You Are Here:Home/Resources/DNS Navigator/DNS Navigator Details
Accountable care organizations (ACOs) seek to partner with skilled nursing facilities (SNFs) that can produce the best quality outcomes while they simultaneously control costs, says Kim Barrows, RN, BSN, LNHA, president of KB Post Acute Strategic Specialists (KB-PASS) in Moores Hill, IN. “That’s the primary difference between the fee-for-service Medicare patient and the ACO patient. You have to make sure that you are helping the ACO control costs—even after the patient discharges from the SNF.”
To work successfully with ACOs, directors of nursing services (DNSs) can put the following steps into practice as they manage their buildings.
October 1 will be here before we know it. And with that comes Medicare’s new Patient-Driven Payment Model (PDPM) for beneficiaries accessing their SNF Part A benefit. It seems like every day there is a new webinar being advertised to help you understand all of the ins and outs of PDPM. It is definitely a more complex system than the RUG-IV system we operate under currently. As we analyze data collected in our facilities, trying to understand where we stand in a PDPM world, there is one other thing to consider: your therapy contract.
For several years now, the Centers for Medicare & Medicaid Services (CMS) has been working to transform both payment and care delivery in the Medicare program. A key vehicle in the agency’s efforts is the Accountable Care Organization (ACO).
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:
When the Patient-Driven Payment Model (PDPM) replaces RUG-IV as the case-mix classification system for the Skilled Nursing Facility Prospective Payment System (SNF PPS) effective Oct. 1, 2019, some SNFs may see their Part A length of stay temporarily increase, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-CTA, president/CEO of Celtic Consulting in Torrington, CT.
“The skilled coverage rules for Medicare won’t change just because we are changing payment systems. However, 95 percent of SNF days are in rehab categories, and many providers have been so focused on obtaining the best rehab RUG score that they have lost sight of what the skilled coverage is,” notes McCarthy. “So length of stay may go up for a period of time as SNFs re-learn how to skill patients for nursing services and become comfortable with understanding when the need for skilled care ends if rehab is not involved.”
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.”
To access this resource, please login or sign up for a membership.