Quality Measure Drill Down: Discharge Function Score

We are excited to kick off our "Drilling Down" series, where we’ll dive deep into the information behind Quality Measure triggers to assess the accuracy of MDS coding and examine the clinical processes that influence our overall quality measure star rating. To begin, we'll focus on our newest measure: the Discharge Function Score.

The Discharge Function Score estimates the percentage of Medicare Part A Skilled Nursing Facility (SNF) stays that meet or exceed the expected discharge function score. As part of the Skilled Nursing Facility Quality Reporting Program (SNF QRP), this outcome measure evaluates the impact of healthcare services and interventions on the health status of Medicare Part A residents, specifically those with completed stays during a 12-month target period.

To drill down on a discharge function score, we should break the process into 5 steps.

Step 1

Identify excluded SNF stays to determine the included records or the total number of Medicare Part A SNF stays that did not meet the exclusion criteria. To do this let’s first review the exclusion criteria for this measure. Exclusion criteria include:

• Non-Traditional Medicare Part A stay
• Incomplete Stays:
  • Unplanned discharge, including Against Medical Advice (AMA).
  • Discharge to acute hospital, long-term care hospital, or psychiatric hospital.
  • SNF PPS Part A stays less than 3 days.
  • Resident who expired during SNF stay.

• Residents with the following medical conditions indicated on the 5-day PPS assessment:
  • Coma, Persistent Vegetative State, Complete Tetraplegia, Severe Brain Damage, Locked-in Syndrome, Severe Anoxic Brain Damage, Cerebral Edema, or Compression of the brain.
• Residents younger than age 18
• Resident discharged to hospice or received hospice while a resident
• Resident did not receive Physical Therapy (PT) or Occupational Therapy (OT) services on the 5-day PPS assessment.

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Step 2

Collect data to determine the total observed discharge score. Functional Items listed below are based on an MDS 3.0 SNF Part A PPS Discharge Assessment - Section GG elements, which include 10 items to calculate a resident’s total observed discharge score. Scores Range from 10-60.

• Discharge Self-Care:
  • GG0130A3 – Eating
  • GG0130B3 – Oral Hygiene
  • GG0130C3 – Toileting Hygiene

• Discharge Mobility:
  • GG0170A3 – Roll left and right
  • GG0170C3 – Lying to sitting on side of bed
  • GG0170D3 – Sit to Stand
  • GG0170E3 – Chair/Bed-to-Chair Transfer
  • GG0170F3 – Toilet Transfer
  • GG0170I3 – Walk 10 Feet*
  • GG0170J3 – Walk 50 Feet with 2 Turns*
  • GG0170R3 – Wheel 50 Feet with 2 Turns*

*Count Wheel 50 feet with 2 Turns value twice to calculate the total observed discharge function score for stays where either Walk 10 Feet has an activity not attempted code at both admission and discharge and either Wheel 50 feet with 2 Turns or Wheel 150 feet has a code between 1-6 at either admission or discharge.

*The remaining stays use walk 10 feet + walk 50 feet with 2 Turns to calculate the total observed discharge function score.

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Step 3

Utilize statistical imputation to calculate the imputed values for items with Activity Not Attempted (ANA) codes as described above. Statistical imputation involves three steps. In the first step, a continuous variable representing a patient's underlying degree of independence for the GG item is determined. The second step assesses the probability that each value would have had the GG item evaluated. In the third step, the imputed value for the GG item is computed. These three steps are repeated for each GG item with an ANA or other NA code.  

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Step 4

Calculate the expected discharge function score by applying the regression equation derived from risk adjustments to each SNF stay. The purpose of risk adjustment is to account for differences among SNF residents that affect their functional status. Risk adjustments create an individualized expectation for the discharge function score for each stay, controlling for admission functional status, age, and clinical characteristics. This ensures that each stay is measured against an expectation that is tailored to the resident’s circumstances when determining the numerator for each SNF. This data is collected from the admission assessments and consists of the following elements:

• Age group
• Cognitive Abilities – If impaired, at what level.
• Communication Impairment - If impaired, at what level.
• Admission Function Score
• Prior Functioning: Self-Care, Indoor Mobility, Stairs, Functional Cognition & Prior Device Use
• Incontinence
• Primary Medical Condition Category
• Comorbidities obtained from Section I.
• History of Falls prior to the SNF admission.
• Prior Surgery
• Nutritional Status – Toal Parenteral Nutrition and BMI.
• Stage 2, 3, 4, or unstageable pressure Ulcer/Injury

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Step 5

Compare the difference between the observed and expected discharge function score. If the observed discharge function score is equal to or higher than the expected discharge function score, the quality measure is trigger for a desired outcome. If the observed discharge function is lower the expected discharge score a root cause analysis is recommended to determine the cause.

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Best Practices

Now that we’ve reviewed the components of the Discharge Function Score and how they’re used to calculate the final outcome, let’s shift our focus to best practice clinical processes that can help improve performance on this quality measure.

While the equations behind the Discharge Function Score are complex and account for various clinical characteristics of the resident, many of which we can’t control—we can influence the accuracy of the data being collected. By ensuring precise and thorough documentation across all key data points, we can positively impact the outcome. Here are a few strategies to support accurate data collection:

• Minimize the use of ANA codes and/or dashes within the GG elements by ensuring an Interdisciplinary Team (IDT) approach to data collection throughout the stay.
• Conduct at minimum thorough weekly Medicare meetings with the IDT to review holistic monitoring of plan of care (POC), discuss GG codes and acute changes on an ongoing basis to identify potential areas of decline and intervene early for best possible outcomes.
• Daily review of skilled documentation for clinical changes along with documentation accuracy with education or interventions as appropriate.
• Discuss risk adjustment data and ensure accuracy prior to the Assessment Reference Date (ARD) of the MDS 3.0 Admission Assessment.
• Ensure appropriate therapy involvement by collaborating on an ongoing basis to determine start of care is timely with the appropriate frequency and duration and that functional goals are related to GG items.
• Evidence that functional activities are carried over to nursing for continuous growth towards functional goals.
• ,Ensure education is provided with the resident and/or family at each step of the rehab process to maximize understanding and compliance.

By taking an interdisciplinary approach, we can enhance timely healthcare delivery and achieve the best possible outcomes for our residents. Stay tuned for next month’s installment of our “Drill Down” series, where we’ll continue exploring quality measures and ways to drive improvement.

Have questions or topics you’d like us to cover? We’d love to hear from you! Your input helps shape future content, and your question might even be featured in an upcoming article. Let’s keep the conversation going as we navigate this ever-evolving industry together.

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