Eight Measures, One Resident: Why SNF VBP Requires an Integrated Team

‍For years, many skilled nursing organizations viewed Value-Based Purchasing primarily through the lens of hospital readmissions. In the absence of timely CMS measurement and reporting, we reviewed transfer reports, calculated rates, discussed potentially avoidable hospitalizations, and asked what nursing could have done differently. Fast forward to FY 2027:

Fiscal Year 2027 Skilled Nursing Facility Value-Based Purchasing Program makes one thing increasingly clear:

Value-based care can no longer belong to one department, one discipline, or one meeting. Most of us have understood this for awhile now, but those who have not come to terms with it have very little time to get ready.

Context:

For the FY 2027 program year, CMS expanded SNF VBP from four measures to eight. Facilities are now evaluated on 30-day all-cause readmissions, healthcare-associated infections requiring hospitalization, successful discharge to the community, long-stay hospitalizations, nursing staff turnover, total nurse staffing, discharge function, and falls with major injury among long-stay residents. CMS continues to withhold 2% of Medicare fee-for-service Part A payments to fund the program, with incentive payment adjustments based on performance.

That is not simply a longer list of quality measures. It is a message about how care must be delivered.

The Measures May Be Separate. The Resident Is Not

Let’s consider one resident admitted following a hospitalization for an infection and significant functional decline.

The resident may require:

·        skilled nursing for medication management, monitoring, and continued clinical stabilization.

·        Rehabilitation may be addressing transfers, balance, endurance, activities of daily living, cognition, or swallowing.

·        Dietary services may be working to improve intake. Social services may be determining whether the resident has adequate support to return home.

·        The wound-care team may be managing skin breakdown caused by immobility, moisture, poor nutrition, vascular compromise, or a combination of risks.

Now complicate the case with:

·        The resident may be fearful of falling.

·        The resident and family may be uncertain about returning home.

and a

·        Facility that is itself managing staffing pressures, turnover, documentation demands, and competing priorities.

One resident could affect or be affected by nearly every SNF VBP measure. That is why these measures cannot be managed as eight separate projects. They must be understood as eight different views of the same care experience. Or perhaps, chapters of one novel. They are not separable and influence each other and tell the outcome or ending.

I have spent much of my career reminding teams that quality measures are not just numbers placed on a dashboard. Every number represents a person, a caregiver, a family, and a team of healthcare professionals trying to make the right decisions often in complicated circumstances. The measures themselves are often frustrating due to limited representation or too isolated to prove true quality, but nonetheless it is the playbook we have to play by.

While quality measurement and tracking systems keep you informed of data performance and benchmarking, it does not and will not fully reflect the care given or the person we are caring for. But we have to try! A comprehensive approach that looks at the whole resident and the entirety of the care continuum inside and outside of the facility working hand in hand is necessary. The best performers are focused on pro-action and preparation.

Readmissions and Infections Begin Long Before the Transfer

A hospital transfer cannot be considered a nursing outcome, because the clinical story frequently begins across multiple disciplines.

A therapist may notice that a resident is suddenly unable to complete a transfer that was manageable the day before. A nursing assistant may recognize decreased intake, increased confusion, or a change in continence. Dietary staff may see that the resident has stopped eating. A wound-care clinician may identify increasing drainage, odor, erythema, pain, or tissue deterioration. A housekeeper may notice that someone who normally speaks to them each morning is unusually quiet.

None of these observations should be dismissed because they did not originate with the person responsible for completing the formal assessment.

Preventing avoidable hospitalization requires a culture in which everyone understands that noticing matters, communicating matters, and responding matters.

The strongest early-warning system in a skilled nursing facility is not a single tool or algorithm.

It is an engaged team that knows the residents.

Technology can help organize information, identify trends, and surface changes. It should support clinical judgment rather than replace the relationships that make early recognition possible. Teams who know their residents and value interdisciplinary roles and free flowing communication will have the greatest success. Relationships, awareness, observation and skilled intuition do not require an EHR or special test and are your greatest strategies for avoiding unnecessary hospitalizations.

Discharge to Community Is Not a Therapy Outcome Alone

The addition of both successful discharge to the community and discharge function to SNF VBP will naturally brings greater attention to rehabilitation. CMS defines the Discharge Function Score as the percentage of SNF stays that meet or exceed an expected discharge function score. The Discharge to Community measure evaluates successful community discharges using a two-year risk-standardized rate. Another ongoing frustrating measure with delayed awareness and claims based measurement albeit somewhat improved unless you have tight self-measurement data analytics. Outside of that, it is simply preparing a resident heal, rehabilitate and safely discharge back to the community better than they admitted to us as or ideally at their prior level of function.

Those who fall into the trap of, only therapy can independently create a successful discharge, will fail miserably.

A resident may make meaningful functional progress during therapy and still be unable to return home safely if medications are not manageable, wounds require care that cannot be provided at home, cognition limits safety awareness, equipment is unavailable, transportation is unreliable, or caregivers have not received adequate education.

Similarly, a resident may meet a functional target on an assessment but struggle to carry those abilities into the bathroom, dining room, hallway, or home environment. Therapy cannot create magic in a few hours a day when the resident has another 21-22 hours without their oversite. It takes very little to “undo” everything a resident learns or advances functionally. The best outcomes come from an IDT that is invested in building and sustaining improvement from the prior day in all areas of care.

Function must become part of the resident’s entire day and not something practiced only during a scheduled treatment session.

We all know to achieve a successful and sustained discharge from the SNF, nursing must know how the resident transfers. Nursing assistants must understand the current assistance level. Restorative nursing must reinforce the appropriate skills. Activities should support movement, engagement, and purpose. Social services must identify environmental and caregiver barriers early. The physician and clinical team must consider whether medical stability supports the planned destination. Rehabilitation may help lead the functional conversation, but the entire facility must help carry the function forward.

“Discharge planning starts on day 1.” Heard that a few times?

Well, it does. And it changes throughout the stay. It is not fixed. A successful discharge is not merely a date on a calendar. It is dynamic and resolute.

It is the result of clinical stability, functional capacity, resident choice, caregiver readiness, thoughtful planning, and honest communication coming together.

Falls Are Everyone’s Responsibility—and Zero Risk Is Not the Goal

Falls with major injury among long-stay residents is another measure that demonstrates why departmental ownership is insufficient. This measure lingers for nearly a year as a reflection of a facility’s quality measurement. It truly has lasting impacts just like a fall with an actual major injury has on the resident.

We all know falls are influenced by strength, balance, cognition, medications, continence, footwear, vision, environmental conditions, staffing patterns, sleep, pain, behavior, mobility devices, and the resident’s willingness to request assistance.

Again-it is not a rehab only measure. Rehabilitation may evaluate balance and mobility. Nursing may manage medications and clinical risks. Nursing assistants may provide most of the hands-on support throughout the day. Environmental services may identify physical hazards. Activities may influence movement and engagement. Leadership decisions affect staffing consistency and whether frontline caregivers have the time and information needed to provide individualized assistance. Residents need to move safely and also not become restrained or unnecessarily immobilized.

The goal cannot simply be to prevent every resident from moving. High-quality care requires us to balance safety with autonomy, function, dignity, and the resident’s right to make informed choices.

Yep we are caring for humans with choices, good or bad that challenge every intervention and keep the care plan dynamic. We are not caring for diagnoses or data points. We are caring for human beings whose goals, choices, fears, and definitions of an acceptable life may be different from our own which by the way is NOT reflected in the measure. Do you also notice how important it is for knowing your resident, engaging the resident and communicating for this measure too? I’m seeing a theme develop.

Staffing Is Not Merely a Number

Two of the eight FY 2027 measures directly address staffing: total nursing hours per resident day and total nursing staff turnover. CMS uses Payroll-Based Journal information to calculate both measures. The inclusion of these measures reflects something every experienced long-term care leader already knows:

Consistency matters. Not just in employment programs, employee job satisfaction, and facility culture. But also in who the residents interact with every day.

Residents recognize the caregivers who know how they communicate, how they prefer to transfer, what changes are unusual, what causes anxiety, and what motivates them to participate.

Turnover affects more than a human resources report. It can affect early recognition of illness, adherence to care plans, safe mobility, skin observation, resident trust, family communication, documentation accuracy, and the everyday details that protect quality.

We should certainly monitor staffing data, recruitment, retention, agency use, onboarding, attendance, and turnover patterns. But we should also ask deeper questions.

·        Do employees feel prepared to perform their roles?

·        Do they understand why the care plan matters?

·        Are they included in clinical conversations?

·        Do they believe their observations are valued?

·        Are we creating environments where good people can continue doing difficult work without losing their own sense of dignity and purpose?

Our industry is built on humans taking care of humans while being humans themselves.

A staffing strategy focused only on filling shifts will never be enough. We must create cultures in which caregivers are educated, supported, heard, accountable, and connected to the purpose behind their work. This is an incredibly large initiative for a couple of quality measures. It goes beyond value and well into operational success, business outcomes and referral patterns. These measures cannot be ignored.

Wound Care Lives Inside the VBP Story

I’d be remiss not to bring up skin and wound care. There is no standalone pressure injury or wound measure in the FY 2027 SNF VBP measure set. That does not mean wound care and outcomes exists outside of the program.

A worsening wound can contribute to infection, hospitalization, functional decline, pain, reduced participation in rehabilitation, delayed discharge, caregiver burden, and falls.

The same is true in reverse.

Poor mobility can increase pressure risk. Staffing instability may affect repositioning, continence care, nutrition assistance, and early identification of skin changes. A fall can create a traumatic wound or reduce mobility. An unsuccessful discharge plan may lead to care needs that cannot be safely managed in the community.

Wound outcomes are influenced by the entire system surrounding the resident.

Advanced treatments may be valuable, but no product can replace consistent fundamentals: appropriate assessment, pressure redistribution, mobility, nutrition, moisture management, vascular evaluation, communication, and follow-through.

We should resist the temptation to make wound care the wound nurse’s responsibility.

Let me say that again for the people in the back: THE WOUND CARE NURSE IS NOT THE ONLY PERSON REPSONSIBLE FOR SKIN AND WOUND CARE.

In fact, I have had many conversations with colleagues about why we even designate anyone as a “treatment nurse” or “wound care nurse” for this exact reason. Ownership gets passed off and care is compromised. It isn’t that the other team members don’t know how important the skin and wound care program is, it is that IT IS that important but add a little bit of apathy, low confidence and busyness, it is just easier to “let” the treatment nurse do it.

Every facility mantra should be: The wound clinician may lead the program, but everyone who touches the resident influences the resident’s skin. Ownership is for everyone.

Quality Cannot Be Delegated to the Quality Department

The expanded VBP program challenges organizations to reconsider who owns quality.

If you are “fortunate” to have a full time singularly designated quality improvement person-great! Whether you do or don’t doesn’t change that quality is a facility mission and activity. The quality department can collect data, identify trends, facilitate root-cause analysis, and support improvement plans. MDS professionals can help ensure assessments accurately reflect the resident’s condition and function. Finance can calculate the payment implications. Administrators can establish priorities and allocate resources. Specialty disciplines can focus on priority populations that influence quality measures.

But none of those roles can produce quality alone and it starts well before the resident enters the front door.

Quality is created during the admission process.

It is created when someone notices a change in condition. It is created during medication review, mealtime assistance, toileting, repositioning, therapy, discharge planning, staffing decisions, family communication, and every transition between disciplines and shifts. I could go on and on but you get the point:

Quality is not a department.

It is the cumulative result of what the organization repeatedly notices, values, communicates, and does. Note emphasis on “repeatedly” and “values”. These cannot come and go like the wind. They have to be hard wired and part of your core culture.

What Should Leaders Do Now?

It is important to understand the timing. The FY 2027 payment calculations use performance periods that generally ended September 30, 2025. Facilities should therefore be reviewing their confidential VBP reports and understanding how earlier performance will affect FY 2027 results, while recognizing that today’s operational improvements will influence later program years. This is the biggest flaw and sticking point for me but again the playbook we have to play by. CMS provides confidential reports through iQIES and scores facilities using achievement or improvement, whichever produces the higher measure score.

The first step is not to launch eight disconnected committees. Instant fail!

Start by building one integrated view of the resident experience.

Bring quality, nursing, rehabilitation, MDS, infection prevention, wound care, social services, human resources, operations, and finance to the same table. Map each measure to the clinical and operational processes that influence it. Identify where information is delayed, where responsibilities overlap, and where teams are working from different versions of the same story. Get your act together if it isn’t. Execute systems and support your mission, vision and culture. The rest will follow.

And don’t forget: there are thresholds and benchmarks for performance which means it is NOT an expectation that NO ONE will fall into one or more quality measure at some point during their stay. It is how you recognize it, manage it, ensure it is not a system failure but a true clinical representation of real life humans who come to us broken, sick and weary and do our very best to improve their condition while under our care.

Then some things you can ask are:

·        Are we reviewing outcomes only after they occur, or are we identifying the conditions that lead to them?

·        Can frontline staff explain what the measures mean in practical terms?

·        Are nursing and therapy using the same functional language?

·        Are changes in condition communicated early and acted upon?

·        Are discharge barriers identified at admission or discovered days before discharge?

·        Do staffing conversations include continuity, competency, and culture, not only hours?

·        Are we using data to improve resident care, or merely preparing data for another report?

The answers will tell us far more about our readiness than the existence of another dashboard. 

And Finally,

Eight Measures. One Resident. One Team.

CMS may calculate eight separate measures, but the resident experiences one organization- your facility they have chosen to be cared by.

The real opportunity within the expansion of SNF VBP?

It is an opportunity to move beyond eight isolated metrics and build one coordinated system of care. It is an opportunity to align professional excellence with human dignity and purpose. Most importantly, it is an opportunity to remember that even in a world of increasingly complex quality measurement, we are still simply humans taking care of humans.

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