The Centers for Medicare and Medicaid Services (CMS) this week released the Minimum Data Set 3.0 quality measures user’s manual, with notable changes being far more sweeping than many in the sector expected.

Two major updates involve the respecification of the long stay antipsychotic measure and a risk adjustor modification to the discharge function score measure, based on the removal of occupational and physical therapy minutes from the MDS version 1.20.1.

Regarding the antipsychotic medication change, Medicare and Medicaid claims and encounter data will now factor into the percent of residents who had such medication ordered or filled for them during their entire nursing home stay, the agency said. Prior to the change, only the MDS seven-day look-back was used.

“With the scope of it, I’ve got major concerns about it,” Joel Van Eaton, vice president of compliance and regulatory affairs for Broad River Rehabilitation, said of the new antipsychotics measure. “It doesn’t take into account anything that happened in terms of antipsychotic reductions.”

The national percentage of residents who received an antipsychotic medication is expected to rise significantly as a result of the new methodologies, from 14.64% to 16.98%, and will directly impact the Five-Star Quality Rating System, Van Eaton said.

“They’ve expanded significantly the amount of time the facilities are going to be dinged for antipsychotics beyond the MDS,” he said.

Today, if a resident were to receive antipsychotic medication outside of the seven-day look-back period, it wouldn’t be captured on the MDS and would not impact the long-stay antipsychotic measure, explained Jessie McGill, senior curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).

Under the MDS change, if the prescription is filled during the target period, it will trigger the measure, even if the medication wasn’t received by the resident, McGill told SNN.

The discharge function score updates, meanwhile, are “befuddling,” he said. The risk adjustment won’t be recorded until the discharge assessment, rather than the five-day assessment.

“It’s much like PDPM, right? You get a HIPPS code to bill based on the resident’s unique characteristics, and all of the characteristics that are covariates are unique to that resident; that’s what determines your expected [discharge function] score,” said Van Eaton. “Now you won’t know that last covariate until the resident discharges.”

It will be difficult for nursing homes to assess quality in real time, he said, with this change making this quality measure inaccessible until the patient discharges.

Overall, nursing home operators should remain vigilant regarding MDS changes, ensuring that staff receive comprehensive training on how to complete an assessment, Jodi Eyigor, senior director of nursing home quality and policy for LeadingAge, told Skilled Nursing News.

On-site surveys could result in citations, while MDS validation audits verify the accuracy of assessment-based quality measures, and audits of claims under the patient-driven payment model aim to safeguard against fraud, waste, and abuse, Eyigor said.

“Staying informed and leveraging all available resources will position providers for success in delivering high-quality, patient-centered care,” noted Eyigor.

New antipsychotic quality measure

Claims will count any antipsychotic medicine ordered or filled at any time during the entire nursing home stay as part of the new measure, not just during the MDS observation window. For long-stay residents, the timeframe goes from a week to several years in a lot of cases, Van Eaton said.

Medicare Part D, Medicaid pharmacy claims and other outpatient or physician claims don’t reflect actual administration of the antipsychotics, only that the medication was filled, he said. The resident may have never taken it, or the facility could have quickly discontinued it after admission.

The move aligns with the agency conducting off-site schizophrenia audits, Van Eaton said, and was done to combat underreporting of antipsychotic use and overreporting of schizophrenia. But, CMS may be pushing too far by making the measure retroactive across the entire stay while ignoring clinically appropriate uses.

Specifically, CMS recognizes schizophrenia, Tourette’s and Huntington’s disease as valid diagnostic exclusions, despite widespread concern that diagnoses like bipolar disorder or schizoaffective disorder are also clinically appropriate indications for antipsychotics.

One addition to exclusions was for hospice services, McGill added. It’s a positive for the sector, considering it allows providers to manage distressing end-of-life symptoms with antipsychotics without being penalized in the quality measure, McGill noted.

“If the claim did not appropriately list the diagnosis, the resident will still trigger the measure,” McGill said.

Real-time improvements will be more difficult

Discharge function score changes can now only be captured at discharge, not on the five-day assessment as before, Van Eaton said. The shift occurred when CMS removed occupational and physical therapy minutes but didn’t adjust the risk adjustment formula accordingly. 

As a result, providers won’t know a resident’s expected functional score at the start of their Medicare Part A stay. Instead, they’ll only know this score after discharge.

The change makes real-time quality improvement much harder and introduces unnecessary complexity, Van Eaton said.

“For most facilities, it’s probably not going to be a big deal,” said Van Eaton. “But for those of us that are looking at this on a regular basis, though, we want to know the discharge function score at the outset so we can make sure that our programming matches the resident’s unique characteristics to achieve that score.”

It tips the scales in favor of operators who have specialized software to calculate expected scores earlier, he said, but the overall impact on national quality results is unclear. Unnecessary complications may impact care planning, therapy programming and, again, Five-Star ratings, Van Eaton said.

“It’s vital information. We just have to assume at admission that they did receive therapy … by and large most people do, but I think it just throws one more cog into the complicated nature of this quality measure, which was not necessary,” said Van Eaton.