SNF QRP Part 4 – Function Quality Measure

This measure, selected by CMS as part of the SNF QRP, will measure the percentage of residents with an admission assessment (i.e. 5-day PPS assessment), and a discharge functional assessment, and a treatment goal that addresses function. This measure is considered a process measure that looks at facility processes rather than a resident functional outcome measure.

The majority of residents who receive post-acute services in a SNF, LTCH, and IRF have functional limitations, and many of these residents are at risk for further decline in function due to limited mobility and ambulation. The clinical practice guidelines Assessment of Physician Function recommends that clinicians should document functional status at baseline, and over time to validate capacity decline or progress. This QM will assess whether post-acute providers have systems and assessment processes in place to comply with this recommendation.

Calculating the Function Quality Measure

As with all QRP Quality Measures, the data used for calculating this QM will come from the MDS. Specifically, data will be derived from the new Section GG that will be implemented as of 10/1/2016.

Section GG will consist of the following functional status items:

Self-Care Items

  • Eating
  • Oral Hygiene
  • Toileting Hygiene

Mobility Items

  • Sit to lying
  • Lying to sitting on side of bed
  • Sit to stand
  • Chair/bed-to-chair transfer
  • Toilet Transfer
  • Walk 50 feet with two turns, if ambulatory
  • Walk 150 feet, if ambulatory
  • Wheel 50 feet with two turns, if applicable
  • Wheel 150 feet, if applicable

The actual Quality Measure will be calculated as follows:

Denominator:

Number of Medicare Part A covered resident stays during the reporting period.

Numerator:

Number of resident stays with functional assessment data for each self-care and mobility activity and at least one self-care or mobility goal.

Both residents with “complete” stays and those with “incomplete” stays will be calculated into the numerator. Here is how the numerator will be determined for each:

Complete Stay:

All three of the following criteria are required:

  • A valid numeric score indicating the resident’s functional status, or a valid code indicating the activity was not attempted or could not be assessed for each of the functional assessment items on the admission assessment (i.e. 5-day assessment).
  • A valid numeric score, which is a discharge goal indicating the resident’s expected level of independence, for at least one self-care or mobility item on the admission assessment (i.e. 5-day assessment).
  • A valid numeric score indicating the resident’s functional status, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the discharge assessment.

Incomplete Stay:

Residents who have incomplete stays are defined as those residents (1) who are discharged to the hospital unexpectedly, (2) who leave the SNF against medical advice, or (3) who expire in the SNF. Discharge functional status data are not required to be reported for incomplete stays.

The following are required for the residents who have an incomplete stay to be counted in the numerator.

  • A valid numeric score indicating the resident’s functional status, or a valid code indicating the activity was not attempted or could not be assessed for each of the functional assessment items on the admission assessment (i.e. 5-day assessment).
  • A valid numeric score, which is a discharge goal indicating the resident’s expected level of independence, for at least one self-care or mobility item on the admission assessment (i.e. 5-day assessment).

Example 1: Complete Stay

Mr. Jacobs was admitted on November 10th, 2016 and discharged to home on December 8th, 2016. The 5-day/Admission assessment indicates that all self-care and mobility items were properly completed in Column 1 (Admission Performance) and at least one self-care or mobility goal was completed in Column 2 (Discharge goal). In addition, the discharge assessment indicates that his functional status was appropriately assessed and coded for all items in Section GG on the discharge assessment.

Mr. Jacobs would meet the criteria to be included in the numerator.

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Example 2: Incomplete Stay

Mrs. Johnson was admitted to the SNF on November 10th and expired on November 30th. The 5-day/Admission assessment indicates that all self-care and mobility items were properly completed in Column 1 (Admission Performance) and at least one self-care or mobility goal was completing in Column 2 (Discharge Goal). Since this stay would be considered “incomplete” no discharge functional data would be required.

Mrs. Johnson would meet the criteria to be included in the numerator.

Facilities would want a higher percentage of residents qualifying for this particular QM as it would demonstrate that the facility has appropriate clinical processes in place to assess a resident’s function upon admission, establish a discharge goal, and assess the functional status upon discharge, as applicable.

Next Issue (coming soon)
Part 5: Introduction to MDS 3.0 Section GG

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