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August 24, 2022, 12:01 EDT

Chapter 15: Appendix H: Value Based Purchasing Program

Updated: 8/25/2022

Nursing Facility VBP Program

In 2021, the Virginia General Assembly directed the Department of Medical Assistance Services (DMAS) to establish a nursing facility (NF) Value-Based Purchasing (VBP) program designed to improve the quality of care furnished to Medicaid members in nursing facilities.

NFs shall be defined as Provider Types 010 (Skilled Nursing Home) or 015 (Intermediate Care Nursing Home). All NFs participating in Medicaid managed care who previously received the enhanced per diem payments as part of the COVID-19 response support and assistance will be eligible for NF VBP program payments. NFs who do not participate in managed care but previously received enhanced per diem payments as part of COVID-19 response support and assistance are also eligible for the NF VBP program. Eligible Nursing Facilities (NF) will partake in the NF VBP program beginning in July 1, 2022.

All managed care facilities eligible for the NF VBP program will receive payments from an attributed MCO. All non-managed care facilities eligible for the NF VBP program will receive payments from DMAS. The size of the performance payments is contingent on the authorized performance pool, NF attainment of performance tiers, total Medicaid days, and improvement for each included measure.

Table 1: NF VBP Evaluated Performance Measures (PM)

Performance Measure

Description

Domain

NF VBP Performance Weight

Days without Minimum RN hours

Facility reported RN staffing hours each day within a quarter. Required standards addressed 42 CFR§ 483.35(b).

Staffing

20%

Total nursing hours per resident day (RN + LPN + nurse aide hours) – case-mix adjusted

Total nurse staffing hours per resident day within a quarter, adjusted for case-mix.

Staffing

20%

Number of Hospitalizations per 1,000 Long-Stay Resident Days

Number of unplanned inpatient admissions or outpatient observation stays that occurred during a one-year period among long-stay residents.

Avoidance of Negative Care Events

15%

Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days

Number of all-cause outpatient ED visits occurring in a one-year period while the individual is a long-term NH resident.

Avoidance of Negative Care Events

15%

Percentage of long-stay High-Risk Residents with Pressure Ulcers

Percentage of long-stay, high-risk residents with Stage II-IV or unstageable pressure ulcers.

Avoidance of Negative Care Events

15%

Percentage of long-stay Residents with a Urinary Tract Infection (UTI)

Percentage of long-stay residents who have had a UTI within the past 30 days.

Avoidance of Negative Care Events

15%

 

 

Table 2: NF VBP PM Attainment and Improvement Thresholds

PM Tiers

Fair

Thresholds

Better

Thresholds

Best

Thresholds

Improvement

Thresholds

Days without Minimum RN Hours

13.00 – 16.00

5.00 – 12.00

0.00 – 4.00

>5%; Up to the Best tier*.

Total Nurse Staffing Hours per resident day (RN, LPN, CNA) – case-mix adjusted  

3.08 – 3.19

3.20 – 3.30

3.31+

>0.5%; Up to the Best tier*.

Number of hospitalizations 

per 1,000 long-stay resident days

1.36 – 1.75

1.00 – 1.35

0 – 0.99

>5%

Number of outpatient ED visits 

per 1,000 long-stay resident days

0.64–0.95

0.39 – 0.63

0 – 0.38

>5%

Percentage of long-stay high-risk residents with pressure ulcers

8.06– 10.92

5.43 – 8.05

0 – 5.42

>5%

Percentage of long-stay Resident with a Urinary Tract Infection (UTI)

2.39– 4.36

1.31 – 2.38

0 – 1.30

>5%

*NF can earn improvement when they move into a higher tier than previously held.

The full amount of NF VBP program funding will be distributed to eligible NFs based on the criteria established in the Program methodology. As actual data for the performance period is not known in advance, DMAS reserves the right to review the results and adjust criteria as necessary to equitably and completely distribute available funding. No payments will be made that exceed the available funding for the program in total. DMAS will provide notice of any such changes to program criteria prior to finalizing payments.

DMAS will make all final determinations with regards to payments under the NF VBP program, including, but not limited to, determinations of any features pertaining to payments as well as any underlying data used to determine such payments. DMAS will work with stakeholders to address any disagreements in determinations on these points, but in the event that DMAS and the stakeholder are unable to come to agreement, DMAS decisions are final and not subject to appeal. For additional detail on the program methodology, see Final DMAS SFY23 NF VBP Program Methodology: https://www.dmas.virginia.gov/about-us/value-based-purchasing/.