Quality Measures

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What's New

July 1, 2024 

MDS 3.0 QM User’s Manual Version 16.0 Risk Adjustment Appendix File – Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V16.0 Risk Adjustment Appendix File is now available. The Risk-Adjustment Appendix File for the MDS 3.0 Quality Measures User’s Manual accompanies the MDS 3.0 QM Manual Version 16, and contains the logistic regression coefficient values used to calculate the risk-adjusted quality measures that are included in the Nursing Home Quality Initiative (NHQI), effective October 1, 2023.

Changes encompassed in the appendix include:

• The removal of the national average and coefficient values for the Percent of Residents who Made Improvements in Function (Short Stay) (CMS ID: N037.03) measure, as it was retired from the NHQI effective October 1, 2023; and
• The addition of the national average and coefficient values for the new Percent of Residents with Pressure Ulcers (Long Stay) (CMS ID: N045.01) and the Percent of Residents with New or Worsened Bowel or Bladder Incontinence (Long Stay) (CMS ID: N046.01) measures, implemented in the NHQI effective October 1, 2023. 

The latest national averages and coefficient values for the new and existing risk-adjusted NHQI measures in this appendix were calculated using MDS data submitted for 2024 Quarter 1.

A new .zip file (MDS 3.0 QM Manual v16.0 Effective 10-1-2023 and Associated User Manual Files Update.zip) containing the v16 Risk Adjustment Appendix is available under the Downloads section of this webpage. This file includes a complete set of the latest user manual files for nursing home quality measures: 

1. MDS 3.0 QM User’s Manual V16.0 (MDS-3.0-QM-USERS-MANUAL-v16.pdf) contains detailed specifications for the MDS 3.0 quality measures, as well as the Quality Measure Reporting Module Table that documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. 
2. Risk Adjustment Appendix File for MDS 3.0 QM User’s Manual V16.0 (Risk-Adjustment-Appendix-File-for-MDS-3.0-Quality-Measures-User's-Manual-V16.xlsx) contains the logistic regression coefficients used for risk adjustment.
3. Nursing Home Compare Claims-based Quality Measure Technical Specifications (Nursing Home Compare Claims-based Measures Tech Specs 2023 Update 03-20-2023.pdf) contains detailed technical specifications for all Nursing Home Claims-based Quality Measures.
4. Nursing Home Compare Quality Measures Technical Specifications Appendix (APPENDIX - Claims-based Measures Technical Specifications Updates 03-20-23.pdf) contains tables and appendices related to the Nursing Home Compare Claims-based Quality Measures. 
5. Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual V5.0 (snf-qm-calculations-and-reporting-users-manual-v5.0.pdf) contains detailed specifications for all SNF QRP Quality Measures effective October 1, 2023.
6. Risk Adjustment Appendix File for the SNF QRP Measure’s Calculations and Reporting User’s Manual V5.0 (Risk-Adjustment-Appendix-File-for-SNF-Effective-10-01-2023.xlsx) contains risk-adjustment values used to calculate SNF QRP risk-adjusted quality measures.

September 21, 2023

Public Reporting Timeline for NHQI Measures Impacted by the MDS 3.0 G-GG Transition

Effective October 1, 2023, Minimum Data Set (MDS) Section G: Functional Status will be replaced with Section GG: Functional Abilities and Goals. This transition will significantly impact the specifications of the following Nursing Home Quality Initiative (NHQI) Quality Measures (QMs):

• Percentage of Residents Who Made Improvements in Function (Short Stay)
• Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay)
• Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)
• Percent of High-Risk Residents with Pressure Ulcers (Long Stay)
• Percent of Low-Risk Residents Who Lose Control of Their Bowel and Bladder (Long Stay)

To address the impact of this Section G to GG transition on the 2024 Nursing Home Care Compare public reporting schedule, the Centers for Medicare & Medicaid Services (CMS) will freeze (hold constant) the aforementioned QMs on Nursing Home Care Compare in April 2024. In October 2024, CMS will replace the Percentage of Residents Who Made Improvements in Function (Short Stay) measure with the new Discharge Function Score measure which was finalized in the FY2024 SNF PPS Final Rule for use in the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) and the SNF Value Based Purchasing (VBP) program. The remaining four measures will continue to be frozen until January 2025 while the data for the equivalent measures are collected.  

Please see the Updates to Nursing Home Care Compare Staffing and Quality Measures Quality, Safety & Oversight Group (QSO) memo for more information.

For more information on the new and re-specified QMs please see the MDS 3.0 QM User’s Manual V16.0, which can be found in the Downloads section of this webpage.

The current nursing home quality measures are:

Short Stay Quality Measures

• Percent of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
• Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
• Percent of Residents Who Newly Received an Antipsychotic Medication
• Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
• Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
• Percent of Residents Who Received the Seasonal Influenza Vaccine*
• Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
• Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
• Percent of Residents Who Received the Pneumococcal Vaccine*
• Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
• Discharge Function Score

* These measures are not publicly reported but available for provider preview.

Long Stay Quality Measures

• Number of Hospitalizations per 1,000 Long-Stay Resident Days
• Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
• Percent of Residents Who Received an Antipsychotic Medication
• Percent of Residents Experiencing One or More Falls with Major Injury
• Percent of High-Risk Residents with Pressure Ulcers
• Percent of Residents with a Urinary Tract Infection
• Percent of Residents Who Have or Had a Catheter Inserted and Left in Their Bladder
• Percent of Residents Whose Ability to Walk Independently Worsened
• Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
• Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
• Percent of Residents Who Received the Seasonal Influenza Vaccine*
• Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
• Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
• Percent of Residents Who Received the Pneumococcal Vaccine*
• Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
• Percent of Residents Who Were Physically Restrained
• Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
• Percent of Residents Who Lose Too Much Weight
• Percent of Residents Who Have Depressive Symptoms
• Percent of Residents Who Used Antianxiety or Hypnotic Medication
• Percent of Residents with Pressure Ulcers
• Percent of Residents with New ore Worsened Bowel or Bladder Incontinence

* These measures are not publicly reported but available for provider preview.

Quality measure specifications are available in the QM Users’ Manual download file, which can be found under the Downloads section below. A sub-group of quality measures are incorporated into the Five-Star Quality Rating System and used to determine scoring for the quality measures domain on Nursing Home Compare.