October 1, 2023 has passed and it’s official, Section G has been removed from the MDS. Here are some of the Quality Measure (QM) items impacted by this change:
- CMS will freeze (hold constant) the following measures on Care Compare starting in April 2024:
- Percentage of Residents Who Made Improvements in Function (Short Stay).
- Will be replaced by the Discharge Function Score (new cross-setting functionality QM) in October 2024. This measure will also impact the SNF QRP and VBP programs.
- Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay).
- Percent of Residents Whose Ability to Move Independently Worsened (Long Stay).
- Percent of High-Risk Residents with Pressure Ulcers (Long Stay).
- Percent of Low-Risk Residents Who Lose Control of Their Bowel and Bladder (Long Stay).
- Percentage of Residents Who Made Improvements in Function (Short Stay).
- The last four measures listed above will continue to be frozen until January 2025, while data for equivalent measures is collected.
- The updated Quality Measure User’s Manual v16.0 is available here.
Our recommendations:
- Read the CMS memo and review the website here.
- Review facility and resident-level CASPER reports.
- Ensure that your team has an effective QAPI program that includes and addresses any concerning QMs on your CASPER Reports.
- Review the recent Section GG changes, your process for collecting Section GG information, and your teams’ accuracy in establishing residents’ “usual performance.”
- Contact QRM if you and your team need additional support.
The Point Is: Freezing some of the Five-Star QMs may temporarily prevent a negative impact on your scores, but it is essential to understand these changes, make appropriate adjustments to your processes, and ensure your team understands how recording information in Section GG affects these QMs.
