What is the metric?
Percent of Residents Who Made Improvements in Function (SS)
What does the metric mean?
This measure reports the percentage of short-stay residents who were discharged from the nursing home that gained more independence in transfer, locomotion, and walking during their episodes of care.
How do we calculate the metric?
The Numerator is the number of short-stay residents who have a change in performance score that is negative:
([valid discharge assessment] - [valid preceding PPS 5-Day assessment or OBRA Admission assessment] < [0]).
Performance is calculated as the sum of:
G0110B1 (transfer: self- performance)
G0110E1 (locomotion on unit: self-performance),
G0110D1 (walk in corridor: self-performance)
NOTE: Scores of 7 or 8 are recoded as 4
The Denominator includes all short-stay residents with a valid discharge assessment AND a PPS 5-Day Assessment OR an OBRA Admission Assessment. Residents meeting any of the exclusion criteria below are excluded from the measure.
Exclusions:
The resident is comatose on the PPS 5-Day Assessment or the OBRA Admission Assessment (whichever is used)
The resident has a life expectancy less than 6 months on the PPS 5-Day Assessment or the OBRA Admission Assessment (whichever is used)
The resident is coded as receiving hospice care on the PPS 5-Day Assessment or the OBRA Admission Assessment (whichever is used)
Any of the metrics used to calculate performance are missing from the PPS 5-Day Assessment or the OBRA Admission Assessment (whichever is used)
Resident is not impaired in function (sum of G0110B1, G0110D1 and G0110E1 = [0]) on on the PPS 5-Day assessment or OBRA Admission assessment, whichever was used in the QM.
Resident had an unplanned discharge on any assessment during their care episode
References
MDS 3.0 Quality Measures User’s Manual V15
Pages 29-30, Table 2-11