Editor's note: This text-based course is a transcript of the webinar, Mastering Quality Measures: Navigating LTC Regulations for Rehab Success, presented by Kevin Cezat, PT, DPT, GCS, RAC-CT.
Learning Outcomes
- After this course, participants will be able to list three or more quality measures relevant to long-term care.
- After this course, participants will be able to describe how three or more quality measures are calculated.
- After this course, participants will be able to identify two or more strategies for therapists to maximize quality measures.
Risks/Limitations
- The applicability and accuracy of the course content may vary by the clinical, geographical, and cultural context; you should evaluate the course accordingly.
- As healthcare is rapidly evolving, new findings may change the validity of the information presented in this course. Providers should always consult the latest research and guidelines from professional associations.
- The interventions discussed in this course may be limited in generalizability, requiring practitioners to consider specific individual and population factors.
- The course may not cover all possible risk factors, diagnostic methods, or treatment options, and complex cases may require additional considerations.
- Healthcare providers should apply cultural competence and sensitivity to ensure effective and respectful care based on their patients’ diverse needs.
- Providers should always evaluate the limitations of diagnostic and screening tools, considering their potential for false results as well as any ethical implications.
- It is the responsibility of course participants to critically evaluate the evidence from multiple sources to guide professional practice.
Introduction
Let's be candid: regulatory and reimbursement structures are not always the most exciting topics. For busy clinicians, finding the time to explore payment models can seem like an impossible task. However, my experience has taught me how critical it is for therapists to engage with this side of our profession, even when it feels peripheral to our clinical duties.
This isn't meant to be alarmist, but a reality check. If you work in long-term care, particularly in Skilled Nursing Facilities (SNFs), you've likely seen that upcoming payer changes and the broader shift toward value-based care are fundamentally about controlling costs.
While this transition brings opportunities to showcase our clinical expertise, the hard truth is that in many of these new models, we are often viewed as a cost center rather than a driver of reimbursement. If we cannot consistently and clearly demonstrate our value, we risk being underutilized or eliminated entirely.
Understanding these frameworks is no longer just about staying informed—it's about professional survival and finding ways to thrive in the models of the future.
To provide some context, I would like to share my background briefly. This will help you understand the lens through which I view these changes and where my own biases might lie.
My entire career has been dedicated to serving the needs of long-term care and older adults. I've worked across the continuum, including skilled nursing facilities (SNFs), assisted and independent living, home health, and Continuing Care Retirement Communities (CCRCs). After many years as a rehab director, I transitioned into my current role focusing on clinical quality and education within these settings.
I'm licensed in Florida, Arizona, and Ohio, and currently serve as the vice chair for the APTA Geriatrics SNF Special Interest Group, which has deepened my involvement in advocacy. While the majority of my work involves large-scale quality initiatives, I remain clinically active, treating patients five to ten hours per week.
As you can see, my experience is heavily rooted in the world of SNFs and long-term care. I strive to bridge the gap between day-to-day clinical realities and the broader strategic picture. My goal here is to be transparent and provide a framework that helps you understand where our profession is headed.
Definitions, Purpose, and Impact of Quality Measures in Long-Term Care
Defining Quality Measures
The term “quality measures” is incredibly broad, and its meaning often changes depending on who you ask. At their core, quality measures are simply metrics used to evaluate aspects of healthcare, such as patient outcomes, patient experience, or internal processes.
However, the interpretation of these measures can vary dramatically. An MDS nurse, a Director of Nursing, and a facility administrator may each have a different understanding of what the term entails. The complexity grows when you consider the setting. Every environment has its own set of quality measures guided by distinct programs and priorities, including:
Acute care
Inpatient rehabilitation facilities (IRFs)
Home health
Outpatient clinics
Skilled nursing facilities (SNFs)
For this course, our focus will be specifically on SNF and long-term care quality measures. Keep in mind that depending on your work setting, you may be operating under several different CMS-based or payer-driven quality reporting programs, each with its own structure and goals.
Purpose and Impact of Quality Measures
The intent behind these measures is straightforward: to ensure a baseline of clinical quality, promote accountability, create public transparency, and foster competition among facilities. They are essential tools for identifying areas that require improvement.
The impact of these measures is significant and multifaceted. They have direct and indirect financial implications, influencing reimbursement rates through programs like the Quality Reporting Program (QRP) and Value-Based Purchasing (VBP). Furthermore, performance is publicly reported on websites like Care Compare, which informs the decisions of patients, families, and referral sources. This public data, including the 5-Star Rating for SNFs, also helps guide state surveyors on what to prioritize during facility inspections.
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that administers the Medicare and Medicaid programs and serves as the central authority for most quality initiatives in the U.S. Nearly all CMS programs use quality measures not only for evaluation but also as a way to communicate performance to beneficiaries.
CMS defines quality measures as standardized instruments used to assess key components of healthcare. These measures are designed to promote high-quality care by aligning with six core objectives:
Effectiveness
Safety
Efficiency
Patient-Centeredness
Equity
Timeliness
The overarching goal is to ensure that frontline healthcare practices are consistently aligned with these broader quality priorities.
Care Compare
A critical tool to have on your radar is Care Compare. If you work in long-term care and aren't familiar with it, I highly recommend exploring the site. Care Compare is a publicly accessible, CMS-managed website that provides detailed information on providers across all care settings. Anyone can use it to search for and compare facilities.
I encourage you to look up your own facility. You can find results from your most recent state survey, staffing level details, and performance on various quality measures. For SNFs, the site prominently displays an overall star rating. This is a powerful resource for patients and families evaluating care options, as it provides a snapshot of facility performance and is a solid starting point for assessing quality.
State Survey Agencies (SAs)
State Survey Agencies (SAs) are contracted by CMS to conduct surveys, ensuring facilities meet all federal Medicare and Medicaid regulations. They examine everything from nursing care to therapy documentation and outcomes, especially when tied to resident decline or quality issues. Quality measures are a key part of their guidance.
When surveyors dig into a facility’s performance, they look for strong interdisciplinary team involvement. Although therapy is not always the primary focus, understanding what surveyors are looking at is crucial to avoid being the cause of a negative finding, or "F-tag."
How Measures Are Categorized
In the SNF setting, quality measures are broken down in several ways. The two most common classifications are by length of stay and by data source.
1. Short Stay vs. Long Stay. This distinction is based purely on the number of days a resident has been in the facility for a given episode of care.
Short Stay Measures: Apply to residents who have been in the facility for 100 days or less.
Long Stay Measures: Apply to residents who have been in the facility for 101 days or more.
It's important to remember this is based on length of stay, not payer type. It doesn't distinguish between a subacute Medicare stay and a long-term care stay; it's simply a calculation based on days.
2. Type of Data Source. Measures are also categorized by the source of the data. The main sources in long-term care are:
MDS-Based Measures: The data is collected from the Minimum Data Set, a comprehensive clinical assessment tool.
Claims-Based Measures: The data is derived from claims submitted to Medicare for reimbursement.
NHSN Data: The data comes from the National Healthcare Safety Network, a surveillance system run by the CDC that tracks infections and other safety events.
MDS Based Measures
From a therapy perspective, understanding the Minimum Data Set (MDS) is perhaps the most important piece of the quality puzzle. The MDS is a comprehensive assessment tool used in all Medicare- and Medicaid-certified nursing homes to collect standardized information on residents.
Facilities must complete these assessments on all residents, regardless of their payer source, gathering data on their physical, psychological, and psychosocial presentation. This is a continuous process, following a regular schedule:
Long-Term Residents: Assessed on admission, quarterly, annually, and whenever there is a significant change in status.
Short-Term ("Subacute") Residents: Assessed on admission and discharge, with an occasional interim assessment if needed.
The data is used to drive care planning, calculate quality measures, and determine reimbursement rates. While therapists are most familiar with Section GG (Functional Abilities and Goals), the entire assessment is extensive.
Examples of MDS-Based Measures. Here are some common quality measures derived from MDS data:
Short Stay
Percent of Residents Who Newly Received an Antipsychotic Medication
Discharge Function Score
Long Stay
Percent of Residents Experiencing One or More Falls with Major Injury
Percent of Residents Who Lose Too Much Weight
Percent of Residents Who Used Antianxiety or Hypnotic Medication
Percent of Residents With Pressure Ulcers
Percent of Residents With New or Worsened Bowel or Bladder Incontinence
Prevalence of Falls
Prevalence of Behavior Symptoms Affecting Others
This is the probably the most important piece from a therapy perspective.
Calculations
MDS-based quality measures are created by looking at the number of residents who have a certain condition within a specific time frame.
The Basic Formula. Although it may sound more complicated than it is, the calculation is straightforward. Each MDS-based quality measure is linked to a specific item on the MDS assessment. The formula is: the number of nursing facility long-stay residents or short-stay residents with certain conditions or problems (e.g., falls resulting in major injury) divided by the total number of residents who had valid stays during that period.
Calculation Example: Falls. The "Falls with Major Injury" quality measure is based on the answer to Section J1900C of the MDS. Let's walk through a simple calculation for a general falls measure:
Numerator: First, identify how many residents in the facility had a fall during the look-back period. Let's say it was 4 residents.
Denominator: Next, identify the total number of residents who had a valid MDS stay during that same period. Let's say the total number of residents was 44.
Result: The facility’s score for that quality measure would be a percentage.
4 ÷ 44 = 0.0909, or 9.09%
This percentage becomes the facility's reported score for that measure.
Risk Adjustment: Leveling the Playing Field
However, the calculation doesn't stop there. CMS adjusts the scores to ensure facilities are compared fairly, a process known as risk adjustment. Two primary methods are used for this: exclusion and logistic regression.
1. Exclusion. This is just what it sounds like. Some residents are excluded from a measure's calculation because their outcomes are not considered within the facility's control. For example, residents with certain diagnoses, such as Huntington's disease, or those in specific situations, like those in hospice care, may be excluded from certain measures. Nearly every quality measure has specific exclusion criteria to ensure the data is relevant.
2. Logistic Regression. This statistical method is a bit more complex. Its purpose is to create a fairer comparison between facilities by accounting for the fact that they may serve resident populations with very different levels of risk. It uses resident-level covariates (specific risk factors) to adjust the raw scores.
Let's look at two examples of how this works:
Example 1: Falls. Imagine Facility A has residents who are, on average, 20 years older and have a 50% higher rate of dementia than the residents at Facility B. You would naturally expect Facility A to have more falls simply due to its higher-risk population. A direct comparison of their raw fall scores wouldn't be fair. Logistic regression adjusts for these differences. It statistically levels the playing field, so the final score reflects the quality of care provided, not just the inherent risk level of the residents.
Example 2: Pressure Ulcer Incidence. When calculating the Pressure Ulcer Incidence measure, the model considers specific covariates known to increase a resident's risk of developing a pressure ulcer. These include:
Immobility
Diabetes
Low BMI
If a facility has a higher-than-average population with these risk factors, the model adjusts its score accordingly. This ensures the facility isn't penalized for admitting residents who are already at a high risk for developing pressure ulcers.
Other Types of Quality Measures
Beyond the MDS, data is also collected from claims and national safety networks.
Claims-Based Measures. These measures are derived from payment requests (claims) submitted to CMS and are therefore more financial in nature. Therapy plays a key role in influencing them:
Medicare Spending Per Beneficiary: Tracks the total cost to Medicare from 3 days before a SNF stay through 30 days after discharge. Therapy Impact: Delivering efficient care, avoiding complications, and supporting timely discharges.
Discharge to Community: Tracks the percentage of residents safely discharged home who remain out of the hospital for at least 31 days. Therapy Impact: Effective discharge planning and ensuring patient safety at home.
Potentially Preventable Readmissions: Measures avoidable hospital readmissions within 30 days of SNF discharge. Therapy Impact: This is a critical area where therapists can demonstrate value. We must "own" our role in maximizing functional outcomes to reduce rehospitalization risk.
SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization: Monitors infections acquired in the SNF that lead to hospitalization.
NHSN-Based Measures. The measures we likely pay the least attention to are from the National Healthcare Safety Network (NHSN), a CDC-run program that monitors infection prevention and staff vaccination rates. Following the COVID-19 pandemic, these measures have gained prominence. They primarily track:
Influenza vaccination coverage among healthcare personnel.
COVID-19 vaccination coverage among healthcare personnel and patients.
Rehab Therapy's Role in Quality Measures
Therapy Impact
So, what is our role in all of this? Therapists are not the ones submitting the Minimum Data Set (MDS), administering vaccines, or directly managing wounds and weight loss. While we contribute vital information to all these areas, our direct ownership is limited.
However, as the healthcare landscape shifts toward value-based care, reimbursement will be less about the specific services we provide and more about the outcomes we achieve. This is our opportunity. Instead of being viewed as a cost center, we can demonstrate our value by showing a direct connection between our interventions and a facility's performance on quality measures.
To do this, we first have to understand the measures themselves. We know our interventions have a significant impact on:
Resident functional outcomes (mobility and self-care scores)
Patient safety and fall reduction
Overall quality of life and care
The key is learning to connect the work we already do to the specific metrics that matter.
Section GG
One of the most direct ways therapy influences quality measures is through Section GG of the MDS. While it’s just one section, its importance for therapists cannot be overstated.
Section GG has evolved significantly since data collection began in 2016. Its primary purpose was to create a standardized functional language across all post-acute care settings. Previously, different settings used different tools—for example, Inpatient Rehab Facilities (IRFs) used the FIM (Functional Independence Measure), while SNFs used other methods. This created inconsistency.
Legislation pushed all post-acute care providers to adopt the same coding mechanism to describe a patient's functional status. Now, whether you work in an IRF, SNF, or home health, Section GG provides a common language.
Initially, SNFs were only required to score Section GG for subacute patients under Medicare Part A. This has steadily changed. The old nursing-focused functional section, known as Section G, was used alongside it for years.
A pivotal change occurred on October 1, 2023, when CMS eliminated Section G and officially merged its functions into Section GG. This was a massive shift, as nursing staff suddenly had to learn an entirely new coding language for functional assessment, which proved challenging for many facilities.
Overnight, the importance of Section GG skyrocketed. It is now required on all MDS assessments, including the admission, quarterly, and annual assessments for long-term care residents. Since therapists are not always involved with this population, nurses had to become experts in capturing this information.
As a result, any data that previously relied on Section G now pulls from Section GG. This means Section GG information now feeds directly into quality measures, care planning, potential F-tags, and reimbursement, making it a cornerstone of facility operations.
Section GG includes:
- GG0100 Prior Functioning
- GG0115 Functional Limitation in Range of Motion
- GG0120 Mobility Devices
- GG0130 Self Care
- GG0170 Mobility
While therapists contribute information to many parts of the MDS, Section GG is where our expertise is most critical. This section captures a resident's functional status, including prior functioning, use of mobility devices, self-care, and mobility. However, as an industry, we still struggle with coding it accurately.
Getting Section GG right is not just about compliance; it has major financial and clinical implications. The data is used in several high-stakes areas:
It is a key component in determining the PDPM daily reimbursement rate for Medicare Part A residents.
It feeds directly into multiple quality measures, such as the Discharge Function Score.
Inaccurate or poorly supported GG coding is a major source of payment denials during audits.
It tells a story of our clinical success, as many organizations track GG improvement scores as a primary outcome metric.
One of the biggest points of confusion is the purpose of Section GG. It is a functional assessment, not a therapy assessment.
Its goal is to provide CMS with a standardized snapshot of how a resident is functioning at admission and again at discharge. It is not designed to be a perfect measure of therapy's specific impact. We know its limitations:
Many self-care and mobility items may not be relevant to a specific resident's plan of care.
A resident may already be performing at their prior level of function in several areas.
Therapy may not be directly addressing every item that gets scored.
While GG improvement scores tell part of the story, it is a mistake to use them as the sole measure of therapy's value. Its primary purpose remains a functional data point for CMS.
Section GG Errors
As an industry, we are still coding Section GG poorly. Here are the most common errors encountered in the field, along with their corrections.
- Misunderstanding Item Definitions. Clinicians often have questions about what an activity includes. When does the "eating" activity officially begin and end? Does a transfer include the final steps away from the surface? The definitions for these items are highly specific.
- Misunderstanding the Independence Scale. The GG 6-point scale does not align perfectly with traditional therapy FIM levels or other assistance scales. This can lead to confusion and inaccurate coding
- Improper Use of Code 09. This is a major point of error. Use code 09 (Not attempted due to medical condition/safety) only if BOTH of the following are true:
The activity did not occur during the 3-day assessment window.
The resident did not perform the activity at all prior to their current illness, exacerbation, or injury.
For example, if a resident was ambulatory before their hospital stay but does not ambulate during the 3-day SNF assessment window, you would not use code 09, because they performed the activity before. Another "did not occur" code would be more appropriate.
- Coding Based on Potential, Not Performance. Scores must be based on actual, observed performance during the 3-day assessment window (the day of admission plus the next two days). While you can gather information from multiple sources—direct observation, interviews with the resident or staff, clinical records—it must all relate to what happened during that specific timeframe.
You cannot score a resident based on their potential or what you think they could do. If an activity did not happen, it must be coded as such.
For example, if a resident does not take a shower or a bed bath during the first three days of their stay, the "Bathing" item cannot be scored with a performance code. It must be coded with one of the "activity did not occur" codes, regardless of whether you believe they are capable of performing the task.
So, how do you resolve these issues? The answer to nearly every Section GG question can be found in one place: the RAI (Resident Assessment Instrument) Manual.
The RAI Manual is a document published by CMS that provides official, detailed guidance on how to complete the entire MDS. While the full manual is over a thousand pages, the Section GG chapter is a more manageable 40-60 pages. This document provides black-and-white definitions for every item, clarifies the coding scale, and explains all rules.
I recommend that every clinician have a digital, searchable copy on their computer and consider printing the Section GG chapter for easy reference. When in doubt, the RAI Manual is your definitive source of truth.
