Percentage of patients aged 18 years and older at the start of the measurement period with one or more inpatient encounters during the measurement period who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge for at least one hospital encounter during the measurement period.
This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.
This measure reports the percentage of long-stay residents in a nursing home who have experienced one or more falls resulting in major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) reported in the look-back period no more than 275 days prior to the target assessment. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period.
This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments of
The Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization measure estimates the risk-standardized rate of HAIs that are acquired during SNF care and result in hospitalization. SNF HAIs that are acquired during SNF care and result in hospitalization are identified using the principal diagnosis on the Medicare inpatient (IP) claims of SNF residents. The hospitalization must occur during the period beginning on day four after SNF admission and within three days after SNF discharge or the end of active SNF care. The measure is risk-adjusted to allow for comparison based on residents with similar characteristics across SNFs. Since HAIs are not considered never-events, the measure's objective is to identify SNFs that have higher HAI rates than their peers.
To calculate the measure numerator, first count the outcome and then apply risk adjustment. The final measure numerator is the adjusted numerator.
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The study population is Medicare Part A FFS SNF stays that ended during the measure time period. To calculate the measure denominator, the number of eligible SNF stays are counted, then risk adjustment is applied. The final measure denominator is the adjusted denominator.
The eligible stays for this measure are all Medicare FFS SNF stays that do not meet the exclusion criteria during the measurement period. Residents who died during the SNF stay or during the post-discharge window (three days after SNF discharge or the end of active SNF care) and residents with an ongoing SNF stay by the end of the measure period are included in the denominator. SNF stays are excluded from the denominator if they meet one or more of the following criteria:
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Endorsement History:
Link to Endorsement Measure Record: Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization (SNF HAI)
Impact Summary: This measure supports the Skilled Nursing Facility (SNF) Quality Reporting Program’s goal of improving care outcomes by identifying skilled nursing facilities with higher risk‑standardized rates of health care‑associated infections that occur during SNF care and lead to hospitalization. The measure enables comparison across facilities and targets opportunities to reduce infections that worsen patient outcomes.
Figure 1 shows the distribution of performance rates over time with medians used to discuss distribution changes over time. The median risk-standardized performance rate for this measure decreased from 7.4% in 2021 to 6.8% in 2022, indicating an improvement in scores among reporting SNFs. From 2022-2024, the rate increased slightly (by only about 0.1% annually). Overall, there is minimal variation for this measure over the years examined.
Table 1 examines average scores from 2024 by decile. The total estimated number of negative outcomes across all deciles is about 83,000. If the average performance of Decile 3 (6.39%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 11,500 fewer patients would contract HAIs requiring hospitalization.
For this measure, the Battelle team reviewed the following publicly available datasets available at Skilled Nursing Facility Quality Reporting Program - Provider Data | Provider Data Catalog:
The Battelle team analyzed all values for “Measure Code of S_039_01_HAI_NUMBER, S_039_01_HAI_VOLUME, and S_039_01_HAI_RS_RATE not marked as “Not Available” from the corresponding Skilled_Nursing_Facility_Quality_Reporting_Program_Provider_Data.csv and Swing_Bed_SNF_data.csv files.
About Figure 1: Figure 1 is a boxplot that shows how scores have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of scores. The dots represent the points where the lowest 5% and highest 5% of scores fall, and the line connecting them shows where 90% of the scores are located. The box itself covers the middle half of the scores, from the 25th to the 75th percentile. Inside the box, a horizontal line marks the median score, which is the middle value, while a “+” sign shows the average score. This type of graph makes overall trends in scores over time as well as the consistency and spread of the results easier to understand.
Figure 1. Boxplot of Measure Score by Year
Figure 1 Interpretation: Although the median risk-standardized rate decreased from 7.4% in 2021 to 6.8% in 2022, the rate has increased by only 0.1% per year since 2022. For this measure, a lower score indicates better quality of care.
About Table 1: Table 1 illustrates the distribution of scores and the number of patients represented within each group for the most recent year with data available. It is important to note that the groups (referred to as deciles, each comprising 10% of the facilities) with the lowest or highest scores may contain more or fewer patients than other groups. For example, if the lowest-scoring decile includes only 5% of the total patient population, then smaller group size may be associated with lower performance scores. The overall average is the average score across the 11,100 facilities.
Table 1. Importance in the Most Recent Year of Data Available (Decile by Measure Score, 2024)
| Overall | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Average Score (Standard Deviation) | 7.27 (1.27) | 5.39 | 6.06 | 6.39 | 6.69 | 6.96 | 7.24 | 7.57 | 7.98 | 8.55 | 9.85 |
| Facilities | 11,100 | 1,100 | 1,100 | 1,100 | 1,100 | 1,100 | 1,100 | 1,100 | 1,100 | 1,100 | 1,100 |
| Patients | 1,155,852 | 185,368 | 115,035 | 102,500 | 98,052 | 102,175 | 99,658 | 107,247 | 105,502 | 113,688 | 126,627 |
Table 1 Interpretation: To estimate the number of negative outcomes (HAIs requiring hospitalization), the number of patients is multiplied by the average score for each decile. In 2024, the total estimated number of negative outcomes across all deciles is about 83,000. If the average performance of Decile 3 (6.39%) is considered a plausible, achievable score, and the entities in Deciles 4 through 10 improved to reach that score, about 11,500 fewer patients would contract HAIs requiring hospitalization.
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
This criterion will be evaluated as part of the full Preliminary Assessment available in September.