This measure reports the percentage of short-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. Short-stay nursing facility residents are identified as those who have had 100 or fewer cumulative days of nursing facility care.
A separate measure (NQF #0677, Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)) is used for residents who have had 101 or more cumulative days of nursing facility care.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
The numerator is the number of short-stay residents who are able to self-report with:
•A selected MDS assessment (OBRA admission, quarterly, annual or significant change/correction assessments or PPS 5-, 14-, 30-, 60-, or 90-day assessments, or readmission/return assessments OR Discharge assessment with or without return anticipated) during the selected quarter, AND
•Report almost constant or frequent pain AND at least one episode of moderate to severe pain in the 5 days prior to the assessment OR who report very severe/horrible pain of any frequency in the 5 days prior to the assessment.
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1.15 Denominator
The denominator is the total number of all short-stay residents in the nursing home who have an OBRA, PPS or discharge target assessment during the selected 6-month period and who do not meet the exclusion criteria.
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Exclusions
A resident is excluded from the denominator if they did not meet the pain symptom conditions for the numerator AND any of the following conditions are true:
1) the resident cannot self-report OR
2) there are missing data in the responses to the relevant questions in the target assessment OR
3) the assessment indicates that the resident had pain or hurting at any time in the last 5 days, but the numeric pain intensity item indicates no pain.
If the facility sample includes fewer than 20 residents after all other resident-level exclusions are applied, then the facility is excluded from public reporting because of small sample size.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Geriatrics and Palliative Care Spring Cycle 2019Initial EndorsementLast UpdatedRemoval Date
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
This is not applicable.
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Risk Adjustment
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6.1.2 Current or Planned Use(s)
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Planned Use
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