What are the SNF QRP Measures?
Measures adopted for and removed from the SNF QRP are listed below. Several are endorsed by the consensus-based entity (CBE) contracted by the Secretary to guide the selection of performance measures for federal health programs. Data for the SNF QRP measures are collected and submitted through three methods:
- Minimum Data Set (MDS) 3.0
- Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
- Medicare Fee-For-Service Claims
Data collected using the MDS 3.0 and submitted to the Centers for Medicare & Medicaid Services (CMS) via the Internet Quality Improvement and Evaluation System (iQIES):
SNF QRP Measure #1: Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) [CMIT Measure ID #00520 (CBE-endorsed)]
This measure was finalized in the fiscal year (FY) 2016 SNF Prospective Payment System (PPS) Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46440 through 46444). Data collection for this measure began 10/1/2016. Public reporting began 10/24/2018.
SNF QRP Measure #2: Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP [CMIT Measure ID #00225 (not endorsed)]
This measure was finalized in the FY 2017 SNF Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52034 through 52039). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.
SNF QRP Measure #3: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury [CMIT Measure ID #00121 (not endorsed)]
This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36572 through 36577). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.
SNF QRP Measure #4: Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients [CMIT Measure ID #00404 (not endorsed)]
This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36583 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.
SNF QRP Measure #5: Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients [CMIT Measure ID #00403 (not endorsed)]
This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36584 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.
SNF QRP Measure #6: Transfer of Health Information to the Provider-Post-Acute Care [CMIT Measure ID #00728 (not endorsed)]
This measure was finalized in the FY 2020 SNF PPS Final Rule which was published in the Federal Register on August 7, 2019 (84 FR 38755 through 38761). Data collection for this measure will begin on October 1, 2023.
SNF QRP Measure #7: Transfer of Health Information to the Patient-Post-Acute Care [CMIT Measure ID #00727 (not endorsed)]
This measure was finalized in the FY 2020 SNF PPS Final Rule which was published in the Federal Register on August 7, 2019 (84 FR 38761 through 38764). Data collection for this measure will begin on October 1, 2023.
SNF QRP Measure #8: Discharge Function Score [CMIT Measure ID #01698 (not endorsed)]
This measure was finalized in the FY 2024 SNF PPS rule, which was published on August 10, 2023 (88 FR 21316 through 21422).
SNF QRP Measure #9: COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date [CMIT Measure ID #01699 (not endorsed)]
This measure was finalized in the FY 2024 SNF PPS rule, which was published on August 10, 2023 (88 FR 21316 through 21422). Data collection for this measure will begin on October 1, 2025.
For more detailed information on data collection and submission deadlines, please refer to the SNF QRP Data Submission Deadlines webpage. For more information on the data sets and guidance related to the collection and reporting of assessment data, please refer to the MDS Resident Assessment Instrument (RAI) manual located on the MDS 3.0 RAI Manual webpage.
CDC NHSN Measures
Data for these measures are submitted via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN):
SNF QRP Measure #10: COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) [CMIT Measure ID #00121 (not endorsed)]
This measure was finalized in the FY 2022 SNF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR 42480 through 42489). Data submission for this measure began October 1, 2021.
SNF QRP Measure #11: Influenza Vaccination Coverage among Healthcare Personnel (HCP) [CMIT Measure ID #00390 (CBE-endorsed)]
This measure was finalized in the FY 2023 SNF PPS Final Rule, which was published in the Federal Register on August 3, 2022 (87 FR 47537 through 47544). Data submission for this measure began October 1, 2022.
Information related to the procedures using the CDC NHSN for data submission for the Influenza Vaccination Coverage among HCP measure can be found on the NHSN website.
For NHSN questions: NHSN@cdc.gov.
Medicare Fee-For-Service Claims-Based Measures
Data for these measures are collected from claims, and no additional data need to be submitted by the SNF.
SNF QRP Measure #12: Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP [CMIT Measure ID #00434 (not endorsed)]
This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52014 through 52021). Public reporting began 10/24/2018.
SNF QRP Measure #13: Discharge to Community - PAC SNF QRP [CMIT Measure ID #00210 (CBE-endorsed)]
This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52021 through 52029). Public reporting began 10/24/2018.
SNF QRP Measure #14: Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP [CMIT Measure ID #00575 (not endorsed)]
This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52030 through 52034). Public reporting began 10/24/2019.
SNF QRP Measure #15: SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization [CMIT Measure ID #00680 (not endorsed)]
This measure was finalized in the FY2022 SNF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR.42473 through 42480). Public reporting began 4/29/2022.
Measures Removed from SNF
Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay)
As finalized in the FY 2018 SNF PPS Final Rule published in the Federal Register on 08/04/2017 (82 FR 36572 through 36577), this measure was replaced in the QRP by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 SNF QRP.
Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
As finalized in the FY2024 SNF PPS rule published on August 10, 2023, this measure was removed from the SNF QRP beginning FY 2024. Data collection for this measure will end on October 1, 2023.
Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients
As finalized in the FY2024 SNF PPS rule published on August 10, 2023, this measure was removed from the SNF QRP beginning FY 2024. Data collection for this measure will end on October 1, 2023.
Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients
As finalized in the FY2024 SNF PPS rule published on August 10, 2023, this measure was removed from the SNF QRP beginning FY 2024. Data collection for this measure will end on October 1, 2023.
*All data cited from CMS (https://www.cms.gov/medicare/quality/snf-quality-reporting-program/measures-and-technical-information)