Methodology and Source

CMS Quality Measures


Centers for Medicare & Medicaid Services:

Data for quality measures come from the national Minimum Data Set (MDS) repository. The MDS is an assessment done by the nursing home at regular intervals on every resident in a Medicare- or Medicaid-certified nursing home. Information is collected about the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to assess each resident's needs and develop a plan of care.

All of these data are reported by the nursing homes themselves. Nursing home inspectors review it, but don't formally check it to ensure accuracy. This information changes frequently as residents are discharged and admitted, or residents' conditions change. The information should be interpreted cautiously and used along with information from the Long Term Care Ombudsman's office, the State Survey Agency, or other sources.

The collection period for quality measures is 12 months for short-stay measures and 9 months for long-stay measures, and they are typically refreshed quarterly, reflecting the most recently available period.


Methodology for Quality Measure Performance Rankings:

For each quality measure, the nursing homes in New York State have been divided into five groups according to their scores, with roughly 20 percent of the nursing homes in each group. The mathematical term for such a group is a "quintile," meaning a fifth (1/5). The group with the lowest scores for a quality measure is usually considered the most preferable group--a five-star ranking. The group with the highest scores is usually considered the least preferable group--a one-star ranking. (For the immunization scores, the highest scores earn the five-star ranking.)

For some quality measures, there are many nursing homes with identical scores. When assigning these homes to a ranking group, all homes with the same score must be assigned the same rank. This results in the five-star group having more than 20 percent of the homes in it, and one or more of the other groups having fewer than 20 percent of the homes. This is okay, the normal result of tie scores. The situation is similar to a footrace in which the two front-runners have tied. They both share the #1 spot on the awards platform, but the runner who finished just behind these two runners stands on the #3 spot, because two runners finished ahead of him.

Please note that the quality measure performance rankings are designed to show how nursing homes rank in relation to other nursing homes in New York State.