Chronic Care in Nursing Facilities
Long-stay nursing home residents who have moderate to severe pain
Long-stay nursing home residents who were physically restrained
Long-stay nursing home residents who spend most of their time in bed or in a chair
Long-stay nursing home residents with a urinary tract infection
Long-stay nursing home residents who are more depressed or anxious
Low-risk long-stay nursing home residents who lose control of their bowels or bladder
Low-risk long-stay nursing home residents who had a catheter inserted and left in the bladder
High-risk long-stay nursing home residents who have pressure sores
Low-risk long-stay nursing home residents who have pressure sores
Long-stay nursing home residents whose ability to move about in and around their room got worse
Long-stay nursing home residents whose need for help with daily activities has increased
Long-stay nursing home residents who lose too much weight
Post-Acute Care in Nursing Facilities
Short-stay nursing home residents with delirium
Short-stay nursing home residents who have moderate to severe pain
Short-stay nursing home residents who have pressure sores
Home Health Care
Home health care patients who get better at taking their medication correctly
Home health care patients who get better at bathing
Home health care patients who get better at getting in and out of bed
Home health care patients who get better at walking or moving around
Home health care patients who have less pain when moving around
Home health care patients who have less shortness of breath
Home health care patients who have less urinary incontinence
Home health care patients who had to be admitted to the hospital
Need for urgent, unplanned medical care.
Home health care patients who stayed at home after an episode of home health care ends
Hospice Care
Hospice patients who received the right amount of medicine for pain
Hospice patients who received care consistent with their stated end of life wishes
Long-stay nursing home residents who have moderate to severe pain.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
113. Long-stay nursing home residents who have moderate to severe pain, United States, 2004, by
CMS, Minimum Data Set (MDS).
Long-term care residents with a valid target assessment.
Residents with moderate pain at least daily or horrible/excruciating pain at any frequency on the target assessment.
Excludes admission assessments and assessments with inconsistent responses regarding the measure.
Long-stay nursing home residents who were physically restrained.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
114. Long-stay nursing home residents who were physically restrained, United States, 2004, by
CMS, Minimum Data Set (MDS).
Long-term care residents with a valid target assessment.
Residents who were physically restrained on target assessment.
Excludes admission assessments.
Long-stay nursing home residents who spend most of their time in bed or in a chair.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
115. Long-stay nursing home residents who spend most of their time in bed or in a chair, United States, 2004, by
CMS, Minimum Data Set (MDS).
Long-term care residents with a valid target assessment.
Residents who were bedfast on target assessment.
Excludes admission assessments.
Long-stay nursing home residents who had a urinary tract infection.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
116. Long-stay nursing home residents who had a urinary tract infection, United States, 2004, by
CMS, Minimum Data Set (MDS).
Long-term care residents with a valid target assessment.
Residents with urinary tract infection on target assessment.
Excludes admission assessments.
Long-stay nursing home residents who are more depressed or anxious.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
117. Long-stay nursing home residents who are more depressed or anxious, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and a valid prior assessment.
Residents whose Mood Scale scores are greater on target assessment relative to prior assessment.
Excludes admission assessments.
Low-risk long-stay nursing home residents who lose control of their bowels or bladder.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
118. Low-risk long-stay nursing home residents who lose control of their bowels or bladder, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and not qualifying as high-risk.
Residents who were frequently incontinent or fully incontinent on target assessment.
Excludes admission assessments, residents with missing values, residents with comatose status, residents had an indwelling catheter or ostomy, or residents with unknown status for these conditions.
For details about this and other measures of the Nursing Home Quality Initiative, please refer to the documentation available at http://www.cms.hhs.gov/NursingHomeQualityInits/.
Low-risk long-stay nursing home residents who had a catheter inserted and left in the bladder.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
119. Low-risk long-stay nursing home residents who had a catheter inserted and left in the bladder, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care low-risk residents with a valid target assessment.
Residents with indwelling catheters on target assessment.
Excludes admission assessments.
High-risk long-stay nursing home residents who have pressure sores.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
120. High-risk long-stay nursing home residents who have pressure sores, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and a valid prior assessment.
Residents with indication of pressure sores.
Excludes admission assessments.
Low-risk long-stay nursing home residents who have pressure sores.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
121. Low-risk long-stay nursing home residents who have pressure sores, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and a valid prior assessment.
Residents with indication of pressure sores.
Excludes admission assessments.
Long-stay nursing home residents whose ability to move about in and around their room got worse.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
122. Long-stay nursing home residents whose ability to move about in and around their room got worse, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and a valid prior assessment.
Residents from the denominator whose value for locomotion self-performance is greater at target relative to a qualified prior assessment.
Excludes admission assessments.
Long-stay nursing home residents whose need for help with daily activities has increased.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
123. Long-stay nursing home residents whose need for help with daily activities has increased, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and a valid prior assessment.
Residents with worsening (increasing MDS item score) in at least 1 or 2 of the 4 Late-Loss ADL self-performance (bed mobility, transfers, toilet use and eating) or at target relative to prior assessment.
Excludes admission assessments.
Long-stay nursing home residents who lose too much weight.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
124. Long-stay nursing home residents who lose too much weight, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary chronic care residents with a valid target assessment and a valid prior assessment.
Residents who have experienced weight loss of 5 percent of more in the last 30 days or 10 percent or more in the last 6 months.
Excludes admission assessments.
Short-stay nursing home residents with delirium.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
125. Short-stay nursing home residents with delirium, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary postacute care patients with a valid SNF PPS 14-day assessment.
Medicare beneficiary postacute care patients at SNF PPS 14-day assessment with at least 1 symptom of delirium that represents a departure from usual functioning.
Excludes residents with comatose status, residents with end-stage disease, residents receiving hospice care, and residents with unknown status for these conditions. Residents with neurodegenerative diseases are not automatically excluded.
PPS refers to Medicare Prospective Payment System for skilled nursing facilities (SNFs). For details about this and other measures of the Nursing Home Quality Initiative, please refer to the documentation available at http://www.cms.hhs.gov/NursingHomeQualityInits/.
Short-stay nursing home residents who have moderate to severe pain.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
126. Short-stay nursing home residents who have moderate to severe pain, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary postacute care patients with a valid SNF PPS 14-day assessment.
Medicare beneficiary postacute care patients at SNF PPS 14-day assessment with moderate pain at least daily or horrible/excruciating pain at any frequency.
Excludes assessments with inconsistent responses regarding the measure.
PPS refers to Medicare Prospective Payment System for skilled nursing facilities (SNFs). For details about this and other measures of the Nursing Home Quality Initiative, please refer to the documentation available at http://www.cms.hhs.gov/NursingHomeQualityInits/.
Short-stay nursing home residents who have pressure sores.
Centers for Medicare and Medicaid Services (CMS), Nursing Home Quality Initiative.
127. Short-stay nursing home residents who have pressure sores, United States, 2004, by
CMS, Minimum Data Set (MDS).
Medicare beneficiary postacute care patients with a valid SNF PPS 14-day assessment and a valid preceding SNF PPS 5-day assessment.
SNF PPS patients who satisfy either of the following conditions:
Excludes patients with missing values. PPS refers to Medicare Prospective Payment System for skilled nursing facilities (SNFs). For details about this and other measures of the Nursing Home Quality Initiative, please refer to the documentation available at http://www.cms.hhs.gov/NursingHomeQualityInits/.
Home health care patients who get better at taking their medication correctly.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
128. Home health care patients who get better at taking their medication correctly, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which patients get better at taking their medication correctly compared to a prior assessment.
The OASIS instrument measures management of oral medications on a 3-level scale from 0 (fully independent) to 2 (entirely dependent) and refers to ability, not medication compliance. Episodes are not included for persons who are at the highest level and cannot improve any more.
Excludes injectable and intravenous medications.
Home health care patients who get better at bathing.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
129. Home health care patients who get better at bathing, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which a person's ability to bathe improved compared to a prior assessment.
The OASIS instrument measures bathing ability on a 6-level scale from 0 (fully independent) to 5 (completely dependent). Episodes are not included for persons who are at the highest level and cannot improve any more.
Home health care patients who get better at getting in and out of bed.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
130. Home health care patients who get better at getting in and out of bed, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which a person gets better at getting in and out of bed compared to a prior assessment.
The OASIS instrument measures transferring on a 6-level scale from 0 (independent) to 5 (bedfast and unable to turn or position). Episodes are not included for persons who are at the highest level and cannot improve any more.
Home health care patients who get better at walking or moving around.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
131. Home health care patients who get better at walking or moving around, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which a person gets better at walking or moving around compared to a prior assessment.
The OASIS instrument measures ambulation or locomotion ability on a 6-level scale from 0 (full, independent ambulation) to 5 (bedfast). Episodes are not included for persons who are at the highest level and cannot improve any more.
Home health care patients who have less pain when moving around.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
132. Home health care patients who have less pain when moving around, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which a person has less pain when moving around compared to a prior assessment.
The OASIS instrument measures frequency of pain on a 4-level scale from 0 (no pain or pain does not interfere with activity) to 3 (constant). Episodes are not included for persons who are at the highest level and cannot improve any more.
Home health care patients who have less shortness of breath.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
133. Home health care patients who have less shortness of breath, United States, 2003, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2003.
Episodes in which a person has less shortness of breath compared to a prior assessment.
The OASIS instrument measures shortness of breath status on a 4-level scale from 0 (never short of breath) to 4 (short of breath at rest). Episodes are not included for persons who are at the highest level and cannot improve any more.
Home health care patients who have less urinary incontinence.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
134. Home health care patients who have less urinary incontinence, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which a person has less urinary incontinence compared to a prior assessment.
Episodes are not included for persons who are at the highest level and cannot improve any more.
Home health care patients who had to be admitted to the hospital.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
135. Home health care patients who had to be admitted to the hospital, United States, 2004, by
CMS, Outcome and Assessment Information Set (OASIS).
All home health episodes that begin and end in 2004.
Episodes in which a person was hospitalized for an acute condition while receiving home health care services.
Reason for hospitalization may be for emergent, urgent, or elective.
Need for urgent, unplanned medical care.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
136. Home health care patients who need urgent, unplanned medical care, United States, 2004, by
Calculated by the Center for Health Services and Policy, Research, University of Colorado, from Outcome and Assessment Information Set (OASIS) data.
All home health episodes that begin and end in the survey year.
Episodes with an assessment indicating that urgent or unplanned medical care was initiated.
Risk-adjusted rates are available for State estimates only. Particulars about risk adjustment and further information about this and other measures of the Home Health Quality Initiative are available at http://www.cms.hhs.gov/HomeHealthQualityInits/.
Home health care patients who stayed at home after an episode of home health care ends.
Centers for Medicare and Medicaid Services (CMS), Home Health Quality Initiative.
137. Home health care patients who stayed at home after an episode of home health care ends, United States, 2004, by
Calculated by the Center for Health Services and Policy, Research, University of Colorado, from Outcome and Assessment Information Set (OASIS) data.
All home health episodes that begin and end in the survey year.
Episodes with final assessments indicating patients remained at home at the conclusion of services.
Risk-adjusted rates are available for State estimates only. Particulars about risk adjustment and further information about this and other measures of the Home Health Quality Initiative are available at http://www.cms.hhs.gov/HomeHealthQualityInits/.
Hospice patients who received the right amount of medicine for pain.
National Hospice and Palliative Care Organization (NHPCO).
Data source does not support detailed tables.
NHPCO, Family Evaluation of Hospice Care Survey data.
Hospice patients age 18 and over.
Subset of denominator who received the right amount of medicine for pain, according to the survey respondent.
The Family Evaluation of Hospice Care Survey is administered to family members of deceased recipients of hospice care. See the Data Sources section of this appendix for further information.
Hospice patients who received care consistent with their stated end of life wishes.
National Hospice and Palliative Care Organization (NHPCO).
Data source does not support detailed tables.
NHPCO, Family Evaluation of Hospice Care Survey data.
Hospice patients age 18 and over.
Subset of denominator who received care consistent with their stated end of life wishes, according to the survey respondent.
The Family Evaluation of Hospice Care Survey is administered to family members of deceased recipients of hospice care. See Appendix A: Data Sources for further information.