James Clyne, Jr. and Susan Chenail of LeadingAge New York joined the Nursing Home Advisory Group call on August 24, 2021 to discuss the LeadingAge Quality Metrics tool. The presentation was then followed by policy updates from LeadingAge staff and a facilitated discussion with group participants.

LeadingAge Quality Metrics

James Clyne, Jr., President and CEO, and Susan Chenail, Senior Quality Improvement Analyst, of LeadingAge New York, discussed the LeadingAge Quality Metrics tool. The Quality Metrics tool was developed in 2013 and advised by LeadingAge state executives and staff. In addition to Nursing Home Quality Metrics, quality metrics tools for home health and hospice are also available.

The Quality Metrics tool provides data and visuals to help providers understand performance on quality metrics over time and as compared to other nursing homes. The tool can be used in advocacy, education, marketing, informing referral sources, and quality improvement initiatives. Data used for the tool is based on the CMS data and is accordingly updated monthly. Data can be downloaded into excel format or exported into graphs and other visuals. The group analysis function is customizable, allowing a provider to compare nursing homes in a particular region, such as a city or state, or to monitor sites such as in a multi-site organization.

LeadingAge Quality Metrics can be accessed here. Training videos and support are available and LeadingAge New York, whose data team supports the Quality Metrics tools, plans to offer training to providers beginning in fall 2021.

Policy Updates

SNF PPS Rule. The FY 2022 SNF PPS rule was finalized on July 29. CMS finalized a 1.2% Medicare payment rate increase for FY 2022 after an adjusted market basket. The patient-driven payment model (PDPM) parity adjustment was not finalized and comments from the proposed rule will inform parity adjustment proposals for FY 2023. Quality measures for healthcare-associated infections (HAI) and COVID-19 staff vaccination rates will be added to the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) program SNF readmission measure SNFRM rating will be suppressed with payment adjustments made for the COVID-19 public health emergency. Read details on these and other provisions here.

Reinstatement of per day CMPs. On July 28, CMS released memo QSO-21-20-NH to announce the reinstatement of per day civil monetary penalties (CMPs) for instances of prior noncompliance. Per day CMPs for prior noncompliance were restricted in 2017. CMS’s July 28 memo retired the 2017 directive and stated that state survey agencies should retain the discretion to impose a per day CMP for prior noncompliance when appropriate.

New products on the LeadingAge Learning Hub. The recording is now available for the Complying with Provider Relief Fund Reporting Requirements webinar held last month. Provider Relief Funds received in the first half of 2020 must be reported by September 30, 2021.

While on the LeadingAge Learning Hub, be sure to register for the upcoming webinar Survey Readiness: Navigating Nursing Home Regulations and Oversight. This webinar, scheduled for August 31 at 2pm ET, will provider an insider’s perspective on nursing home regulations and answer key questions about the survey process in the wake of COVID-19.

CDC Morbidity and Mortality Weekly Reports. CDC has recently released a number of Morbidity and Mortality Weekly Reports (MMWRs) relating to our field and which may be useful in discussions around vaccine hesitancy.

An MMWR on vaccine effectiveness in preventing infection in nursing home residents before and during widespread circulation of the delta variant reported that effectiveness of COVID-19 vaccination declined in nursing home residents during circulation of the delta variant to 53.1%, demonstrating the need for continued prevention and mitigation strategies including vaccination of staff, residents, and visitors and potential additional doses of vaccine to boost effectiveness.

An MMWR on vaccine effectiveness in preventing hospitalization among adults aged 65 and older reported that full vaccination with one of the 3 approved vaccines in the United States was highly effective at preventing hospitalization in adults aged 65 and older. The Pfizer and Moderna vaccines were both 96% effective at preventing hospitalization in those aged 65-74 and 91% (Pfizer) and 96% (Moderna) effective in those aged 75 and older. The Janssen (Johnson & Johnson) vaccine was 84% effective in preventing hospitalization in adults aged 65-74 and 85% effective in those aged 75 and older.

Finally, an MMWR on reinfection after COVID-19 vaccination showed that individuals who were previously infected with COVID-19 in 2020 were slightly more likely to be re-infected in 2021 without vaccination than were their vaccinated counterparts. CDC recommends that all eligible individuals, including those who were previously infected with COVID-19, get vaccinated.

Infrastructure bills. House Democrats passed the budget resolution on August 24 that will permit the “care infrastructure” legislation to proceed by reconciliation. The vote is set for September 27 and Congress is on recess until September 20, though the committees continue critical work to develop the legislation that will be merged into one bill. Target date for that resolution is September 15. Check out our Action Alerts here to advocate to your members of Congress.

Nursing Home Improvement and Accountability Act of 2021. New legislation was introduced in the Senate on August 10 in response to the many hearings and reports on nursing homes and COVID-19 in the past year. Two major provisions in the bill include restoring the Obama Administration’s prohibition on pre-dispute binding arbitration agreements and an FMAP bump specifically earmarked for staffing.

Elder Justice Reauthorization. The Elder Justice Reauthorization and Modernization Act of 2021 was introduced on August 6. LeadingAge worked extensively with committee staff on this bill that contains 5 major sections: nursing home worker training grants designed to support recruiting and retaining workers through wage grants that provide wage subsidies, child care, transportation, legal assistance, employer subsidies for paid leave and other grants; medical-legal grants to develop evidenced-based approaches to establishing or improving linkages between health and social services; grant programs to assist Area Agencies on Aging and community-based organizations to address social isolation among vulnerable older adults and adults with disabilities; and funding for Adult Protective Services.

Unemployment benefits. Expanded unemployment benefits are scheduled to expire on September 6. In a letter to Congressional leaders on August 19, Secretary Treasury Janet Yellen and Labor Secretary Marty Walsh stated that they will not seek to extend the $300 weekly boost to unemployment insurance and expanded benefit programs.

Nursing Home COVID-19 Vaccine Mandate. On August 18, the White House announced a mandate for COVID-19 vaccination of long-term care workers in nursing homes. A press release from CMS followed announcing an interim final rule to be released in September. The rule will require all staff in nursing homes to be fully vaccinated against COVID-19. Staff will include employees of the nursing home, contractors, consultants, licensed practitioners and others providing care and services in the nursing home under contract or arrangement. Details such as effective date, compliance date, enforcement, exemptions, and interplay with state requirements are unknown at this time.

LeadingAge immediately sprang into action following the announcement, sending a letter to the Administration advocating that if a vaccine mandate is to be enforced, it must be extended to all CMS-certified healthcare settings rather than singling out the nursing home setting. LeadingAge further advocated that the Administration needs to do more to address the workforce shortage that was already at crisis levels and may be exacerbated by a vaccine mandate. Read the letter here.

A members-only Town Hall was held on August 26 to address members’ questions and solicit feedback on the vaccine mandate. Workforce issues were a resounding concern expressed by members. Read a summary of the event here. LeadingAge is maintaining a list of Frequently Asked Questions related to the nursing home mandate that will be updated as new information becomes available.

Member Feedback

The vaccine mandate and staffing concerns dominated the discussion during the member feedback section of the call. Many expressed concern over how such a mandate will impact already crisis-level staffing. Participants noted that particularly in areas of low vaccination, a vaccine mandate will not only result in staff leaving nursing homes to seek employment in other areas of healthcare that do not require vaccination, but that a vaccine mandate will also pose a barrier to hiring new staff to replace those who leave.

Participants noted that staff loss could impact resident care and even nursing home capacity as wings or beds are taken off-line due to insufficient numbers of staff to provide care. Participants additionally expressed concern over how this vaccine mandate-related turnover will impact nursing homes who are simultaneously facing steep new minimum staffing ratios being introduced in some states.

There was additional discussion about whether others entering the nursing home, including agency staff, state and federal surveyors, ombudsmen, and family visitors would be subject to a mandate. Others expressed concern over logistics of the requirement, such as compliance dates that don’t allow ample time for staff to become fully vaccinated or how exemptions should be handled.

It is important to note that opposition to the vaccine mandate does not automatically represent opposition to vaccination. Many participants felt that a vaccine mandate was untenable due to the strain it would place on the workforce, as noted above, regardless of one’s position on vaccination. Others felt that individuals should have the right to individual choice related to vaccination and other medical treatments. They pointed to high rates of voluntary vaccination among nursing home residents and the use of other mitigation measures including personal protective equipment and regular testing as effective in protecting nursing home residents and staff from COVID-19 infection. LeadingAge values the feedback provided by members as we shape our advocacy.

The LeadingAge Nursing Home Advisory Group call takes place on the last Tuesday of every month. If you are a LeadingAge nursing home member and would like to join this group, please email Jodi Eyigor jeyigor@leadingage.org. Our next monthly call will take place Tuesday, September 28 at 2pm ET and will be a special edition Town Hall Conversation.