Value-based care program (VBP) measures proposed by the Centers for Medicare & Medicaid Services (CMS) have long loomed over skilled nursing operators, and now it seems more are finally on their way for 2026.
Staffing-related measures, rehospitalization, discharge and infection prevention are all areas of focus for CMS’ proposed and finalized measures alike. Moreover, proposals are expected to add health equity and long-stay metrics, with the federal agency showing interest in factoring in both the medical complexity and dual eligibility of patients at facilities, experts said.
Brian Ellsworth, vice president of public policy and payment transformation at Health Dimensions Group, said one major measure to look out for is actually the only one that has been in place thus far – rehospitalization.
“That’s been suppressed. [CMS is] proposing to unsuppress it,” said Ellsworth. “That adjustment may be coming back into play.”
If approved, the 30-day all-cause readmission measure would be unsuppressed starting Oct. 1, Ellsworth said.
Another measure proposed for 2026 implementation is staffing turnover. It’s one of the “most significant,” and one that operators should be focused on for multiple reasons, he said.
“One is, its potential inclusion into this adjustment, but also, because it’s an indicator of quality of care,” said Ellsworth. “Not only does [reducing turnover] improve your metrics for these calculations, but more importantly, it lowers your costs and helps you keep a scarce workforce.”
SNFs must pay close attention to certain measures at least by 2024, as CMS plans to use two years of such data for reimbursement calculation, according to Trish Richardson, chief nursing officer for CareWork.
Another area of focus of incoming VBP measures is survey and certification of nursing homes, with many measures tied to oversight and patient safety. CMS’ emphasis on this is reflected in the funding the agency is requesting for this endeavor, and operators should be paying attention to it too, Richardson said. The agency recently asked for $566 million just to focus on survey and certification program funding.
Ultimately, CMS aims to create an infrastructure to manage a variety of metrics through VBP over time, incorporating these measures into quality review programs like the Five-Star Rating System. And, measures will affect how facilities are perceived by the general public and referring entities.
“This is all part of a larger trend. Once [CMS] creates these metrics and the infrastructure to measure them, they use them in a variety of programs,” noted Ellsworth. “It won’t just be affecting your Medicare Part A payments, it will also be reported on websites and eventually incorporated into star ratings.”
What VBP measures are in the final rule?
Overall, skilled nursing facilities can expect three finalized measures, along with several proposed measures for future years related to the value-based purchasing program, outlined by CMS in May.
Measures finalized by CMS in the 2023 SNF PPS Final Rule include:
- Monitoring SNF healthcare-associated infections requiring hospitalization (SNF HAI), to be incorporated in 2026.
- Monitoring total nursing hours per resident day staffing, to be incorporated in 2026.
- Tracking discharge to the community from post-acute care, set to take effect in 2027.
And Richardson notes, “2024 is a big year for the two new measures coming out in 2026, HAI and staffing, and then you’ve got your discharge to community coming after that.”. These changes highlight infection control and care quality, she said. “This is what we need to be focused on. This is what regulators are looking for.”
Richardson even considers infection control and care quality to be a “hyper focus,” for regulators, a trend years in the making as government agencies at the federal and state level bring operators on a “regulatory rollercoaster.”
Measures proposed by CMS in the 2023 final rule include:
- Replacing the SNF 30-day all-cause hospital readmission measure (SNFRM) with the SNF within-stay potentially preventable readmission measure (SNF WS PPR) by 2028.
- Monitoring total nursing staff turnover beginning in 2026.
- Monitoring percentage of residents experiencing one or more falls with major injury and resulting in a long stay starting in 2027.
- Monitoring the percentage of SNF residents who meet or exceed an expected discharge score during the reporting period by 2027.
- Monitoring the number of hospitalizations per 1,000 long-stay resident days by 2027.
The staffing turnover measure stood out to Richardson, with the federal minimum staffing standard due to be released by CMS. It goes back to focusing on where the agency plans to tie reimbursement to quality goals, she said.
“[CMS] said that Medicare reimbursement would likely be linked to [staff] retention – that doesn’t surprise me,” said Richardson of the proposed staffing measure. Turnover would be the first of the proposed measures to take effect in 2026.
“They call it turnover, but it’s really churn,” said Richardson. “And I think what concerns me the most is that we still don’t have a funding measure in place to support the initiatives needed to address turnover.”
It’s a data point that has wide cost implications for operators, she said. It usually takes around 95 days to fill one position.
An operator may hire 10 people, but maybe half actually show up, and then about three make it to the floor. Meanwhile, operators are spending time, talent and money to bring in as many staff as they can.
It costs SNF operators upwards of $50,000 to $60,000 to replace one RN, and $5,000 to $8,000 to replace one CNA, she said.
Formulaic changes and Medicaid implications
Proposals would also establish case minimum and measure minimum policies, incorporate a health equity adjustment (HEA), add scoring methodology for proposed measures, and update the SNF VBP validation process.
Ellsworth sees these proposed changes as a concerted effort by CMS to move some of these measures toward long-stay, dual-eligible residents.
These more formulaic, technical changes essentially “risk-adjust” the metrics, he said, and open the door to states potentially adopting such measures for Medicaid patients as well.
“To the extent that CMS is creating metrics and measurement platforms that are looking at long-stay patients, and dual eligibles, that increases the likelihood that states will adopt some of these metrics and attach Medicaid payments to them,” said Ellsworth.
It’s a significant long-run play for the federal agency, he added, focusing on health equity and long-stay metrics.
“The implication is on Medicaid payments, but also how the general public is viewing facilities and sorting out facilities that may be focused on the short-term Medicare rehab population versus facilities that take more medically complex, long-stay, dual-eligible populations,” said Ellsworth. “CMS is starting to move in the direction of creating metrics that recognize that difference.”
Richardson likens these updates and changes to best practices in the industry, while also calling on CMS to at the same time to look at lost revenue, a byproduct of staff turnover.
“You wouldn’t do the same thing over and over again and not make an update and change based on a new best practice,” added Richardson.
Know where you stand
While expected start dates are crucial in helping operators focus on particular measures instead of all at once, benchmarking where a facility stands with all measures is also a good approach to ensure there are no surprises in a few years, Richardson said.
Ellsworth echoed these sentiments, adding that operators’ “first order of business” is figuring out performance on readmission and turnover metrics.
“Take a look at how you’re performing today and ask, where are you within those areas? We know CMS Care Compare, the data, is two years old; you have a two-year ramp up,” said Richardson. “You’re measuring against yourself, you’re benchmarking against yourself and skilled nursing facilities around the country.”
Richardson’s advice to operators is to identify where a facility stands with certain measures, and to keep in mind that they have two years to “ramp up” while acknowledging that reimbursement will be based on that data.
Given this, nursing homes will need a personal plan of correction, a serious “introspective perspective,” as Richardson puts it.
“It’s basically looking in the mirror. Where are you today? What do you need to be focused on today? Can you identify where in your business operations today that you have opportunities? I look at it like an old school SWOT analysis – your strengths, weaknesses, opportunities and threats,” said Richardson.
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