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Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”
That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”
It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”
Here are seven key steps a DNS can take to get out in front of PDPM:
The MDS-based CASPER Quality Measures (QMs) that are posted on Nursing Home Compare, some of which drive the QM domain in the Five-Star Quality Rating System, are a frequent source of headaches for directors of nursing services (DNSs). “Everyone wants Five-Stars in the overall composite rating to attract clients, but adverse events often linger on the CASPER QMs much longer than many DNSs and administrators think they will,” says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
DNSs should have a basic idea of how long adverse events will impact the CASPER QMs, but that shouldn’t be the primary concern, suggests Maher. “The QMs will impact the overall Five-Star rating, but they have a lesser impact than the survey/health inspection and staffing domains. You must have Five-Stars in your QM domain to be able to add a star to your overall rating, and even Five-Stars in the QMs won’t help if your health inspection rating is one star and you’ve already added a star via the staffing domain. In addition, you have to have only one star in the QM domain to negatively affect your overall rating.” Note: For more information, see the “Overall Nursing Home Rating (Composite Measure)” section of the Nursing Home Compare Five-Star Quality Rating System Technical Users’ Guide.
So the CASPER QMs are most important as a tool that DNSs can use to identify opportunities for improvement, stresses Maher. “If you focus on providing person-centered care and improving care, you will get to five stars.”
Valued-based purchasing is coming to long-term care facilities nationwide—and it’ll be here before you know it.
This payment model is designed to support the practice of resident-centered care—which many long-term care facilities have already implemented to some degree. Still, in an industry with deep traditional roots, particularly in regard to reimbursements, the shift in payment model may be jarring—and preparing for the change may be overwhelming.
But it doesn’t need to be.
With the help of a few tools and a little advance planning, you can help make your facility’s transition to value-based care a simple one.
“It's important that we stay ahead of the curve, and that's always a challenge,” says Michelle Bulger.
Bulger, alongside Patty Embree, vice president of innovation at Vincentian Collaborative System, will be co-instructing a conference session at the 2018 AADNS annual conference in National Harbor, MD, on this very subject. The June 29 session, called “Making the Move to Value-Based Care,” will shed light on practical, actionable steps and tools you can implement within your own facility today to prepare for this coming change.
Historically, many providers have treated the MDS and the Resident Assessment Instrument (RAI) process as a silo of government-mandated busywork. That’s always been a problem because, since day 1, the primary purpose of the MDS has been to identify resident care problems that are addressed in an individualized care plan. However, the footprints of the MDS are now carved deep into multiple facets of facility life, including:
· The Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS);
· Some Medicare Advantage payment systems;
· Some Medicaid payment systems;
· The MDS-based quality measures (QMs) that are publicly reported on Nursing Home Compare and used in the Five Star Quality Rating System; and
· The MDS-based QMs that will be publicly reported under the Skilled Nursing Facility Quality Reporting Program (SNF QRP) beginning in October 2018 assuming ongoing data issues are resolved timely. Note: SNFs also must meet an MDS-based reporting threshold under the SNF QRP to avoid a SNF PPS payment penalty each fiscal year.
Last but not least, the new Long-term Care Survey Process (LTCSP) makes sure that surveyors have MDS-based clinical indicators to guide their investigations from the moment they walk in the door, according to the LTCSP Procedure Guide.
As early as spring 2018, the Centers for Medicare & Medicaid Services (CMS) intends to replace the current staffing measures posted on Nursing Home Compare and used in the Five Star Quality Rating System that are calculated from information submitted on the CMS-671 form, said agency officials during the Nov. 2 Skilled Nursing Facility/Long-term Care Open Door Forum (SNF/LTC ODF). The new staffing measures currently under development monitor, for example, the level of hours per resident per day, as well as rates of turnover and tenure. These new staffing measures will be calculated using Payroll-Based Journal (PBJ) data—with an assist on census from the MDS.
While CMS isn’t ready to release details like the applicable data collection timeframes or the technical specifications of the new measures, one point is clear: Timely submission of both PBJ staffing data and the MDS assessments/records that drive census is paramount.
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