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Home and Community Services

Long Term Care

Long Term Care

3 improvements have been made to the Five Star Nursing Home Quality Rating System.

  • Incorporated the 2 nursing home quality measures for antipsychotic use into the Quality Measure Rating
  • Increased the number of points necessary to earn a Quality Measure Star Rating of 2 or more start. 
  • Changed the Scoring method for the Staffing star rating. Nursing homes must earn a 4 star rating on either the RN or total staffing rating to achieve an overall staffing rating of 4-stars. 

Many nursing homes will see a lower quality measure rating as a result of these changes, even though the underlying QM data may not have changed.

Table 4

+1 star – 2 facilities
No change – 14 facilities
-1 star – 4 facilities

The Centers for Medicare & Medicaid Services (CMS) added six new quality measures to its consumer-based Nursing Home Compare website ( . Three of these six new quality measures are based on Medicare-claims data submitted by hospitals, which is significant because this is the first time CMS is including quality measures that are not based solely on data that are self-reported by nursing homes. These three quality measures measure the rate of rehospitalization, emergency room use, and community discharge among nursing home residents. They include:

  • Percentage of short-stay residents who were successfully discharged to the community (claims-based)
  • Percentage of short-stay residents who have had an outpatient emergency department visit (claims-based)
  • Percentage of short-stay residents who were re-hospitalized after a nursing home admission (claims-based)
  • Percentage of short-stay residents who made improvements in function (MDS-based)
  • Percentage of long-stay residents whose ability to move independently worsened (MDS-based)
  • Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-based)



Nearly 90 percent of seniors want to stay in their own homes as they age, often referred to as “aging in place.” In 2013 Avera started bringing its owned home health and hospice agencies into one central program, known as Avera@Home. Avera@Home is positioning itself to meet patient preferences and provide high quality care by transitioning its care delivery to integrated care management. This coordinated care delivery model is patient centered and evidence based.

A large percentage of Avera hospital acute patients – 74 percent – are discharged to home or self-care. Because patients who receive home care have a significantly lower readmission rate, Avera@Home is participating in an enterprise Avera Health project to ensure acute patients have the correct discharge disposition. The national rate for acute care Medicare patients readmitted within 30 days as stated on Hospital Compare is 17.8 percent, while the Avera@Home readmission rate is 10.84 percent.

Avera@Home Hospice Nurse Mary Pistulka was chosen as the National Association for Home Care and Hospice (NAHC) 2014 of the Year. Mary’s commitment to putting the patient first and honoring their wishes is evident in this patient story. Mary recalls working with one particularly memorable patient - a seasoned truck driver with end stage COPD. “He always knew exactly what he wanted, whether it was driving a riding motor or smoking. Often it was not something the hospice team thought would be best, but we did support his wish to avoid going to a nursing home. By gradually gaining his trust, and mediating several team/patient meetings, I was able to convince my patient to make some compromises. As a result, he was able to remain home with his beloved wife and spend his last days there with the continued support of hospice.”

Care Transitions

Avera Care Transitions Program

Care Transitions is an innovative self-management program through Avera. The goal of Care Transitions is to help you better understand and manage chronic health conditions. It also helps address the transitions you may make from one health care setting to another, or between care facilities, such as from the hospital to your home. Care Transitions uses a team approach to help you reach your personal health goals and help prevent unnecessary hospitalizations.

Patients diagnosed with acute myocardial infarction, chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or pneumonia and experience a stay at one of Avera’s 29 hospitals in the five-state region; patients have the opportunity to enroll in the free program. As part of the program, patients receive educational materials and other tools to help them understand their medications and disease process, keep upcoming provider appointments and recognize potential symptoms.

Each patient also is assigned a transitional care coordinator, who visits the patient at home within 24 to 48 hours of discharge to review medications, answer questions and ensure that a follow-up provider appointment is scheduled. Patients gain the opportunity to work with their transitional care coordinator to create follow-up schedules, which include at least four telephone consultations during the first 30 days.

Since 2012 Avera has served over 6,561 patients in the program. 2,122 patients were in the last year. Of the patients that were enrolled into the Care Transitions program only 11.49% were readmitted for an inpatient hospitalization. This readmission rate is much lower than the national average of 18.3% and South Dakota’s rate of 14.2%

Live Better. Live Balanced. Avera.

Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values.

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