Two of Five-Star’s short-stay measures come from Medicare claims, not the MDS: residents who went back into the hospital within 30 days of arriving, and residents who had an emergency department visit in those same 30 days. They share a denominator, a time window and a risk model, so they are explained together here.
What they measure
| Measure | A stay counts if, within 30 days of entry or reentry, the resident had |
|---|---|
| Short-stay residents re-hospitalized after a nursing home admission | An unplanned inpatient admission, or an outpatient observation stay |
| Short-stay residents who had an outpatient emergency department visit | An ED visit that did not end in an inpatient or observation stay |
Both are worth up to 150 points in Five-Star’s short-stay rating, both are risk-adjusted, and for both a lower rate is better. No MDS item puts a resident in either numerator. The MDS still matters, as the denominator and risk model below show.
Who is in the denominator
The unit is a nursing home stay: from the entry or reentry date on the MDS to the discharge date. A stay is included when:
- The resident entered or reentered the building within one day of discharge from an inpatient hospital stay. Inpatient rehabilitation facility and long-term care hospital stays don’t count as the index hospitalization.
- The entry or reentry falls in the 12-month window.
A stay is excluded if any of these is true:
- The resident didn’t have Original Medicare Part A and Part B for the whole risk period, from the month of the hospital stay through the month after the nursing home discharge. Medicare Advantage residents are not in these measures.
- The resident was enrolled in hospice at any point in the stay.
- There is no MDS assessment within 14 days of entry or reentry.
- The first MDS after entry codes the resident as comatose (B0100 = 1), or leaves B0100 missing.
- Any claims or MDS item used for the numerator, denominator or risk adjustment is missing.
The 30 days keep running after discharge
This is the part that is easiest to miss.
“This includes inpatient or observation stays occurring after discharge from the nursing home but within the 30-day timeframe.”
The ED measure works the same way. A resident who goes home on day 10 and lands in the hospital on day 25 still counts against the building. So discharge planning, the handoff to home health and the follow-up call are part of these measures, not separate from them.
Planned readmissions are not counted. CMS uses its Planned Readmission Algorithm (version 13.0) to find them: admissions for things like transplant, maintenance chemotherapy or radiotherapy, rehabilitation, fitting of prostheses, and a pre-specified list of other procedures. An admission for an acute illness or a complication of care is never planned. Observation stays count whatever the diagnosis, and so do ED visits.
A trip that starts in the ED and ends in an admission is counted once, as a rehospitalization:
“In other words, ED visits that were billed as an outpatient event but resulted in admission to a hospital for an observation stay or an unplanned inpatient stay would not be “double-counted” across the short-stay outpatient ED visit measure and the short-stay re-hospitalization measure.”
A worked example. Resident D comes from the hospital after a heart failure admission and goes home with home health on day 9. On day 22 she goes to the emergency department short of breath. If she is admitted, or kept for observation, the stay counts in the rehospitalization measure. If she is treated and sent home, it counts in the ED measure instead. Either way, it counts, though she left the building two weeks earlier.
The window and the lag
“The numerator and denominator include stays that started over a 12-month period. The data are updated every quarter (in January, April, July, and October of each year), with a lag time of six months (i.e., stays that started 6-18 months ago).”
So what Care Compare shows today reflects admissions from six to eighteen months ago. Nothing done this month shows up for at least half a year.
Risk adjustment, and where the MDS comes in
CMS predicts each stay’s chance of the outcome with a logistic regression, averages those chances into the building’s expected rate, and then divides the observed rate by the expected rate and multiplies by the national rate. The predictors come from two places:
- Claims: age, sex, length of the hospital stay before admission, any ICU time, Medicare entitlement through disability, end-stage renal disease, hospital stays in the prior year, the principal diagnosis category and a comorbidity index.
- The first MDS within 14 days of entry: items such as communication (B0700), cognition (C0100 to C1000), acute change in mental status (C1310A), rejection of care (E0800), wandering (E0900), coughing or choking with meals (K0100C), walking and two-person help in Section GG, shortness of breath (J1100A, J1100B), end-stage prognosis (J1400), surgical wounds (M1040E), oxygen, IV medications, transfusions and antibiotics, several active diagnoses, and whether the resident came back after a hospitalization. The two measures use slightly different lists.
That makes the 5-Day, or whatever the first assessment is, part of both measures. Each of those items moves the expected rate, so each should describe the resident as they were. An item left blank can remove the stay from the measure altogether, and a missing B0100 does so by name.
Common mistakes
- Treating discharge as the finish line. The 30 days run from entry, wherever the resident is.
- Under-coding the first assessment. Oxygen, IV medications, shortness of breath and a terminal prognosis are risk factors only if they are on it.
- Leaving B0100 or other risk items blank on the first assessment.
See your building’s rehospitalization and ED visit rates, free.
How Five-Star scores them
Both are decile measures, 15 to 150 points, calculated on a full year of stays. A measure needs at least 20 stays in the year to be reported.
| Points | Rehospitalized | Outpatient ED visit |
|---|---|---|
| 150 | 13.03% or lower | 4.09% or lower |
| 135 | 13.04% to 15.55% | 4.10% to 5.58% |
| 120 | 15.56% to 17.11% | 5.59% to 6.65% |
| 105 | 17.12% to 18.45% | 6.66% to 7.70% |
| 90 | 18.46% to 19.73% | 7.71% to 8.66% |
| 75 | 19.74% to 20.96% | 8.67% to 9.74% |
| 60 | 20.97% to 22.32% | 9.75% to 10.93% |
| 45 | 22.33% to 23.81% | 10.94% to 12.55% |
| 30 | 23.82% to 26.37% | 12.56% to 14.89% |
| 15 | 26.38% or higher | 14.90% or higher |
SuperQM shows these claims measures next to the ones your own MDS drives, so the whole short-stay rating is in one place.
