 pressure ulcer/injury 13. Stage 3, 4, or unstageable pressure ulcer/injury 14. Cognitive abilities 15. Communication impairment 16. Urinary continence 17. Bowel continence 18. History of falls 19. Nutritional approaches 20. High body mass index (BMI) 21. Low BMI 22. Comorbidities 23. No physical or occupational therapy at the time of admission See covariate details in Table RA-5 and Table RA-8 in the associated Risk-Adjustment Appendix File. 65 Admission function score is the sum of admission values for function items included in the discharge score. NAs coded on admission items are treated the same way as NAs coded on discharge items, with NAs replaced with imputed values. Walking items and wheeling item are used in the same manner as in the discharge score. 66 Admission function score is the sum of admission values for function items included in the discharge score. NAs coded on admission items are treated the same way as NAs coded on discharge items, with NAs replaced with imputed values. Walking items and wheeling item are used in the same manner as in the discharge score. |
Develop an integrated, interdisciplinary approach to section GG
“Section GG is at the core of the accurate MDS completion that is needed for this QM,” says VanEaton. “No interdisciplinary team (IDT) can afford to have a passive approach to completing section GG where some team members think, for example, ‘This is not my department, so I don’t have to worry about it.’”
The IDT must take an interdisciplinary approach to achieve the most accurate section GG possible, suggests VanEaton. “With 10 section GG items involved in just this measure and no Rule of 3 to drive coding decisions, it really begs the application of a much more integrated approach to completing section GG. You don’t want to guess or hope that the way that you code section GG on discharge is an accurate reflection of the gains that have been achieved in the therapy department.”
An accuracy-first approach should include the following core components:
- Understanding what usual performance is. “The IDT has to capture the resident’s usual performance in GG0130 (Self-Care) and GG0170 (Mobility) at admission and then again at discharge from Part A,” says VanEaton. “Every team member who is either assessing the resident or providing documentation to support that assessment needs to understand how CMS defines usual performance in chapter 3 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual).”
Note: Learn how to apply the definition of usual performance to section GG coding decisions in the AAPACN podcast Section GG: Key Insights into Determining Usual Performance and the AAPACN article “GG0130 and GG0170: Using Clinical Judgment to Establish Usual Performance.” - Understanding the six-point rating scale. “All participating team members also have to be comfortable with the six-point rating scale that is used to code both GG0130 and GG0170,” says VanEaton.
- Working as a true IDT to make a coding decision. “You have to come together as a team to be sure that the information that’s recorded on the MDS is an accurate reflection of what everyone agrees is occurring with that resident,” says VanEaton. “You don’t want therapy alone, nursing alone, or even the NAC alone to make that call. It needs to be a team decision made by IDT members who understand how to code section GG—and backed up by supporting documentation.”
Be proactive obtaining iQIES reporting
Nurse leaders can’t afford to be passive about accessing reports from the Internet Quality Improvement & Evaluation System (iQIES), says VanEaton. “You need to understand which reports are available across the three quality-focused programs and how to monitor those reports for accuracy.”
For example, late last year CMS posted the December 2024 quarterly confidential feedback reports for the FY 2026 SNF VBP in iQIES, says VanEaton. “These reports included information on the four QMs that will affect FY 2026 payments under the SNF VBP, and you had 30 days to make correction requests for potential calculation errors.”
It’s important to go ahead and learn how to access and interpret the Quarterly Confidential Feedback Reports before the reports transition to eight measures for the FY 2027 program, says VanEaton. “With all of these QMs at risk, including the Discharge Function Score measure, you don’t want to assume, ‘It’s the SNF VBP, so there’s not really a lot that I can do.’”
Instead, nurse leaders should be prepared to monitor CMS’s calculations, says VanEaton. “By the time that you begin to get your first FY 2027 reports in early December 2025, you should be used to how the scoring works, and you should be ready to evaluate whether your SNF VBP incentive multiplier is accurate.”
Note: Learn more about Quarterly Confidential Feedback Reports, as well as the separate Early Look Performance Score Reports that also may be issued this year, here.
For Five-Star,CMS already includes the Discharge Function Score on the MDS 3.0 Resident-Level QM Report that is available via iQIES, says VanEaton. “Two measures on the MDS 3.0 Resident-Level QM Report come from the SNF QRP: the Discharge Function Measure and Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury. So, this report that you have always used to look at your quality has begun to be impacted by these shared QMs.”
VanEaton has advocated with CMS to get the Resident-Level Reports expanded to include more actionable information. “The current reports don’t allow you to see why a resident did not trigger this QM (i.e., they did not meet or exceed their expected discharge function score),” he explains. “Instead of having to dig for this information, you should be able to review the resident’s expected and observed discharge function scores on these reports. And, why did they not trigger? What section GG scoring affected the observed score? How did the covariate list impact the expected score? We need to be able to access this information without having to buy a separate piece of software, so my team and I will continue to press for it.”
Note: Learn more about currently available on-demand iQIES reports and how to access them in the iQIES Reports User Manual. Reports are explained in Appendix A, “List of Reports Generated On Demand.”
What to expect in the conference session
VanEaton’s upcoming session will include a review of the differences between the Discharge Function Score and the measure it replaced in Five-Star (i.e., the Percentage of Residents Who Made Improvements in Function). “The Discharge Function Score is by no means an equivalent measure to the prior QM,” he stresses. “Comparing the two measures will help you understand just how complicated the new measure’s technical specifications are.”
VanEaton also will dive deeper into the individual components of the technical specifications. “For example, not understanding the application of the expected discharge function score—how you can be sure that you are meeting or exceeding it—is a common problem. So, session attendees will learn how these components work together and how the data that they collect generates the expected discharge function score,” he says. “We will walk through a scenario so that you can understand how to determine your expected score on your own.”
This will help attendees lay the foundation to do some investigation into those residents who did not trigger for the Discharge Function Score measure, says VanEaton. “Your goal is to find the residents who did not trigger and figure out why they didn’t achieve an observed outcome that met or exceeded that expected outcome. Did you have an MDS coding error or a documentation error? Or, for example, did your IDT not evaluate the residents from their covariate perspective, which resulted in you not having the right programs in place for those residents who failed to trigger?”
VanEaton’s session will also highlight the iQIES reporting that can help nurse leaders do some of the investigations that need to be done. “Ultimately, you should walk out feeling like you know how to create a plan to ensure that your facility is being represented appropriately by the Discharge Function Score measure in all three programs,” he explains.
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