Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization (SNF HAI) (3728)

On behalf of Commonwealth Care Alliance (CCA), we appreciate this opportunity to comment on measure # 3728, Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization (SNF HAI). 

CCA supports the proposed Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization (SNF HAI) measure. Infections acquired during in-patient stays, such as during a SNF stay, are common and often preventable, or manageable if detected and treated early. This measure appropriately focuses on only the most severe of such infections as the numerator is limited to infections that have progressed to requiring inpatient hospitalization for management. 

We thank you for your consideration of our response and look forward to continuing to collaborate on these matters. Do not hesitate to reach out if we can provide additional information.

Sincerely,

Nicole Waickman

Director, Medicare Policy

Commonwealth Care Alliance

About CCA

Headquartered in Boston, CCA is a multi-state integrated care system influencing innovative models of complex care nationwide. CCA’s model is consistently recognized as one of the best in the country at managing whole-person care across the continuum, including full integration of primary and acute care, behavioral health, long-term services and supports (LTSS), and services that address social needs. We advocate for equitable and cost-effective policies that lead to high-quality health care for individuals who need it most. 

CCA was a founding plan in the 2004 launch of Senior Care Options (SCO), the first dual eligible demonstration in Massachusetts and the fourth dual eligible demonstration in the nation approved by the Centers for Medicare and Medicaid Services (CMS). Now operating under permanent authority as a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP), CCA serves 14,000 SCO enrollees. For the past three years, our SCO program has received a 4.5-Star rating or better from the CMS Quality Rating System for excellence in quality health care. 

CCA was a thought leader in the development and implementation of One Care, the first Medicare-Medicaid Plan (MMP) program implemented through the Financial Alignment Initiative demonstration and the only such program in the nation exclusively serving dual eligible enrollees aged 21 to 64 at the time of enrollment. CCA’s One Care program has been a top-rated MMP for six consecutive years, based on an annual consumer survey required by CMS, and today serves more than 30,000 enrollees. 

In 2021, CCA began a multi-year, mission-aligned geographic diversification growth strategy to extend our proven care model throughout the United States. With newly launched MA plans in Massachusetts and Rhode Island and recent acquisitions in Michigan and California, including D-SNPs in Rhode Island and Michigan, CCA now serves more than 100,000 individuals, including more than 45,000 dually eligible individuals.

The Association for Professionals in Infection Control and Epidemiology (APIC) has long supported measurement and public reporting of data for improved care and outcomes. Our position on the use of administrative data has not changed since the position paper we authored in October 2010 (http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/ID_of_HAIs_US_Hospitals_1010.pdf ). Exclusive use of administrative data is not a precise measure for identifying HAIs and APIC does not support the use of administrative data for public reporting. We continue to recommend the use of standardized definitions and risk stratification methods such as those established by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) which are considered the gold standard. Use of NHSN has served patients receiving care in acute care facilities well. The CDC’S annual National and State Healthcare-Associated Infections Progress Reports demonstrate that analysis of the acute care data has identified opportunities that with intervention have improved patient outcomes. While we recognize the measure aims to decrease the administrative burden on skilled nursing facilities (SNF), we do not believe the information will be actionable in a way that will improve resident/patient outcomes.  

In response to 2b.01) Level of Validity Testing (p. 50 of the Quality Measure Submission Form):  APIC believes that an additional validity testing level should be conducted for this measure -- Systematic assessment of face validity of performance measure score as an indicator of quality or resource use (i.e., is an accurate reflection of performance on quality or resource use and can distinguish good from poor performance). We recommend that a comparative analysis be conducted with a test population comparing the coding sourced infection data vs. standardized HAI surveillance with definitions for the same population. NHSN surveillance data should be the ruler against which this measure is evaluated for face validity. 

APIC feels obligated to express our concern and support once again for dedicated full-time infection preventionists (IP). If skilled nursing facilities had the dedicated resource of full time IPs, data collection following the NHSN process would be manageable and would provide real time data for action. The risk stratification methodology has already been established and many healthcare providers are familiar with the terms and methods utilized, providing reliable benchmarking capabilities.

Prior to the SARS-CoV-2 pandemic, few skilled nursing facilities had familiarity with and/or access to NHSN. Because of the COVID-19 reporting requirements, skilled nursing facilities have had exposure to NHSN and have been utilizing the system for reporting. 

As proposed, the acute care facility will be coding for an occurrence that directly impacts another level of care, namely skilled nursing facilities. Sp.31 (p. 23 of Quality Measure Submission Form) states that this measure uses data from the Medicare Enrollment Database (EDB) and SNF and inpatient claims. It is not clear to us how a SNF will obtain the “inpatient claims data”, especially if it is not affiliated with the hospital at which the patient is receiving inpatient care. Is there already an established methodology or process for this? We would appreciate clarification on this. 

While we recognize this is a Centers for Medicare & Medicaid (CMS) measure, we feel strongly that all post-acute healthcare-associated infections are important, not just those identified in the Medicare Part A fee-for-service SNF population. We recognize that this is the population from which the numerator and denominator data will be available, but that is another example of the limitations of using claims as the data source. 

The standardized risk ratio appears to be rather complicated and will be difficult for facilities to interpret and explain. The ability to collect the data necessary for the risk adjustment, for both the numerator and denominator (in order to get a calculated standardized risk ratio, e.g., SRR; observed: expected) will be cumbersome and difficult to collect. Also, there is no information as to where or how this SRR will be calculated, e.g., will it be submitted to a third party or external software vendor? 

APIC also requests clarification on the numerator for the HAI identification and the proposed application of the 14-day repeat infection timeframe. Sp. 14) Details needed to calculate the numerator, Step 3 (Quality Measure Submission Form, p. 13) states “Following HAI identification, application of the 14-day repeat infection timeframe is determined to exclude infections that are preexisting to the SNF stay from the measure numerator.” Although NHSN surveillance includes assessment for repeat infection timeframes, it is unclear how the ICD-10 codes will be able to take this into account.  The metric goes on further to claim that this infection data is obtained from “the prior hospital claim.” How will this information be obtainable to the SNF doing the reporting? 

APIC supports the need for measurement of equity and disparity but cautions that the data must be standardized and validated, and measure collection should be incorporated into broader healthcare surveillance systems in a way that minimizes administrative burden to facility staff. The APIC Health Equity Committee is looking at multidisciplinary approaches to improving health equity and we look forward to ways to partner in using data on race, ethnicity, and other social determinants of health to find evidence-based, measurable solutions to address healthcare disparities and provide equitable care to all sectors of our population.

APIC is a nonprofit, multidisciplinary organization representing 15,000 infection preventionists whose mission is to create a safer world through prevention of infection. We are committed to improving the quality of patient/resident care across the healthcare continuum. We have seen the positive impact required reporting has in the prevention of healthcare-associated infections (HAIs) in acute care facilities and in order to provide safe care for all we support continued expansion of these best practices across the continuum.