Take your Best Shot at Getting Vaccination Quality Measures Right!

In total, there are eleven quality measures related to vaccination.  Four quality measures each for resident Seasonal Influenza and Pneumococcal Vaccinations. One for COVID-19 Up to Date Vaccination for residents.  There are two vaccination quality measures for Healthcare Personnel (HCP) – COVID-19 Up to Date Vaccination and Influenza Vaccination Coverage Among HCP.

The eight MDS, process-based measures for Seasonal Influenza and Pneumococcal vaccinations look at assessment and appropriate administration, receipt of vaccinations, offering and declination of vaccinations, and not received due to medical contraindications.  Additionally, these measures impact short-stay and long-stay residents.

For short- and long-stay residents, the measures are determined as follows:

Both measures have 12-month reporting periods.  However, the Seasonal Influenza Vaccination measures are calculated once per 12-month influenza season, beginning on July 1^st and ending on June 30^th of the subsequent year.

In addition, both the short- and long-stay Seasonal Influenza Vaccination Measures have an exclusion:

• Resident’s age on target date of selected target assessment is 179 days or less.

The Pneumococcal Vaccination Measures for short-stay residents also have an exclusion:

• Resident’s age on target date of selected target assessment is less than 5 years (< 5^thbirthday)

This exclusion does not apply to the Pneumococcal Vaccination Measures for long-stay residents.  There are no exclusions for the long-stay measures.

All the Seasonal Influenza and Pneumococcal Vaccination Measures, short- and long-stay, impact the Provider Preview Reports.  The short- and long-stay measures for the Percent of Residents Assessed and Appropriately Given the Seasonal Influenza/Pneumococcal Vaccine also impact Care Compare.

There are also 3 vaccination measures impacting the SNF Quality Reporting Program (QRP).  These include:

1. Percent of Residents who are up to date with COVID-19 Vaccination
2. COVID-19 Up to Date Vaccination Coverage among HCP
3. Influenza Vaccination Coverage among HCP

The measure Percent of Residents who are up to date with COVID-19 Vaccination is an MDS based, process measure. The numerator is the total number of Medicare Part A SNF stays in the denominator meeting either of the following criteria:

1. Type 1 SNF Stays where the resident is up to date with COVID-19 vaccine, as indicated at discharge
2. Type 2 SNF Stays where the resident is up to date with COVID-19 vaccine, as indicated at admission

The denominator is the total number of Medicare Part A SNF stays with a Medicare Part A SNF Stay End Date during the target period.

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The two measures for HCP are National Healthcare Safety Network (NHSN), process measures.  These measures look at the percentage of HCP who are up to date with recommended COVID-19 vaccines and Seasonal Influenza vaccines.  

For the COVID-19 Measure for HCP, the formula is as follows:

Up to date vaccination status for the numerator is what the CDC refers to as up to date as of the first day of the reporting quarter.

The denominator includes HCP in four categories:

1. Employees: Those receiving a paycheck from the reporting facility
2. Licensed Independent Practitioners (LIPs): Physicians, Advance Practice Nurses, and Physician Assistants affiliated with the reporting facility, not directly employed
3. Adult Students, Trainees, and Volunteers: Medical, nursing or other health professional students, interns, medical residents, or volunteers aged > 18 years affiliated with the facility, not directly employed
4. Other Contract Personnel: Personnel providing care, treatment, or services at the facility through a contract and do not fall into other categories.  

The exclusion for this measure is those personnel with a medical contraindication as specified by the Food and Drug Administration (FDA), or Center of Disease Control and Prevention (CDC), or Advisory Committee on Immunization Practices (ACIP).

The Influenza Vaccination Coverage Among HCP Quality Measure is a bit more involved.  The numerator includes HCP in the denominator who from October 1 through March 31^st of the following year:

1. Received an influenza vaccine at the facility or provided in writing proof the vaccination was received elsewhere; OR
2. Were determined to have medical contraindications; OR
3. Who declined the vaccine.

These 3 sub-measure numerators are reported along with an overall numerator, which is an aggregate of the 3 sub-measures.  

The denominator is the number of HCP eligible to work in Facility for at least 1 day during the reporting period.  It includes HCP in the same categories as described for the COVID-19 vaccine - Employees, LIPs, and Adult Students, Trainees, and Volunteers.  It does not include Contract Personnel. Although, this optional information may be reported in NHSN. There are no exclusions for this measure.

To learn more go to Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Measures and Technical Information | CMS.