Five-Star Management Challenges NACs Are Facing

LTC NAC Chat – Five-Star Management Challenges NACS Are Facing – Full Transcript

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Amy:

Hello, thank you for joining LTC NAC Chat, a podcast brought to you by the American Association of Post-Acute Care Nursing (AAPACN). I’m your host, Amy Stewart, Chief Nursing Officer for AAPACN, and I’m here today with Jessie McGill, Senior Curriculum Development Specialist for AAPACN. Jessie joins us to discuss the Five-Star management challenges nurse assessment coordinators are facing today. Welcome, Jessie!

Jessie:

Thanks for having me today, Amy.

Amy:

Jessie, let’s dive right in. In a recent survey in the AAPACN Leader for the NAC newsletter, members describe difficulty understanding how the different parts of Five-Star work together. What makes this system so challenging for NACs to interpret and manage?

Jessie:

That’s a great question. One of the biggest challenges of Five-Star is that we have a lot of different data coming from different areas and using different time frames. So we have the health inspection domain, which uses the two most recent standard surveys, so it’s looking at your health inspections, and 36 months of infection control and complaint surveys. So, we already have a couple different time frames just with health inspections and a couple different data points that are impacting your health inspection.

For the staffing domain, this looks at the hours that the facility self-reports in the Payroll-Based Journal, and it looks at 12 months of data and it’s updated quarterly.

The quality measure domain is also updated quarterly and uses four full quarters of data but with a delay. And the quality measure domain pulls from different quality measures

that are both MDS-based as well as a few claims-based measures. So, a couple different data points with quality measures also.

For the NAC, one of the ways to look at Five-Star and hopefully make it a little less challenging is to understand that they’re not the sole responsible person for managing all aspects of Five-Star. They may be highly involved with the understanding and reporting when it comes to the QM domain because most of the quality measures used for that domain are MDS-based. But that should be more to understand the underlying data and then working with your entire team to understand how the domains work together for your overall Five-Star rating.

Amy:

Thank you for that. Another challenge noted by the survey respondents was documentation, especially for section GG. How can NACs overcome documentation challenges and ensure accuracy when coding the MDS?”

Jessie:

Oh, GG always gives us so many challenges. When we look at section GG, we have essentially two different processes that are going on. The first is the underlying documentation. This is what’s actually happening during those three-day windows

for each of those episodes of care, whether it’s with the CNAs, the nurse, or the therapy team.

And then you have the second part, which is the review of all of that documentation during the three-day window to determine the resident’s usual performance. And so we have to have two strong processes in place.

First is a strong process for that underlying documentation. And the second is a strong process to determine usual performance.

The underlying documentation requires that we have really consistent and ongoing education with the staff members who are going to be documenting or charting those GG tasks, such as:

• How did the resident eat?
• How did they transfer?
• How did they move from sitting to lying?
• How did they transfer into the bath?

So for all of those different GG tasks, the direct care staff needs to understand the RAI User’s Manual definition—what is included as well as what is not included? And also understanding the performance levels. So what is partial-moderate assist, what is substantial-max assist, as well as supervision or setup help only? So there’s a lot that goes into those performance levels as well as the different tasks.

Now, one of the cool things that AAPACN has is a GG Trivia Game, which we actually have two versions now. And the GG Trivia Game is an education tool, it’s free for members, that you can use with your direct care staff to help reinforce in a game fashion different GG tasks in the different performance levels. So, creating education that’s fun is a great way to reinforce your other training.

Another thing that we need to do with that direct care staff is we have to validate that what is being charted is accurate. So, that may include different types of audits or validation processes.

One of my favorite ways to validate if the charting is accurate is to, especially during the lookback period for an MDS so that that really has a good impact on the accuracy of that assessment, is going out and watching how the resident performs tasks with the nurse aide and then looking at how they charted that specific task. If there were inconsistencies or inaccuracies with how it was charted, that gives you the opportunity to provide real-time education.

And whenever you are learning and you can apply what you learned to something

that you experience, that is a great way to reinforce that education.

When it comes to the usual performance determination, I think one of the best things the teams can do is to make this a team process. Put together a collaborative team of your qualified clinicians that can review that charting documentation and help to make those decisions.

Some of your charting is going to be very clear and you won’t need to have that additional conversation of what is usual.

So, for example, if a resident eats independently every day, every episode during that three-day window, their usual performance is independent. But if you have fluctuations, that is when your team will need to look at all of the documentation from therapy, direct care staff, everyone who is involved and had documentation to support the performance during that period and then make that determination of the resident’s usual performance.

When we tie that back to Five-Star and QMs, when we focus on not the outcome of those quality measures, but when we focus on the accuracy of section GG, that’s what’s going to give us an accurate MDS and accurate quality measures.

Now, if we identify there is a process we need to work on such as towards that discharge function score or ADL decline, that’s something that we need to address outside of MDS accuracy once we’ve validated that the MDS is accurate.

So, a lot of moving pieces there, but education and the focus on MDS coding accuracy are your key ways to make sure GG is accurate.

Amy:

Thank you for that. Several respondents emphasized a lack of ownership and communication across the IDT and leadership. How can stronger collaboration among nurses, supervisors, the DNS, and other leaders support the NAC’s Five-Star management efforts?

Jessie:

Oh, I love this question. It goes back to how complex Five-Star is and it’s so complex that oftentimes no one wants to own it. As the NAC, a lot of times because this is a quality measurement program, you’re highly involved in it. However, the Five-Star program should never be viewed solely as the NAC’s responsibility. And for that matter, QMs should also not be viewed as solely the NAC’s responsibility. The quality measures are really a measure of the care that we provide. And the MDS is just the messenger. So, it’s the way that CMS collects the data in an organized way.

To be successful with Five-Star with your quality measure programs, we can’t have the focus just on the MDS or just on those outcomes. We actually have to look back at that root cause of why did that QM trigger? What was the event or the condition that allowed that quality measure to trigger?

So, for example, if we have falls, pressure ulcers, if we have readmissions, or emergency department visits, the focus cannot just be on how is the MDS coded to capture that, but what systems and processes does the facility have in place to prevent the falls, to prevent pressure ulcer development, or to heal pressure ulcers timely, to ensure safe discharges home, to prevent rehospitalizations, to prevent unnecessary emergency department visits?

And when we focus on the prevention, and we focus on the systems and processes

that lead up to that quality measure being triggered, that’s where we’re going to see ongoing quality improvement efforts. And it really takes the entire facility and a facility culture of process improvement.

When we tie Five-Star into that, the Five-Star data is old. It is how your facility performed,

not how your facility is performing right now. So, while it’s important to know what your Five-Star rating is because a lot of different consumers are looking at that—you might have hospital discharge planners that are looking at this and sharing this with potential referrals; you may have Medicare Advantage plans looking at this as part of their contracting; you may have other residents looking to come in from the community looking at Five-Star as part of their facility selection process. And that’s just one piece of the overall puzzle of what your facility is and how you perform.

And again, it’s more historical data. So, when you have that opportunity to share what you’re doing today for quality improvement, what goals you’ve achieved, what outcomes you’ve achieved that maybe aren’t yet reflected in Five-Star is how you can really help your team and your leadership understand your overall performance, where you’re at today, and how that compares to your Five-Star rating.

And this should be something that leadership is also highly involved in. So leadership should bring the trends, the root causes, and share that with your IDT as part of a culture

of process improvement, while the NAC can bring the MDS point of view of what kind of successes we’re seeing on a day to day basis.

The team should celebrate big successes such as when you achieve a higher rating in your Five-Star and also those small successes such as a trend down in rehospitalizations or a trend down in falls.

The NAC is really there to help interpret the data from the MDS, but it really takes the entire team to have success and manage the Five-Star and quality measures in general.

Amy:

Thank you for that.

I think this is a great opportunity for the directors of nursing and the nurse leaders to work with the MDS because as you said, the MDS is where we document it, but it’s often a deeper-rooted problem such as a system issue. So that’s a great opportunity for the two people to work together.

Jessie:

Completely agree, Amy.

Amy:

Another common concern with Five-Star is that many of the measures are influenced by events that NACs cannot directly control, such as rehospitalizations, which you mentioned, and emergency department visits, unplanned discharges, and staffing instability. How should the NAC approach these types of measures?

Jessie:

When it comes to these types of measures, I always say focus on what you can control

and learn from any mistakes made. And if you don’t like calling them mistakes,

then we can call them opportunities, or missed opportunities.

For example, if you have a resident that has an unplanned discharge to the emergency department or hospital, the team should focus on the root cause. And as you said, Amy, this is a great opportunity for the director of nursing to partner with the NAC to really not just focus on how is this captured on the MDS, but what happened and when? What caused this event? What caused the resident to have an unplanned discharge to the emergency department? Was it a fall? Was it a miscommunication? Was it a failure to do a comprehensive assessment and communicate that to the physician?

Oftentimes, when we are looking at it retrospectively, so again, we’re not trying to prevent this event from happening that’s already occurred, but we’re looking at it with an open mind, saying, “Okay, what happened? And was there a system, process, or communication that broke down that we can improve, fix, adjust—some kind of small change to move towards process improvement?”

Again, we can’t change the fact that that resident already went out to the emergency department or hospital. However, when we identify that root cause or contributing factor, it could be something like a care plan intervention wasn’t in place. And then looking at, “Well, why wasn’t it in place? Would it have prevented the event?” And digging even more into that why it wasn’t in place—was it not communicated to staff? Was equipment missing? That entire process of root cause analysis will help us get down to identifying the process, system, and policy. And even if we step back and we say, you know, this really wasn’t preventable, oftentimes there is a piece of it where we can control and we can tighten up those quality improvement efforts. So even though a lot of it seems like it’s out of our control, oftentimes there are pieces of it that we can control and we can improve. And that’s the part we want to focus on.

Amy:

Excellent, thank you for that.

The survey also revealed frustration with the delay between making improvements

and seeing those changes reflected in the Five-Star results. How can NACs explain this delay and maintain momentum when waiting for their progress to be publicly reported?

Jessie:

This goes back to some of the things we’ve already talked about Amy, but it is so important to understand that Five-Star is old data. Again, it’s how you performed, not how you are performing. And an example of that is we just had our July 2026 Refresh, it was at the end of July. And this refresh added the quarter one (Q1) 2026 data as the most recent data. So when you’re looking at that four full quarters of data that’s reported for the QMs and Five-Star, the most recent quality measure data as of the end of July is March 31st. So we have quite a gap there.

And by the time we get to the October Care Compare Refresh, which is the next time the QMs will be updated, that March 31st data is the most recent data all the way through that October refresh. So it stays on there a while.

And that is one of the reasons why I say you have to be aware of your Five-Star outcome—so you’re aware of your star rating, aware of where your opportunities are, where your successes are for Five-Star, so you can speak to those. But your quality improvement efforts must be focused on what you are seeing today and measured on more real-time reports.

So whether that is a more real-time report within your electronic health record, or your software, or you’re running iQIES reports for your quality measures more frequently. So you might be updating them once a week, every other week, to see the changes in your QM reporting of new triggers, who’s come off, and better understanding your current quality improvement efforts.

When we focus on just the residents who triggered, and I see this happen often when we’re talking about quality measures, is when I have residents who have triggered and I’m focused on when they will come off, that is just a timing. You’re just waiting out the time for that trigger to fall off the measure. And if no new residents trigger, then yes, your QMs will improve.

But if you change nothing other than waiting for that resident to come off, you will likely have new residents who will just replace that resident or continue to grow, because your focus is on the MDS and waiting for them to come off, and not the underlying process or system that allowed them to trigger in the first place.

So again, the MDS is only the messenger, and the underlying processes and systems have to be where our focus is. And so, when we’re waiting for a Five-Star to update, when we’re waiting for those improvements to show in our Five-Star rating, our day-to-day focus has to be on the quality improvement efforts that we’re making to those underlying processes and systems.

We’re not going to get ahead if we’re only focused on the MDS and when residents will start or stop triggering.

Amy:

I think that’s my favorite part of this podcast, Jessie, because I do see a lot of that. When can we do an MDS so this person falls off? But you’re absolutely correct. If you’re not looking at it to prevent future occurrences, you really aren’t fixing the underlying problem. So thank you for that. Before I let you go, are there any tips that you would like to share today with our listeners?

Jessie:

Oh, I think I’m going to kind of just add on to what you just said, Amy, with that focus

on waiting for the MDS to just improve. And when I talk about quality measures and a lot of different settings, I often see the MDS as a blame for the quality measure. And I think this speaks not just to the NAC and wanting to know when I can do another MDS so that resident will stop triggering, but also to the directors of nurses and any nursing home administrators.

Knowing that when we focus on the MDS, the MDS is just the messenger. It’s the one carrying that data from our clinical record to CMS. It’s not the problem. The problem is that underlying event. So, whether it’s a fall, or a pressure ulcer, or an unplanned discharge,

even though that’s more claims-based, not on the MDS, but any of those quality measures—the focus has to be on the underlying system.

And this, again, not just for NACs, but for the entire IDT, focus on that culture of process improvement and realize that the quality outcomes are just a reflection of what is the care provided in your facility and what the MDS has been coded based on that underlying documentation.

And I’ll add just one more thing on the broader topic of Five-Star, because Five-Star is never the full story of your facility’s performance—whether it is the health inspection, staffing, or quality measures, it’s all snapshots in time. And it doesn’t show where your facility is today. It shows the history of your facility’s performance for health inspection, staffing, and quality measures. And, always be prepared as a team to be able to speak to your current efforts and what you’re doing today for quality improvement efforts. Because, again, Five-Star is older data. It’s important, but it’s not the full story.

Amy:

I really appreciate you sharing your expertise with our listeners today.

Jessie:

Thanks for having me, Amy.

Amy:

Listeners, thank you for joining us today. For more resources and tools for nurse assessment coordinators, please visit our website at www.AAPACN.org. To ensure that you never miss an episode, subscribe to the LTC NAC Chat podcast.

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