This measure reports the percentage of long-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. This measure is risk-adjusted for resident cognitive status. Long-stay nursing facility residents are identified as those who have had 101 or more cumulative days of nursing facility care.
A separate measure (NQF #0676, Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay)) is used for residents who have had 100 or fewer cumulative days of nursing facility care.
- Electronic Clinical Quality Measure (eCQM)Level Of AnalysisCare SettingNumerator
The numerator is the number of long-stay residents who are able to self-report with:
• A selected MDS assessment (OBRA quarterly, annual or significant change/correction assessments or PPS 14-, 30-, 60-, or 90-day 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.DenominatorThe denominator is the total number of all long-stay residents in the nursing home who have an OBRA, PPS or discharge assessment during the selected quarter and who do not meet the exclusion criteria.
ExclusionsA resident is excluded from the denominator if the target assessment is an admission assessment, a PPS 5-day assessment or a PPS readmission/return assessment or if the resident 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 pain assessment items 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 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.Testing Data Sources
- Measure StructureNon Condition SpecificTarget PopulationNational Quality Strategy PrioritiesEffective Communication and Care Coordination
- Risk Adjustment
- Current or planned use(s)Current Use(s)Planned Use
- Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Geriatrics and Palliative Care Spring Cycle 2019Initial EndorsementEndorsement StatusLast UpdatedRemoval Date
- Steward Organization EmailSteward Organization Copyright
This is not applicable.