| What They Reward, and the Critical Factor They Miss

| Cory Fosco

| On October 1, 2025, the Skilled Nursing Facility Value-Based Purchasing Program entered its first year of scoring facilities on four quality measures rather than one. Most people outside the field will never see that change, but the shift alters what Medicare puts money behind.

The mechanics shape behavior. CMS withholds 2 percent of a facility’s Medicare fee-for-service Part A payments and returns 60 percent of that pool to facilities based on how they perform. The other 40 percent stays in the Medicare Trust Fund. For years the score rested almost entirely on the rate of unplanned hospital re-admissions within 30 days. Now the quality measures include 

• 30-day re-admissions
• healthcare-associated infections that require hospitalization
• nursing staff turnover
• total nursing hours per resident day  

In July 2026, CMS finalized a further expansion to eight measures for 2027, adding, among others, whether a resident is successfully discharged back to the community and whether residents reach an expected level of function by discharge.

The idea behind these changes is not new. Mark Parkinson, the former president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), told me in 2011, “Quality is reimbursable.” Perform well on the measures CMS sets, and the payment follows. Fifteen years later, the payment system is finally built to reflect that philosophy. These incentives, however, represent an experiment that suffers from some regrettable blind spots.

I have worked in long-term care for 34 years, in social work and admissions inside skilled nursing and on the technology side of the field. I read these rules the way an admissions director does, as a description of what the building is now paid to care about. What stands out is how much of the new scorecard describes outcomes that begin long before a resident arrives.

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Consider the measures that touch families most directly. A successful discharge to the community is never just clinical. It depends on whether there is a safe place to return to, whether the family understands the plan, and whether the supports at home are arranged while the person was still in the building rather than scrambled for on the day of discharge. That gap is one of the things that can turn a shaky discharge into a re-admission. The clinical work inside the facility can be excellent, and the return home can still come undone when no one at the kitchen table was ready for what recovery actually required. 

The payment system is moving toward rewarding continuity and successful transitions. I am a big fan of this approach. But the incentives reach the facility, not the family, and the family is often where a transition holds together or comes apart. There is no measure for whether a daughter three states away understands her father’s trajectory, or whether a spouse knows the difference between what rehabilitation covers and what long-term care requires. Those understandings help decide whether a discharge holds, yet they sit outside the score.

From outside the system, these programs blur together. Value-based purchasing in skilled nursing is a specific federal program tied to Medicare Part A payments. It is not the same as the rules that govern assisted living, Medicaid home and community-based services, Medicare Advantage, or accountable care arrangements. Those operate under different rules and different budgets. Skilled nursing is the corner of the system where the incentives are most explicit, which is exactly why the gap it exposes is so instructive. The signal is clearest here, and it still stops at the facility door. 

Rewarding better staffing, fewer infections, and more successful returns home is the right direction. A payment system can reward a good discharge. It cannot manufacture the family readiness that makes one possible. That work happens earlier, in conversations most families do not know to have until a hospital discharge forces the decision, often on 72 hours’ notice.

The most practical move CMS could make would be to treat family understanding as part of the care pathway rather than an afterthought at discharge. Admissions and social work teams already recognize how much this process matters. They watch families arrive without a shared picture of what is happening or what comes next, and they know when a transition needs more support long before the scorecard records how it turned out. That gap closes when families read the signals earlier and understand their options before a crisis decides for them. 

The money now rewards getting a resident home and keeping them there. The family that helps make that happen is still not part of what the system counts. No measure sees them, and a yet great deal depends on them.

Cory Fosco is the author of The Question of When: A Practical Guide to Knowing When It’s Time for Assisted Living, Memory Care, or Skilled Nursing (Campion Hall Press, 2026).