Long-Term Data Strategies

Long-Term Data Strategies Quality Measures Blackout: What’s Next?

By Jeannette Petten, MSN, RN, Chief Nursing Officer, eHealth Data Solutions, LLC Skilled nursing facilities (SNF) can now and should be using the 20 new Quality Measures (QM) approved and issued by the National Quality Forum (NQF) this March.

The Centers for Medicare and Medicaid Services (CMS) and the NQF have replaced the 21 QMs that had been in effect from 2004 until last October with new measures for skilled nursing care. Even though CMS has imposed a QM “blackout” by suspending the beginning of MDS 3.0 Quality Measures reporting until April or May of 2012, SNF leadership can use this QM blackout as a time to improve and advance quality in readiness for future public reporting.

It is important for facilities to get quickly up-to-speed using the new QMs, not only to improve quality of care, but to avoid painful surprises when CMS starts using the new QM data to rank facilities on Nursing Home Compare next spring.

Under MDS 2.0 these QM-based rankings were statewide. eHealth Data

Solutions (eHDS) serves more than 1,300 SNFs, more than many states.

Beginning with MDS 3.0 data now under the QM blackout, eHDS has used nearly 1 million assessments from 160 organizations to rank these facilities and to assist SNF leadership with benchmarks and percentiles that enables them to evaluate their relative QM performance. Critical to putting the QMs to work targeting areas for quality improvement are comparison benchmark charts and Statistical Process Control (SPC) Charts that enable facilities to track important changes to their quality performance in real time and over time, and plan accordingly.

What are the new QMs and how do they differ from the previous ones? First some good news: For the most part, the new QMs are not significantly different from

the old QI/QMs. However, there are a few adjustments. For example, the pressure ulcer QM is largely the same but drops Stage 1 pressure ulcers; the new falls QM now counts only falls involving major injury; and the weight loss QM includes only residents who lose 5 percent weight in 30 days or 10 percent in 180 days without the weight loss being prescribed by a physician. In the MDS, items that are virtually unchanged as triggers between MDS 2.0 and 3.0 include the item subset questions that trigger the QMs for vaccination, urinary tract infections, urinary incontinence, decline in activities of daily living (ADLs) and indwelling catheters. continued on page 11

Table of ContentS 1 Quality Measures Blackout:

4 Hospital Readmissions Will

2 Putting the Quality Measures

4 Cutting Readmissions: The

What’s Next to Work

Cost You

Spectrum Health Program

6 To V or Not To V: The Importance of V Codes

7 Logic Flags Meet MDS 3.0 8 Catastrophe vs. Renewal: Strategies to Cope with Recent Medicare Cuts

Putting the Quality Measures to Work Consultant Demi Haffenreffer recently completed the first stage of a federally-sponsored project to create the ideal model for long-term care quality assurance. The Quality Assurance Performance Improvement (QAPI) project outlines the key components of a facility quality improvement program, including optimal use of quality measures (QM). The project, which was developed by the Colorado Foundation of Healthcare (the state’s Quality Improvement Organization), has been assumed by the University of Minnesota for implementation and testing.

The Centers for Medicare and Medicaid Services (CMS) is soon expected to issue a 184-page manual based on the project’s findings. Haffenreffer discusses how facility QMs figure into the QAPI process and how that process can be improved by longitudinal tracking using run charts, such as the eHealth Data Solutions’ (eHDS) CareWatch Statistical Process Control Chart (SPC).

The New Short and Long Stay Quality Measures

In your research for the QAPI project, what did you learn about facilities’ traditional use of QMs? We found that facilities were using them in ways that not only failed to identify the problem, but sometimes made them worse. A facility would print out its QMs for a particular month, discover that it was among the lowest percentile facilities in the state for a QM and immediately attempt to “correct” the problem.

In fact, they were reacting to inadequate data gathered over much too short a period of time, not analyzing them properly and creating more complications than solutions. I urged them to plot their QM percentages over time to see if there really was an issue and what might be done to address it. The nice thing about the CareWatch SPC charts is that all this is done for them.

How do you select the data to collect and analyze?

The first step in putting QMs to work is to identify the specific QMs that are important to measure based on your facility’s care and services. At the very heart of quality improvement is knowing what data to collect and then developing a data collection plan. A data collection

Long-Term Data Strategies

plan includes identifying what is important, setting goals or thresholds (also known as “indicators”), and determining how the data will be collected, how it will be analyzed and by whom. It is important to provide your staff with training on this process. There is a plethora of data in CareWatch that can assist with this process.

How do you make sure that the data you obtain from this process is valid and reliable?

The first step is knowing how to formulate and analyze run charts. This is critical in assisting with the specific action(s) the facility must take. For example, in analyzing a variation in the data, a key distinction is made between common causes and special causes. If there is normal variation around the center line (mean or median), that is a “common cause.” The goal in all processes is to narrow that variation.

Most problems are related to common cause. When a wide variation that is a common cause exists, it signals a need to examine that system and the processes within needed changes. In the effort to improve a common cause, easy items — such as upgrading standardized practices or training staff to improve standard practice methods — yield big results.

Short Stay QMs • Percent of residents on a scheduled pain medication regimen on admission who report a decrease in pain intensity or frequency

• Percent of residents assessed and appropriately given the seasonal influenza vaccine during the flu season

• Percent of residents who self-report moderateto-severe pain

• Percent of residents assessed and appropriately given the pneumococcal vaccine

• Percent of residents with pressure ulcers that are new or worsened

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Interview with Demi Haffenreffer, President, Haffenreffer & Associates, Inc., Portland, Oregon

Special cause variation, on the other hand, is due to special circumstances and require special analysis and not necessarily a system or process change.

A run of five data points above or below the center line indicates a special cause.

To respond to QMs before identifying patterns one way or the other leads to problems. If, for example, pressure ulcer incidence increases one month and the facility reacts immediately to change its process, this actually increases variation and leads to more problems. I appreciate CareWatch for its ability to distinguish between common and special causes automatically, as a matter of course.

How many data points do you need for reasonable validity?

A minimum of 7 to 12 data points is a start, but 15 or more would go further toward eliminating false positives and false negatives. That doesn’t necessarily mean that each data point can represent one month’s resident assessment. You could track the data weekly for multiple residents and speed up the data gathering. Either way you’re accumulating a series of data forming patterns that may point you reliably in the right direction for quality analysis and improvement.

Could you be more specific as to what the SPC chart show?

SPC charts show how predictable and reliable a metric is. They show the highs, the lows and the mean of the data being tracked over a given period of time. The SPC chart is a “bell” curve of each time period plotted over time. If it shows the curve becoming wider, it means that variation has increased and performance is less predictable. If it shows narrowing over time, the measure becomes more predictable. Given sufficient data over time, the SPC chart allows you to specify causes and plan accordingly for improvement.

Which of the QMs have you found to be the most useful to the skilled nursing facility?

I would say falls, nutrition (particularly weight tracking), pressure ulcers and decline in activities of daily living (ADLs).

The ADLs QM, for example, may show a decline either because the facility has adopted a policy of admitting more frail residents or because it has a problem with its restorative program. The QM alerts the facility where to focus its attention.

Another QM sure to be useful is the new QM for pain management. One confounding factor in measuring pain in an SNF is that many residents are experiencing pain when admitted to the facility because of a medical condition or procedure. In this case, a run chart would be crucial in determining how pain intensity evolves over time under the facility’s care.

Final thoughts?

With the MDS, SNFs are accumulating vast quantities of data that can be overwhelming and seemingly impossible to track. SNFs actually have a rich trove of data available, but they need to know how to organize and analyze it to improve quality. eHDS’ CareWatch is one instrument that has gone a long way in helping facilities move in this direction. Demi Haffenreffer can be reached at Haffenreffer & Associates, Inc., 10050 NW Ash St., Portland, Ore. 97229, phone (800) 733-6590, email demihaff@earthlink.net, website www.consultdemi.net.

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Long Stay QMs • Percent of residents experiencing one or more falls with major injury

• Percent of residents with urinary tract infection

• Percent of residents whose need for help with activities for daily living has increased

• Percent of residents who self-report moderate-to-severe pain

• Percent of low-risk residents who lose control of their bowels or bladder

• Percent of residents who lose too much weight

• Percent of high-risk residents with pressure ulcers

• Percent of residents who have or had a catheter inserted and left in their bladder

• Percent of residents who have depressive symptoms

• Percent of residents assessed and appropriately given the seasonal influenza vaccine

• Percent of residents who were physically restrained ehds.biz

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Hospital Readmissions Will Cost You Based on an interview with John Sheridan, President/CEO, eHealth Data Solutions, LLC Hospital readmissions coming from long-term care providers are one target in the federal government’s new vigorous campaign to reduce Medicare costs. By federal law, hospitals must reduce readmissions occurring within 30 days or risk significant reductions in their Medicare reimbursement.

The long-term care facilities, which include skilled nursing facilities, assisted living facilities, home care agencies and even day care providers that are sources of those readmissions, stand to lose referrals from those hospitals.

Providers that gear up to track and analyze their 30-day-or-less readmissions have less to worry about than those that don’t. And, fortunately, analytical tools have been developed to help facilities with this mission. One is INTERACT

(Interventions to Reduce Acute Care Transfers), as well as eHealth Data Solutions’ (eHDS) own recently introduced Readmission Watch report.

involving chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) to its watch list. According to MEDPAC, these three, plus the original three diagnoses, account for 30 percent of the $15 billion spent on Medicare 30-day readmissions.

This situation grows from an Accountable Care Act provision requiring the Centers for Medicare and Medicaid (CMS) to develop a Hospital Readmissions Hospital readmissions can occur for Reduction Program that focuses on the any number of reasons. The eHDS initial diagnoses of myocardial infarction, Readmission Watch program analyzes congestive heart failure and pneumonia.

In October 2012 (Fiscal Year 2013), hospi- them this way: tals are scheduled to begin reporting on • A readmission occurring within seven those specific readmissions, which were days suggests a problem with hospital identified specifically in a Medicare Paycare or procedures such as providing ment Advisory Commission (MEDPAC) inadequate information for care planning; 2007 report as the cause of $2.5 billion • A readmission occurring within 8 in potentially wasteful and unnecessary to 15 days suggests problems with Medicare expenditures. Beginning in FY long-term care facility policies or 2015, CMS plans to add readmissions procedures;

Cutting Readmissions:

The Spectrum Health Program

Nearly two years ago, our facility — a 278-bed Skilled Nursing Facility (SNF) with 67 dedicated sub-acute rehabilitation beds — was experiencing a problem not uncommon to SNFs around the country: too many hospital readmissions.

This became especially clear when the healthcare reform Accountable Care Act required hospitals to begin reducing readmissions and assume the risk of losing federal funding for “unnecessary and wasteful care.” In our case, 27 percent of all our admissions to the SNF were returning to the hospital within 30 days.

Fortunately, tools had evolved to help us deal with this problem — specifically, the 4

Long-Term Data Strategies

INTERACT and INTERACT 2 instruments.

The focus is on reducing avoidable care transfers by reviewing readmissions using SBAR analysis, i.e., Situation, Background, Assessment, Recommendation.

But we went further than that with a “Stop and Watch” program that we developed for families and began in the summer of 2010. It requests that families of the patient watch for changes in a loved one’s condition that might lead to rehospitalization and inform the staff about this. In addition, we also developed index cards for our certified nursing assistant (CNA) staff that focus on whether sub-acute patients are eating and drinking sufficient quantities, getting turned every two hours to prevent

pressure ulcers, experiencing respiratory difficulty and so forth.

But tools of any kind are only as good as the staff using them. To make optimal use of these tools, we reorganized our staff processes to encourage communication. We created a rounding program that requires nurses to round on sub-acute patients twice each shift for all three shifts and ask CNAs the index card questions. Our nurse managers — the director of nursing and assistant director of nursing — would also round twice each shift to get the nursing staff’s feedback on clinical care questions, such as changes in vital signs, symptoms and lab values.

• A readmission occurring within 15 to 30 days raises the question of family involvement in healthcare decision making, including palliative care.

Research conducted by eHDS has disclosed that 7-day readmissions amount to 11.2 percent of readmissions; 15-day amount to 9.7 percent; and 30-day amount to 10.9 percent. Readmission Watch analyzes these with even more granularity, focusing on periods of 24 hours, 72 hours, 7 days, 8-14 days and 15-30 days and tracks them to alert providers to possible problem situations in a timely manner.

Going beyond the alert, INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.

(For more information on INTERACT, visit www.Interact2.net.). INTERACT’S focus, as its name suggests, is to understand and prevent avoidable acute care transfers (ACT). All the facilities involved

were invited to use INTERACT and its SBAR criteria (Situation, Background, Assessment, Recommendation) to identify and explore common reasons for ACT, such as acute mental status change, fever, pneumonia/lower respiratory illness, dehydration, urinary tract infection and congestive heart failure. INTERACT also guides the facility to review its intraand inter-facility communications; the care paths being used; and care planning options.

Both for business and for quality-of-care reasons, it is more important than ever for facilities to pay attention to Medicare readmissions. Data indicate that as many as 45 percent of Medicare patients are readmitted to a hospital within 100 days of discharge, a startling statistic in its own right. CMS’ focus on 30-day readmissions is serious and involves a firm timeline for enforcement. Medicare has become an increasingly significant payer to long-term care, and facilities can ill-afford to develop sub-standard clinical reputations and proceed to lose business as a result. The time to focus on readmissions is now.

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Based on an interview with Paul Pruitt, Administrator of Spectrum Health Systems, Grand Rapids, Michigan When a readmission occurs, we ask our medical director to get all available information about the case and personally contact the emergency department physician making the readmission assessment. If we discover that we can, in fact, handle the specifics of the case, we ask that the patient be returned to us as soon as possible.

As a final administrative check, every morning after any readmission, I review the case and challenge the staff with questions, based on the information staff has developed.

Needless to say, this was (and is) laborintensive, and very stressful to staff.

Although it sounds simplistic to say that

it got staff talking to each other more, this improvement in communication alone was a big change in staff behavior and culture. In the past, they may have noted changes in a patient’s condition but not think it was important enough to mention. Now they are expecting to be asked. When this involves as many as 100 nurses and CNAs in the first shift alone, that’s asking for a lot of change.

And it’s proving effective. By September — three months after starting the program — we saw a drop in 30-day readmissions from 27 percent to 9 percent. We have maintained that rate, on average, during the year since. Our current goal is to reduce readmissions

to less than 5 percent within the next four to six months.

This means we are going to have to push harder for results. We’ve addressed the “low-hanging fruit” of getting staff talking more. Now we will be getting into possibly substantive upgrades to reduce readmissions — perhaps there is a need to hire a respiratory therapist, obtain new equipment or conduct special training programs for staff. In short, we are moving into the heavy-lifting phase of the program.

But considering the needless care, expense and transfer trauma we are avoiding with this program, the effort is well worth it.

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To V or Not to V:

The Importance of V Codes Based on an interview with John Sheridan, President/CEO, eHealth Data Solutions, LLC

One of the more confusing recent developments in Medicare documentation has been the sudden importance of V codes in documenting admissions to skilled nursing facilities (SNFs). In general, the V codes from the ICD-9 (International Statistical Classification of Diseases, Ninth Revision) are used to indicate treatment incidental to an acute care procedure — for example, physical therapy for rehabilitation of a hip replacement. Although they make sense as a descriptor of what skilled facilities do — providing therapy and supportive care rather than acute procedures — SNFs have typically avoided use of them for several reasons:

should have his/her admitting diagnosis and principal diagnosis (the main reason for continued care) recorded as V codes.

At a minimum, SNFs should code V 57.xx for patients admitted for rehabilitation, or V 57.89 if patients have been admitted for multiple therapies. These codes can only be listed as first, or admitting, diagnoses. Other V codes that can be

• V codes are not required by the Resident Assessment Instrument.

• V codes appear to be more specifically clinical than SNFs have tended to view their principal missions. Even when providing post-acute care, SNFs have traditionally viewed themselves as care managers rather than treatment providers. As someone once said, “Many SNFs view themselves as Part B players in a Part A world.”

• V codes took more space than the MDS 2.0 (Minimum Data Set) allowed after various Long Term Care Resident Assessment Instrument (RAI) diagnostic codes for conditions still being treated were listed. MDS 2.0 provided only five spaces for this.

Additions to the most recently published Medicare claims processing manual in March 2011 changed all that. Of particular interest, Chapter 8 of the Manual states that a patient admitted to an SNF

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Long-Term Data Strategies

first-listed are more often used as secondary, or principal, diagnoses, in which examples might include amputation status or therapeutic monitoring of drug therapy. V codes that are only secondlisted include drug resistance, long-term drug use or hospice. Although it is possible to first-list V codes pertaining to personal or family history, it is rarely done and in these situations, facility supervisors should always be consulted before first-listing them.

Why has the recording of V codes suddenly become more important for SNFs? Because now the Medicare

claims processing manual requires it.

Both Universal Bills (UBs) and MDSs submitted without them become fair game for Recovery Audits (RAs) and consequent denial and application of a default Resource Utilization Group (RUG), with an ultimate refund to Medicare.

What’s more the RA can be initiated fully within 18 months following submission of the claim, posing a potentially nasty and unexpected surprise for the facility. It goes without saying that RAs and fiscal penalties are of particular concern these days to SNFs, especially with the intense political pressures for Medicare cuts as a part of federal debt reduction proposals.

Receiving a percentage of the savings gives RA contractors an incentive to pursue this aggressively.

It is only prudent for SNFs to begin using V codes on the MDS. Fortunately, the “lack-of-space” rationale for failing to do so has been diminished by MDS 3.0, which now offers 10 spaces for recording diagnoses. The real problem for SNFs in accommodating the V codes may simply be a lack of appropriately trained coders to do the work. Professional coders are not commonplace on SNF staffs, and it is not unusual to find one coder managing the documentation of multiple facilities in an organization.

Even when coders are available, chances are they’ve been trained in the hospital setting, where V codes are seldom used and viewed as inappropriate.

Nevertheless, it is strongly recommended that SNFs get up to speed on this issue and learn to V code on all documentation for the post-acute care they provide.

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Logic Flags Meet MDS 3.0 Whatever the strengths or weaknesses of the Minimum Data Set (MDS) may be, and whether it is MDS 2.0 or 3.0, one thing is certain: Consistency of coding is a major challenge. A resident might be reported as “walking with unsteady gait” by the nursing department and “unable to walk” by social services. A resident may have no recognizable diagnosis.

If a high-risk resident with a pressure ulcer apparently has no special mattress

“The great thing about this process is that once staff actually looks at the Logic Flags, any identified issues are quickly addressed.”

– Co-MDS Manager Kathy Bradley provided, was it because documentation was overlooked or the support surface was simply not available? There may have been a communications breakdown quite possibly affecting quality of care.

Eventually the discrepancies end up in the hands of a Medicare intermediary reviewing the MDS, and delays, denials and confusion ensue.

Avoiding such costly errors is the purpose behind the Logic Flags on eHealthDataSolutions’ (eHDS) CareWatch, which screen the completed MDS for such logical inconsistencies and omissions, and alerts the staff. But Logic Flags are no more useful than staff allows them to be. If they’re ignored, a potentially bad situation persists, until, that is, the facility

is brought up short by surveyors or payors. On the other hand, putting them to carefully planned use can improve care and expedite reimbursement.

One organization taking this seriously is the Cypress Health Group, a 45-center chain with centers located in Florida, Georgia, Louisiana, Illinois, Kansas, Missouri and Texas. Recently Cypress’ corporate MDS managers expanded a Logic Flag-based pilot project to enable all its centers to participate. MDS coordinators are asked to review Logic Flags triggered by completed MDS assessments, record flags triggered and take appropriate steps to address them.

“Specifically, they are asked to log in any Logic Flags triggered, inform the departments involved and report on any changes,” says Amy Cranow, CoCorporate MDS Manager for Cypress.

“We’re finding this is a great training tool for nursing personnel, as well as for helping MDS coordinators understand the quality improvement process better and become more familiar with the RAI Manual.”

According to Co-MDS Manager Kathy Bradley, the Logic Flags are particularly timely because they play to a strength of MDS 3.0. “MDS 3.0 is clearly designed to promote teamwork. Information and data are blended from one section to the next so that nursing, dietary, social services, activities, restorative and others can see the relationships and the need to get together to solve problems.”

It starts out with the building’s MDS coordinator printing out and distributing the Logic Flag to the departments

involved.

Beyond that, processes differ.

Bradley says that each building in the Cypress organization has its own approach to managing the Logic Flag alerts. Some schedule interdisciplinary team meetings and others call interdepartmental “corridor consults” on an as-needed basis. “Different buildings have different operational styles,” Bradley explains.

But everyone is expected to perform the login and report functions and take part in periodic, perhaps bimonthly, conference calls. She and Cranow are compiling individual “scorecards” for each building to offer helpful feedback on their Logic Flag performance. During her travels to various buildings, Bradley already has observed that “MDS accuracy has improved tremendously and RAI Manuals are getting used more than ever as staffs research solutions.”

This can only be a good sign. Cranow notes that MDS coordinators have been particularly under the gun since MDS 3.0 went to discharge assessments instead of the MDS 2.0 discharge tracking notes — a 30-minute process vs. a 5-minute process. “Turnover has been huge because of this and expediting documentation is crucial,” she adds.

As for the ultimate goals of improved quality of care and more accurate reimbursement, says Bradley, “The great thing about this process is that once staff actually looks at the Logic Flags, any identified issues are quickly addressed.”

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Catastrophe vs. Renewal:

Strategies to Cope with Recent Medicare Cuts

By John Sheridan, President and CEO, eHealth Data Solutions, LLC The challenges confronting professionals providing skilled care in the wake of what might be a 20 to 25 percent Medicare payment reduction are immense.

Is 2012 to be a year of tragedy caused by cuts in healthcare funding for Americans? Or will 2012 be a year for a RESTART for long-term care?

Will the forthcoming cuts in Medicare

reimbursement deal a serious blow to the long-term care profession or provide a stimulus to sustain services? We can only hope that providers and the key stakeholders — Medicare and Medicaid beneficiaries — can adapt quickly to the myriad of complex changes the Centers for Medicare and Medicaid (CMS) is introducing, apparently without fully considering their impact on beneficiaries as well as providers.

CMS plans to reduce Medicare payments to skilled nursing facilities (SNFs) by at least $3.87 billion, starting October 1, 2011. According to CMS Administrator Donald M. Berwick, M.D., this cut was

due to SNFs unexpected utilization of the higher-paying resource utilization categories for rehabilitation under RUGIV (Resource Utilization Group-Version 4).

With the recently announced new rule, CMS attempts to shift payment toward less expensive RUGs. In effect, CMS has stopped paying providers for efficiencies providers have found, especially those that permitted offsets to allow therapists to serve patients and the skilled care system to provide non-billable services. At present, therapists are unpaid to obtain, prepare, update and educate to make sure the care provided meets evidencebased best practices and includes examples such as participating in care

In summary, the changes for 2012 are: 2012 CMS Action Challenging Providers

Provider Strategy to Respond

1 An 11.1 % Medicare rate reduction

Conduct an analysis of current therapy costs vs. new payment structure and use the data to determine best plan of action. The alternative is to accept and do our best, monitoring cost and ameliorating potential harm due to CMS payment cuts. Note: Rural SNFs will likely struggle most because providing access to therapists 7 days per week is difficult for them to achieve.

2 Payment reduction for RUG rates and payment that drops due to reallocation of group therapy (Estimate @ 7% reduction)

Prior to FY 2011, individual, concurrent or group therapies were modalities determined by patient need, not payment. The CMS FY 2011 rule created modality-based payment rules and incentives. Increasing allocation of resources to occupational, physical, and speech therapies is now an incentive again based on CMS reimbursement decisions.

Allocating more resources to therapy means: 1) Creating more therapy capacity by delivering the exact minutes reimbursed and eliminating overage except as concurrent or group minutes.

2) Hiring more therapists to offset the impact of these changes.

3) Hiring less costly staff to do the non-therapy tasks now assigned to therapists so that therapists can provide hands-on patient care every single hour they are at work.

4) Committing to workflow improvement in the therapy department so that patients are scheduled and transported by less costly personnel and therapists can stay put treating patients one after the other.

5) Employing fewer therapists based on the fact that the group policy will result in a greater proportion of Medicare days in lower intensity RUG categories and therefore fewer reimbursable minutes of therapy time will be necessary to maintain the RUG. This assumes that the specific patient continues to receive the clinically necessary level of therapy to reach his/her full potential in a reasonable period (length of stay).

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Long-Term Data Strategies

planning and evaluations for Medicaid beneficiaries, restorative care planning, and even administrative tasks to help prepare for survey. As a result, the CMS focus on exclusively reimbursed therapy minutes will cause therapy and, as a result, nursing, scopes of practice to change. This CMS change to save Medicare dollars encourages providers to reduce services that are unpaid and grow services like Medicare where the reimbursed services are clear.

In addition to these new or newer challenges, the old challenges remain to improve survey, build and maintain qual-

ity census and manage to better results.

The environment in which our patients expect to receive care also needs change. Private rooms, accommodations with individual bathing and toileting facilities, flat screen 3-D TVs, instant access to Wi-Fi, Skype and more are on the horizon. Individualized resident-centered care environments that deliver high quality clinical services are raising the bar for the long-term care professions.

CMS pays and does not pay. State Medicaid programs cut, cut more, and delay payments. Yet, despite these obstacles, our industry continues to sustain the

tradition of growth and change through inventing and providing spectrums of care, branching from home-and-community-based service to safety and security and, most importantly, loving long-term care in SNFs. In addition, the profession will move on to reduce hospital readmissions, eliminate redundancy and waste, increase professional competency and efficiency, and struggle to succeed even with tight budgets. Thanks to the insights of our forbearers, especially the guardians of skilled nursing care, we have great clinical assessment tools, better understanding of care plans, and a movement to merge clinical/medical continued on page 10

3 Payment reduction due to required change of therapy assessments (COT OMRA) that lower RUG scores and payment and increase the workload of assessment professionals, e.g., a therapy discipline completes treatment on day 9 (COT OMRA mandated); RUB drops to RVB for 6 days at $150 less per day than the RUB rate (Estimate @ 4% reduction)

Improve therapy evaluations and care plans so that clinical evidence supports extended treatment, with progress reported daily at Interdisciplinary Team Conference.

Outcomes improvement and stronger documentation will justify treatment continuation. Strengthen coordination between therapy and nursing, increasing application of restorative care to improve outcomes and make them more lasting. Note, therapy combined with restorative nursing may offer benefit for a longer period, reducing readmissions and improving service.

Prepare and train staff to anticipate and respond to unexpected increased workloads in the already highly complicated MDS and billing offices to avoid mistakes and create the documentation needed to support the RUG and revenues.

4 Mandated daily tracking of therapy minutes by modality and discipline beginning the day following the assessment reference date (ARD) to capture those dates where a change of therapy has happened and to then complete the change of therapy (COT OMRA)

Increase the number of internal meetings for constant assessment of therapy minutes and restorative nursing during the successive sequential 7-day periods between ARDs. Inherent in this practice is capturing when changes occur in therapy intensity and frequency.

5 Payment reduction associated with change of the assessment schedule: The ARD options for the 14 day Medicare assessment change from days 11-14 to days 13-14. For 2011, therapy minutes delivered on days 4-11 counted for reimbursement beginning day 16; For 2012, therapy minutes delivered on days 8-18 count. If a therapy discipline pulls out of treatment on day 9, the therapy minutes for treatment are reduced and the RUB score may drop to RVB. (Estimate @ 4% reduction)

Generate discharge challenge tests in which patients/residents receive occupational therapy and help for instrumental activities of daily living (IADLs), to strengthen the resident’s quality of life after discharge.

Implement Clinical Pathways or Care Maps for the most common DRG-based diagnoses treated in the facility. Standardizing treatments and episode time-lines based upon existing best practices will help with patient communication, establishing outcome expectations and measuring results versus plan.

Identify and implement stronger individualized care and treatment by tracking patient/ resident experience after discharge to improve SNF service effectiveness.

continued on page 10 ehds.biz

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Catastrophe vs. Renewal: Strategies to Cope with Recent Medicare Cuts continued from page 9

services with social models. While there will be major cuts in reimbursement for Medicare, we fervently hope there will be no more cuts in Medicaid payments.

CMS-1351-F 42 CFR Part 413, CMS does not believe it is “appropriate to consider the impact of other policy changes for FY 2012 as part of the 2011” fee cuts.

In conclusion, CMS has introduced new regulations for 2012 in an attempt to create cost savings through policies that motivate providers to do well by doing better. However, CMS states in the final 2012 rule that “it can be difficult to predict provider behavior in response to any given policy changes…given the ability of facilities and stakeholders to adapt quickly to the changes in the SNF system.” Further in the final 2012 rule

One thing is certain. We will unquestionably continue attending to the care of residents/Medicare beneficiaries by providing the highest quality care we can under the constraints of reimbursement.

A strategic review of operational and communication processes within the SNF is therefore essential. Attending to information requirements and data accuracy is the responsibility of senior operational, fiscal and clinical managers.

This responsibility cannot be delegated to department heads without management and operational support.

Knowing how to use the great quantities of data now available to us, and learning new lessons needed to enhance life, delay death and celebrate quality, amount to a crucial opportunity. Successful providers will sustain high performance and reimbursement through careful scrutiny of their important data. Through daily application of this approach, SNF leaders will show that they are aware of and prepared for the new challenges.

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2012 CMS Action Challenging Providers

Provider Strategy to Respond

6 Studies to target diagnosis-specific hospital readmission within 30 days to eliminate redundant care that results from readmissions to hospitals

1) Generate greater cooperation with hospitals, extending hospital best practice into the SNF environment and bringing more active physician treatment into the SNF to assist return-to-home- and community-based living.

2) Determine the core competencies of your staff, in particular your nurses’ ability to assess and implement a plan for emergent situations.

3) Use the discharge challenge tests to better prepare people for discharge to a lowercost setting. (It is only a matter of time before CMS begins reviewing readmissions during the entire 100-day Medicare benefit period.)

4) Train your nursing staff on optimizing physician communications and preparing to provide information to the physician when emergent situations occur. Staff should also be prepared to state the response capabilities of the facility to improve physicians’ levels of comfort and less likely to defer to the hospital’s emergency department.

See “Hospital Readmissions Will Cost You” and sidebar, p. 3, Supplement

7 Implementing new Quality Measures (QMs)

Become familiar with the QMs, target and improve clinical practice and database accuracy to strengthen continuous quality improvement efforts. Analyze your QMs, as opposed to reacting to one score and making changes to systems that do not require change. This will prepare for pay-for-performance (P4P) payment innovations.

See “Quality Measure Blackout — What’s Next” and sidebar, p. 1, Supplement

8 Initiating studies and pilot programs for medical payments innovations

Prepare for bundled payments for orthopedics and vascular care and for the accountable care organization (ACO) models that may emerge. Consider what it would mean to your facility to accept financial risk linked to outcomes, QMs, length of stay or customer satisfaction.

9 Stronger enforcement of existing Medicare and Medicaid integrity policies. All payment contractors are required, per Medicare Program Integrity Manual Publication 100-08, Chapter 6, Section 6.1, to access the MDS from the repository when completing reviews of Skilled Nursing Facility (SNF) Prospective Payment System (PPS) claims, to audit the claims and to use advanced analytics to justify or deny payment.

Strengthen corporate compliance. Automate the data/documentation review or your triple check process and make it an interdepartmental check process, looking at therapy documentation, nursing notes, diagnoses and ancillary services and accuracy of the billing data. Focus on increasing compliance during the entire Part A stay.

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Long-Term Data Strategies

Quality Measures Blackout: What’s Next? continued from page 1 There are now three QMs measuring pain, including one tracking pain management. The Pain Management QM for short-term residents identifies those who are on an ordered pain management protocol and determines whether the patient’s pain level or frequency has improved. The QMs for those residents experiencing moderate to severe pain for both short- and long-term stays are limited by the new MDS 3.0 resident self-reporting requirements. Unlike the

To help SNF nursing and quality improvement teams sustain continuous quality improvement, the CareWatch product from eHealth Data Solutions (eHDS) offers multiple ways to view quality, including benchmark reports with rank and percentiles, triedand-true “run” charts and Statistical Process Control (SPC) charts.

MDS 2.0 QI/QMs, the MDS 3.0 pain measures exclude those residents who are unable to report their pain in the QM. Another major difference is how depression is defined. The QM that measures depression in the “long stay” resident uses the nine item depression scale of

the Patient Health Questionnaire (PHQ-9) score for both interview- and staff-based assessments, as opposed to the former specific individual fields used in MDS 2.0 and the old QMs. (The PHQ-9 is a validated tool with recommendations for clinical follow-up and referral based on its score.)

Our biggest challenge for interpreting the new QMs and their application to assessments involves the differing assessment intervals prescribed by the new QMs vs.

MDS assessment interval requirements.

The National Quality Forum (NQF) has defined “short stay” as 100 days or less; a “long stay” is more than 100 days.

Under the Prospective Payment System (PPS), the “episode of care” is defined by statute as 100 days, so all PPS assessments are easily defined as “short stay” assessments/residents. It is not clear how to reconcile this with the first OBRA quarterly assessment that is due within 92 days of the admission assessment. Will NQF refine the definition? At present we think not, however, residents in census after 100 days from admission become long stay and fit the “long stay” QM protocol. Perhaps the NQF workgroups that developed the QMs were unfamiliar with MDS requirements; NQF members were often hospital-based, and hospitals rely on data from billing documents. As a result, if the quarterly assessment was completed at 100 days or less, it would be calculated with the “short stay” QMs. Once the resident reached 101 days, the assessment information would be removed from the “short stay” QMs and used in the “long stay” QMs. This can become very confusing for facility staff that monitors QMs on a monthly basis. For the sake of consistency, we have adopted a “rule” that all PPS assessments are “short stay” assessments. Until CMS weighs in authoritatively on this, we believe

the 100-day rule for PPS Medicare A benefits falls within the “short stay” intent of the NQF QMs. To help SNF nursing and quality improvement teams sustain continuous quality improvement, the CareWatch product from eHealth Data Solutions (eHDS)

Our biggest challenge for interpreting the new QMs and their application to assessments involves the differing assessment intervals prescribed by the new QMs vs. MDS assessment interval requirements. offers multiple ways to view quality, including benchmark reports with rank and percentiles, tried-and-true “run” charts and Statistical Process Control (SPC) charts. Following residents’ MDS assessments, as recorded at the appropriate intervals over weeks and months, the run and SPC charts show facility staff whether individual residents under their care are improving or declining on a particular QM, and allow staff to assess patient histories, relevant risk factors and potential interventions to improve outcome. With careful attention to continuous outcome data shown in the QMs and appropriate planned response, facilities will be able to use the QMs for the purpose intended.

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