The number of residents used to calculate my Post-Acute Care (PAC) Quality Measure (QM) is incorrect. Shouldn the denominator be larger because we admitted many more residents to our SNF/TCU unit?
Before concluding your PAC QM is incorrect, it is important to review how residents are included in the PAC QM calculations. The PAC sample spans a six-month period and selects resident’s most recent 14d SNF PPS MDS assessment (AA8b = 7). Residents who were admitted for SNF stay, but leave before a 14d SNF PPS assessment is completed, are not included. Approximately 50% of all SNF stays leave before 14 days. Also, AA8b is not usually completed for residents with Medicare Managed Care, other insurance (e.g. indemnity insurance) or paying cash and therefore are not selected for inclusion in the PAC QM calculations. The end result of this selection process is that the denominator used to calculate the PAC measures will usually be less than the total number of residents admitted to your SNF-PAC-subacute unit. How much less will depend on your volume of non-Medicare residents and length of stay less than 14 days for your Medicare residents. If after re-examining your SNF/subacute care admis
