Datalign

Overview

This report shows data about resident stays, with a focus on entries from and discharges to hospitals, to facilitate a better understanding of  hospitalizations during a resident's stays at the SNF.

The report includes:

• Three rollup tables that show counts of stays for key scenarios useful for analyzing hospitalizations.
• One rollup table with  counts of diagnoses or events commonly associated with hospitalizations.

All counts in the tables are clickable links. Clicking on a count opens a modal displaying all stays included in that number.

The data is sourced from MDS assessments, with stay logic based on the CMS rules from the MDS 3.0 Quality Measures User’s Manual (V17).

Hospitalization Rollup Tables

The following rollup tables contain:

1. a count of stays meeting the rollup’s criteria, divided into length buckets, and

2. a ‘total’ count, specific for each rollup (as defined below) used in the calculation of percentages.

Rollups tables are:

• Readmissions to hospital after entry from hospital: 
  Stays that began with entry from a hospital and ended with a discharge to a hospital.

  • Total: The count of all entries to the SNF from a hospital, regardless of whether the resident was later discharged to a hospital, to the community, or is still in the facility.

• Reentries from hospital after discharge to hospital:
  Stays that began with reentry from a hospital that was immediately preceded by a stay that ended with a discharge to a hospital.

• Total: The count of all discharges to a hospital in the selected period, regardless of whether the resident reentered the SNF and from what location the resident reentered from.

• Reentries from hospital after discharge to community:
  Any stay that began with reentry to the SNF from a hospital that was immediately preceded by a stay that ended by discharge to the community.

• Total: The count of all discharges to the community in the selected period, regardless of whether the resident later reentered from a hospital, from the community, or never reentered.

• Counts of stays grouped by falls and diagnoses:
  Counts of  falls (by level of severity) and selected diagnoses documented on  discharge assessments from the selected period.

  • Total: Count of all stays in the selected period.

Rollup Buckets

The data in the rollup tables are grouped into standardized time buckets (in days) based on either:

• Stay length: The duration of the stay in the facility, or

• Absence length: the time between a discharge and a subsequent reentry.

Cumulative stays:

• Each bucket in the “Cumulative stays” row includes all buckets of shorter duration. For example, the cumulative row for 4–7 days includes all stays lasting 7 days or less.

Percentages: 

• The row below each count shows that count as a percentage of the total in that table as defined above.

Clickable Counts

Clicking on a count in the report will display the stays behind that number for deeper analysis.

Examples:

• Clicking on the count in the bucket 2–3 days opens a modal that displays data on all stays in that length range.

• Clicking on a count in the  “Cumulative stays” row for a time bucket will display all stays shorter than or equal to that range.

• Clicking on the Total count will display all stays in that rollup’s total (e.g., for diagnoses rollup’s total, the modal will show a list of all stays, and for the “Readmissions to hospital after entry from hospital”rollup the modal shown when clicking on the “Total” count will  include all stays that began with an entry  from a hospital).
  
  

Stays Table Modal

The stays table includes:

• Resident details: Name, MRN, and a link to the resident’s census records in PCC.

• Stay details: Admission date (for the episode of care), entry date, discharge date (if applicable), length of stay, and payers (see definitions).

• Entry to /Discharge From Location

• Falls: Falls recorded on the discharge assessment, color coded to indicate no injury, minor injury, major injury. Counts of falls are displayed as “1” or “2+” (two or more).
  
  

Report Controls

• Date range filters:

  • The date finder allows a user to define which stays are included in the rollup tables . The definition of the date range selected changes based on the

  • “Discharge in Range” toggle:

    • Discharge in range: includes all stays with a discharge date within the date range (ongoing stays are excluded). This is the default view of the report.

    • Entry in range: includes all stays with an entry date  within the date range, including ongoing stays.

• Payer filter:

  • The Payers filter allows a user to define which stays are included in the rollup tables, based on their payer type:

    • Payer types are: Medicare, Medicare Other, Medicaid, Medicaid Pending, Other.

    • Multiple payer types can be selected.

  • The payer filter displays the payer at discharge or entry depending on the  date range type selected:

    • If Discharge in range is on → payers are defined by the discharge assessment.

    • If Entry in range is on → payers are defined by the entry assessment.

      • Example: The same stay could be “Medicaid Pending” at entry but “Medicaid” or “Other” at discharge. Similarly, a stay may start with Medicare coverage but end with a different payer after the Medicare covered part of the SNF stay ends.
        
        

Definitions

• Admission, entry and discharge dates:

  • Source: MDS assessments, with imputation of entry and discharge dates (where needed) based on CMS rules. See MDS 3.0 Quality Measures User’s Manual, Version 16 (pp. 70–76).

• Entry from, discharge to:

  • Source: MDS assessments, items A8105 and A2105 respectively

  • CHS.care groups the responses as follows:

    • 01, 12: Home / Community

    • 02, 03: SNF / Nursing Home

    • 04, 11: Hospital

    • 05: LTACH

    • 06: IRF

    • 07: Psychiatric Hospital

    • 08: ID / DD Facility

    • 09, 10: Hospice

    • 13: Deceased

    • 99: Other

• Payers business rules:

  • Medicare Part A: Valid Medicare number on MDS + active Medicare stay.

  • Medicare Other: Valid Medicare number on MDS but no Medicare stay.

  • Medicaid: Valid Medicaid number on MDS.

  • Medicaid Pending: Identified by characters in Medicaid number on MDS indicating pending status.

  • Other: Any assessment  not fitting the above categories.

• Diagnoses: Taken from the discharge MDS section I.

• Length of stay: Defined as (End – Start). Based on CMS rules, if discharged on the same day as entry, length of stay = 1 (not 0). So a stay with length = 1 (included in the ≤24H bucket) means the discharge occurred either on the same day or the following day.