I am a fan of C.S. Lewis. If you have not read “The Chronicles of Narnia,” you should. You may have seen the more recent three films based on these books. As good as they were, as is usually the case, the books are better.

In “The Lion, the Witch and the Wardrobe,” the second in the book series, four children find themselves in the land of Narnia. 

In Narnia, a faun called Tumnus remarks to Lucy that because of the White Witch, it is “Always winter but never Christmas; think of that!” To which Lucy replies, “How awful!”

That’s the sort of static seasonal lamentation we might all express if it were true for us. Fortunately, the story does not leave us there. It truly is a must-read!

I was thinking about Tumnus’ observation as the April Care Compare Refresh came and went. Did you notice? Surprise! There were no changes to the MDS QM thresholds. 

You may remember four years ago in QSO-19-08-NH, CMS indicated that, “Every six months, QM thresholds will be increased by 50% of the average rate of improvement in QM scores. For example, if there is an average rate of improvement of 2%, the QM threshold would be raised 1%. Similar to setting new thresholds, this action also aims to incentivize continuous quality improvement.”

Due to COVID-19, CMS put those plans on hold. However, the 5-star users’ guides that CMS posted for the April and October 2022 refreshes indicated that they had moved forward with these plans. Subsequently, the thresholds were increased in both updates.

That set a precedent. October and April would be the six-month intervals to expect these changes. And so, when Care Compare was refreshed last month, I immediately looked to see how the thresholds had changed.  

To my surprise, there was no update to the 5-star users’ guide and no notification on the 5-star preview reports regarding threshold changes So, I emailed CMS to see if I had missed something Here’s how they responded.

“CMS has planned regular updates to the quality measure (QM) thresholds every six months when there is improvement. With the April 2023 refresh, the QM thresholds were not changed because the QMs did not improve since the last rebasing in October 2022.”  

“(We) looked at the period from July 2022 to January 2023 when deciding whether to rebase in April.” 

“The rate of improvement will be measured again in October 2023, and at that time the QM thresholds may be updated if there is improvement in the QMs.”  

By the way, are you curious to know what time periods were evaluated that affected the April and October 2022 QM cut point changes? I was.

It turns out that since CMS chose to delay the threshold changes until April 2022 because of COVID, they used the time period of April 2019 to January 2022 to determine improvement. That’s a long time. For the October 2022 update, CMS used January 2022 to July 2022. 

I was also curious as to what specifically changed in the QMs themselves relative to these previous updates, so I dug a little deeper. I shared my findings in a blog post and a web presentation. I found the results very interesting. You may as well. 

That data seemed to indicate that at least some of the improvements were an artifact of COVID-19. The coronavirus naturally had a devastating effect on some QMs, like ADL-related measures and pressure ulcers. These naturally improved once COVID waned. Here’s an example.

Curious as to what timeframes will affect the October 2023 update, I continued questioning CMS. They indicated, “With the October 2023 refresh, CMS will be looking at improvement during the period of July 2022- July 2023.” 

Ostensibly, since no improvement was noted between July 2022 and January 2023, the period affecting the April rebase, CMS will evaluate for improvement for the October update using the entire year since the last improvements were noted. 

I would have liked it if CMS had somehow made us aware of their decision not to rebase the QM cut points in April, and why. But then, you wouldn’t be reading this column, and my curiosity would have been satisfied without all the effort.

Always winter and never Christmas? Well, not so much, I suppose. No change/increase in the QM thresholds is not such a bad thing. The long stay and short stay cumulative point values necessary to achieve a QM star rating will remain at their current levels through the July 2023 update at least.

Yet, it does signal that there was no national improvement in the QMs that drive the star rating thresholds. What does that mean? Time will tell. 

At the end of the day, it may be a signal for providers to spend some quality time with their own QMs. Continuous quality improvement, after all, is the reason we have quality measures.

Without that, from the resident perspective, maybe it would feel a little like “Always winter and never Christmas.” To which we should reply, “How awful!”

Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.