The Quality Measure for Discharge to Community evaluates the rate at which beneficiaries in the Skilled Nursing Facility (SNF) are successfully discharged to the community. This Claims Based Measure is part of the Quality Reporting Program (QRP). It further impacts Care Compare and Five Star.
Eligible SNF Medicare Part A stays for the collection period are identified by those resulting in a successful discharge to community to either home, home under care of a Home Health Agency (HHA), home with a planned readmission, or discharge home under an HHA with a planned Acute Care Hospital (ACH) readmission. The collection period for this measure is a Calendar Year (CY).
SNF stays are excluded from the measure based on the following:
- Resident is under 18 years of age at start of stay
- Resident was NOT discharged from an acute facility within 30 days prior to SNF admission
- Resident discharged from SNF against medical advice (AMA)
- Resident discharged from SNF to psychiatric hospital or another SNF
- Resident discharged from SNF to federal hospital, disaster alternative care site, or court/law enforcement
- Resident discharged from SNF to hospice or hospice benefit period overlaps with the31-day post SNF discharge window
- Resident was NOT continuously enrolled in Medicare Part A for at least 365 days prior to SNF admission and for at least 31 days after SNF discharge
- Resident discharged from an acute care facility within 30 days prior to SNF admission, but the stay was for non-surgical treatment of cancer
- Stay associated with problematic or incomplete data
- Planned discharge from the SNF to an ACH, inpatient psychiatric hospital, or an LTCH
- Care received outside the 50 states, District of Columbia or Puerto Rico, and U.S. Territories
- Long-term nursing home stay in the 180 days preceding their most recent hospitalization
- Stay occurred in a Critical Access Hospital (CAH)
This measure is risk-adjusted. The covariates for risk-adjustment are as follows:
- Age and sex categories
- 65years old and the reason for entitlement code is disability or end-stage renal disease and disability
- Clinical Classification Software (CCD) category of principal diagnosis from proximal acute stay
- Comorbidities based on the prior acute stay and/or a 365-day lookback,
- Surgical procedure categories from acute care stay
- Dialysis, without ESRD, during acute care stay
- Length of acute care stay, if stay was in non-psychiatric hospital OR indicator if stay was in psychiatric hospital
- Ventilator use during SNF stay
- Number of ACH stays in prior 365 days prior to SNF admission – excludes ACH stay prior to admission
For this measure, a National Observed Rate is determined as well as a Provider-level final score. This Claims Based Measure affects the QRP, as stated above, and as such impacts the Annual Percentage Update (APU). The APU can lead to an up to 2% reduction if data is not submitted for at least 80% of MDS assessments or performance is poor. The threshold for data submission is being raised to 100% in FY 2026 (starting October 1, 2025).
To ensure successful discharges, an Interdisciplinary Team approach should be utilized to address issues related to:
- Appropriate goal development for discharge, i.e., ability to ambulate up and down 1 to 2 stairs to enter home, independent medication management or self-care tasks, simple meal preparation
- Assessment, recommendations, and attainment of needed equipment and environmental modifications for the discharge environment
- Assessment and assistance with establishing transportation for such trips as doctors’ appointments and medication and grocery pickup
- Assessment and education of medication management
- Addressing possible food insecurities through meals on wheels, treatment addressing simple meal preparation with use of microwave or oven, or family preparing meals
- Assessment and education of safety measures, i.e., dialing phone/911, fall alarm, fire alarm and extinguisher
- Referrals to appropriate follow-up services, such as Home Health, Outpatient Therapy, Wellness Programs, Physicians, or other local services (i.e., religious services, adult day care)
- Assessment, education, and assistance with hygiene and housekeeping tasks to prevent skin breakdown, tripping hazards, and other physical and environmental hazards
A process should also be established to follow-up with residents at specified intervals within the 31 days post discharge to ensure they have needed resources and to answer any questions which may have arisen upon their return home.
To avoid hospital readmission or death, teamwork among the Interdisciplinary Team, the resident, and their family and friends is essential to ensuring a successful discharge to home.
To learn more about the Quality Reporting Program, go to Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) | CMS.