Assessment Data

Percentage of patients with chart documentation of preferences for life sustaining treatments.

The MSPB Hospital measure evaluates hospitals’ risk-adjusted episode costs relative to the risk-adjusted episode costs of the national median hospital. Specifically, the MSPB Hospital measure assesses the cost to Medicare for Part A and Part B services performed by hospitals and other healthcare providers during an MSPB Hospital episode, which is comprised of the periods 3-days prior to, during, and 30-days following a patient’s hospital stay. The MSPB Hospital measure is not condition specific and uses standardized prices when measuring costs.

This measure reports the percentage of long-stay, high-risk, residents in a nursing home who have Stage II-IV or unstageable pressure ulcers on a selected target assessment in the target quarter. 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. A nursing home resident is defined as high-risk for pressure ulcer if they meet one or more of the following three criteria:
1. Impaired bed mobility or transfer
2. Comatose

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 measure reports the percentage of low risk, long-stay residents who have had an indwelling catheter in the last seven days prior to the assessment reference date on the target assessment. In this case, low-risk refers to residents who do not have preexisting conditions, such as neurogenic bladder or obstructive uropathy, which predispose catheter use. 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 reports the percentage of long-stay nursing home residents with a target Minimum Data Set (MDS) assessment (OBRA, PPS, Discharge) that indicates a weight loss of 5% or more of the baseline weight in the last 30 days or 10% or more of the baseline weight in the last 6 months, which is not a result of a physician-prescribed weight-loss regimen. The baseline weight is the resident’s weight closest to 30 or 180 days before the date of the target assessment. Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

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.

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.

The measure reports the percentage of short-stay residents or patients who are assessed and appropriately given the seasonal influenza vaccine during the most recently-completed influenza season. The influenza vaccination season (IVS) is defined as beginning on October 1, or when the vaccine first becomes available*, and ends on March 31 of the following year. This measure is based on the NQF´s National Voluntary Standards for Influenza and Pneumococcal Immunizations.

This measure reports the percentage of long-stay residents in a nursing home who have a urinary tract infection in the 30 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. Long-stay nursing home residents are identified as those who have had 101 or more cumulative days of nursing home care.