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  • Writer's picturekatherinepiette

Striving for 5 Stars

Updated: Mar 30, 2021


Observation of the Centers for Medicare and Medicaid Services’ (CMS) march towards value-based care should serve to alert all skilled nursing facilities (SNF) of what’s coming down the road. Initially, CMS collects data, analyzes that data and then utilizes that data to change care delivery and reimbursement methodology. CMS has noted large variations in the cost and quality of care provided in SNFs. As a result, CMS is starting to limit the participation of poor performing skilled nursing facilities (1 and 2 star SNFs) in new value based models of care. This move should communicate to all SNFs that in order to remain viable in the future, they need to be actively working towards becoming or maintaining a five-star rating.

With CMS’s 1998 roll out of the Nursing Home Compare website, the federal government has been publically reporting on the care provided by Skilled Nursing Facilities. This website allowed patients and their families to compare different facilities and make an informed selection. With the passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, a five star rating system was added to the website in 2008.

SNF Star Ratings

Launched in 1998, Centers for Medicare & Medicaid Services' (CMS) Nursing Home Compare website was designed to help consumers and their families find nursing homes and to encourage higher quality of care through public reporting of nursing home performance. A decade later, CMS enhanced the website to include a five-star rating system for measuring nursing home performance. A facility’s five-star rating reflects a combination of scores in three categories:

1. Health and Fire Safety Inspections:

This category comprises more than half of the overall rating and is obtained from deficiencies identified at annual health inspections and investigations into complaints by patients, their families, or others.

2. Staffing Levels:

Ratings are based on the number of Registered Nurse (RN) hours per resident per day and the total staffing (RN, Licensed Vocational Nurse (LVN) and Certified Nursing Assistants (CNAs)) hours per resident per day.

3. Quality of Care:

Ratings are based on quality indicators for fifteen long-term and nine short term residents such as rates for pressure ulcer acquisition, falls, significant weight loss, depression, etc. These include CMS’s recent (April 2016) addition of six additional quality measures such as rehospitalization rates and emergency room usage rates.

SNF Performance

A 2015, Kaiser Foundation Report reveals:

  • SNFs

    • Poor Performers (1 & 2 stars) accounting for 39% of the SNF population

    • Average Performers (3 stars) accounting for 20% of the SNF population

    • High Performers (4 & 5 stars) accounting for 41% of the SNF population

  • States (see map below)

    • In 22 states, more than 50% of SNFs are high performers (4 or 5 stars)

    • In 11 states, more than 40% of SNFs are poor performers (1 or 2 stars)

    • In 9 states, more than 20% of SNFs only a 1 star rating

CMS has taken note of these incongruities in the quality of care in SNFs. In addition, upon analysis of the most common type of Medicare surgery ($7B/year) - knee and hip replacements, CMS noted a large variation in their costs ($16,500 - $33,000) which was primarily attributed to the cost of post surgical SNF care. On April 1, 2016, CMS rolled out the Comprehensive Care for Joint Replacement (CJR) Model in 67 regions. This is a bundled model in which the hospital is given a sum of money to manage the care of the patient for 90 days following the joint replacement including care provided by SNFs, home health agencies, and physicians. CMS added an additional caveat that takes effect in 2017; any participating SNF in CJR Model must have a three-star or better rating during seven of the last 12 months at the time of the patient’s episode. This means nursing homes with lower quality ratings could see a significant drop in referrals and corresponding revenue. Joint replacements are just the first of many procedures to be bundled in the near future; in fact, on July 25, 2016, CMS announced new bundled payment models for cardiac care and extension of existing hip replacement bundled payments to include other hip surgeries. Nursing homes with poor star ratings need to take warning and launch improvement programs to elevate their star ratings and STRIVE for 5 STARS.

Corstrata’s team of board certified wound specialists stand ready to assist SNFs in their improving their wound related quality measures and reaching for the stars. If you need a hand, we're happy to help - just get in touch with us!


Kaiser Family Foundation (2015, May 14). Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State. Retrieved August 21, 2016 from


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