Elderly

This measure updates CMS’ MDS 2.0 QM on bowel and bladder control. It is based on data from Minimum Data Set (MDS) 3.0 assessments of low risk long-stay nursing facility residents (those whose cumulative days in the facility is greater than 100 days). This measure reports the percent of long-stay residents with a selected target assessment who are frequently or always bladder or bowel incontinent as indicated on the target MDS assessment (OBRA, PPS or discharge) during the selected quarter (3-month period).

This measure is based on data from MDS 3.0 assessments of long-stay nursing facility residents. The measure reports the percentage of all long-stay residents 5 years and older who were assessed and appropriately given the Pneumococcal Vaccination as reported on the target MDS assessment (OBRA, PPS or discharge) during the 12-month reporting period. This proposed measure is harmonized with NQF’s quality measure on Pneumococcal Immunizations.(1) The MDS 3.0 definitions have been changed to conform to the NQF standard.

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.

The measure reports the percentage of short stay nursing home residents or IRF or LTCH patients who were assessed and appropriately given the pneumococcal vaccine during the 12-month reporting 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

This measure is based on data from MDS 3.0 assessments of nursing home residents. Either a resident interview measure or a staff assessment measure will be reported. The preferred version is the resident interview measure. The resident interview measure will be used unless either there are three or more missing sub-items needed for calculation or the resident is rarely or never understood, in which cases the staff assessment measure will be calculated and used. These measures use those questions in MDS 3.0 that comprise the Patient Health Questionnaire (PHQ-9) depression instrument.

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 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 all long-stay residents who were physically restrained daily during the 7 days prior to the target MDS 3.0 assessment (OBRA, PPS or discharge) during their episode of nursing home care ending in the target quarter (3-month period). Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.