This measure, based on data from the Minimum Data Set (MDS) 3.0 assessment of long-stay nursing facility residents, estimates the percentage of long-stay residents in a nursing facility whose need for assistance with late-loss Activities of Daily Living (ADLs), as reported in the target assessment, increased when compared with a prior assessment. The four late-loss ADLs are: bed mobility, transfer, eating, and toilet use. This measure is calculated by comparing the change in each ADL item between the target assessment (OBRA, PPS or discharge) and a prior assessment (OBRA, PPS or discharge). Long-stay nursing facility residents are those with a nursing facility stay of 101 cumulative days or more.
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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 long-stay residents who have a selected target MDS assessment (OBRA, PPS, or discharge) reporting a defined amount of decline in ADL function when compared with a prior assessment (OBRA, PPS, or discharge). This decline in function is captured as an increase in the resident’s need for assistance with late-loss ADLs, when compared with the resident’s prior assessment, indicated by a higher score on the applicable MDS items on the more recent assessment (which are coded such that a higher score indicates the need for more assistance with an ADL task). Late-loss ADL items are bed mobility, transfer, eating, and toilet use. The threshold increase in need for assistance (suggesting decline in function) that results in a resident being counted in the numerator is met if the score for at least one late-loss ADL item increases by two or more points or if the score for two or more of the late-loss ADLs items increase by one point. The typical interval between the target and prior assessment dates is approximately 90 days.
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1.15 Denominator
The denominator includes all long-stay residents with a selected target MDS assessment (OBRA, PPS, or discharge) during the quarter and a prior assessment who did not meet the exclusion criteria. Long-stay residents are defined as residents who have stayed in the nursing home for 101 cumulative days or more.
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Exclusions
There are six exclusions applied to the denominator: (1) self-performance total dependence on all four late-loss ADL items during the prior assessment (and therefore it is not possible for the resident to decline sufficiently to be counted in the numerator), (2) self-performance total dependence on three late-loss ADL items during the prior assessment and self-performance extensive assistance on the fourth late-loss ADL item (and therefore it is not possible for the resident to decline sufficiently to be counted in the numerator), (3) comatose status on the target assessment, (4) prognosis of life expectancy of less than six months on the target assessment, (5) receiving hospice care on the target assessment, or/and (6) the resident is not in the numerator and has missing values for any of the four ADL items on the target or prior assessment.
Nursing facilities are excluded from public reporting if their denominator size is less than 30 residents.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Patient Experience and Function Fall Cycle 2019Initial EndorsementLast UpdatedRemoval Date
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
None
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Risk Adjustment
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6.1.2 Current or Planned Use(s)
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