Time Study (STRIVE)

STRIVE Project

Analyses of data collected in CMS national nursing home time study used to establish RUG-IV model

In 2005, the Centers for Medicare & Medicaid Services (CMS) initiated a national nursing home staff time measurement (STM) study, the Staff Time and Resource Intensity Verification (STRIVE) Project. The STRIVE project was the first nationwide time study for nursing homes in the United States to be conducted since 1997, and the data collected were used to establish payment systems for Medicare skilled nursing facilities (SNFs) as well as Medicaid nursing facilities (NFs).

STRIVE began on-site data collection in the Spring of 2006 and finished in the late summer of 2007. The study collected staff time and resident-level clinical information regarding health status, medical conditions, services received, and facility resources used to provide care from 205 nursing homes located across 15 states. A variety of people and organizations--from State agencies and nursing home associations to college students and clinicians—contributed their time and efforts to make this STM study a comprehensive examination of both post acute and long-term care populations.  Almost half of the States use a version of the RUG-III classification system to pay for nursing home care under their Medicaid programs.

Prior to October 1, 2011, CMS reimbursed Medicare Part A SNF services on the basis of a prospective payment system (PPS), which uses the Resource Utilization Groups, version 3 (RUG-III) classification system to determine payments based on patient data. This system was introduced in 1998, and was constructed on the basis of STM studies conducted in 1990, 1995, and 1997. As time passed, CMS came to believe that the introduction of the current prospective payment system may have altered industry practices, and significantly affected the nursing and other staff resources required to treat different types of patients. The updated information from STRIVE reflects the most recent care practices and resource needs of nursing homes.

The contractor, Iowa Foundation for Medical Care (IFMC), utilized an in-depth data analysis using staff time and resident characteristic information from approximately 9,7000 residents. The IFMC team includes: Brant Fries, Ph.D. (University of Michigan); Robert Godbout, Ph.D. (Stepwise Systems, Inc.); David Malitz, Ph.D. (Stepwise Systems, Inc.); and Dave Oatway, M.P.H. (CareTrack Systems, LLC).

STRIVE benefited from stakeholder input, starting with the December 2005 Open Door Forum to which the public was invited. The educators, researchers, beneficiary advocates, clinicians, consultants, government experts, and representatives from health care, nursing home, and other related industry associations serving on the STRIVE technical expert panel (TEP) provided valuable insights on topics such as sample populations.  From 2005 until 2009, IFMC held five TEP meetings.

Slides from the Open Door Forum and TEP meetings are available below under Related Links Outside CMS. (Click on QTSO Time Study (STRIVE) Website). Items posted on the QTSO website include Frequently Asked Questions, Train the Trainer materials, and assessment forms distributed during the data collection phase.

An  examination of RUG III-related resource times and payment rates has suggested that SNF care patterns have changed over the decade since the last STM studies.  Evaluation of the STRIVE data ultimately culminated in SNF PPS refinements and established the RUG-IV model.

Reports from Phase I (Data Collection) and Phase II (Data Analysis) of the STRIVE study are available in the Downloads section below.

Minimum Data Set, Version 3 (MDS 3.0) and STRIVE

In response to changes in nursing home care, resident characteristics, advances in resident assessment methods, and provider and consumer concerns about the performance of the Minimum Data Set (MDS) 2.0, CMS contracted with RAND and Harvard to undertake a significant revision and national testing of Version 3.0 of the MDS. The MDS 3.0 and RAND Final Report are available on the MDS 3.0 website (see Related Links Inside CMS below).

Please see the download section below for information which may be used to calculate case-mix indexes for the various RUG systems.