CMS has released an update to the 5 star rating system that’s included in Nursing Home Compare. In this post we’re going to look at changes in the staffing portion of the update. We’ve covered staffing and star ratings in the past, here , here and comprehensively here. So here we go again.
According to CMS in the announcement for this new change:
In recognition of the importance of RN staffing, the method by which the RN staffing rating and the total nurse staffing rating are combined to generate the overall staffing rating is changing to provide more emphasis on RN staffing.
To accomplish this, CMS has increased the requirements (or cut points in their language) to achieve RN stars. (If you are not familiar with the way staffing stars work, refer to this post.)
The chart below shows the current and new cut points. On average, the requirements are increasing by 20% for RN hours.
RN Star Cut Points
The cut points for overall nursing hours are changing as well. These changes are essentially small tweaks to the current numbers. The cut point to get to 2 stars actually went down slightly. The overall nursing hours required to reach 5 on the overall nurse staffing rating (not overall staffing rating) is going up 3.8%.
Overall nursing hours cut points.
CMS also changed the way RN and overall nursing hours are mapped to your staffing star. (This is the one that can cause you to get a bonus overall star if you reach 4 or 5 staffing stars.)
click to enlarge
I’ve highlighted some changes here. Green stars are new and red stars have been taken away. You can see the emphasis on RN hours clearly here.
Analysis
Overall this change brings higher resolution to the five star system. As we’ve covered in the past, nearly 30% of skilled nursing facilities have 5 overall stars and more than 50% are either 4 or 5 overall stars. The system is skewed high, which doesn’t drive improvement. While getting RN hours in the skilled nursing setting is very challenging, especially in certain areas of the country, adjusting the star rating system in this way will help to highlight those problems and drive improvements, especially as more facilities lose the 4th staffing star. The only downside to this change is timing: with PDPM coming in October, there is precious little time to implement changes.
Using the latest data from CMS, we can visualize the change in staffing star ratings. The animation below shows both the current and April 2019 limits on a graph. Each blue dot represents a skilled nursing facility in the US. (I’m not sure if this will show up for blog subscribers. If you don’t see it, click the link to view the actual posting.)
This graph is arranged like the star table above. The RN rating is on the left and increases as it goes down. The overall nursing rating is on the bottom and increases as it goes to the right. You can see quite a few homes get downgraded as the limits change.
Staffing Star Distribution Shifting
This change shifts the staffing star distribution much closer to normal. See below.
Current Staffing Star Distribution (click to enlarge)
April 2019 Staffing Star Update (click to enlarge)
Impact on Overall Star Rating
While the staffing star is an important part of the star rating, it is especially important to those facilities with 4 staffing stars and less than 5 stars on the state survey. The loss of the 4th star will lower the overall star rating. Using the CMS data to calculate staffing star ratings before and after, there are 1750 facilities (11.9%) that we estimate will lose an overall star due to this change. (Note: There are also some significant changes to the quality measures portion of the star rating. This analysis ignores quality measures.)
More importantly, (for some at least) we estimate that 245 facilities (1.7%) will go from 3 overall stars to 2, which in some markets will negatively impact Part A admissions.
How close is your facility to losing a staffing star? An Overall star? You don’t have much time to react, but you can plan for the future and make improvements. Let’s talk it over! Contact us today! Let Broad River Rehab help!
