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Under the Patient-Driven Payment Model (PDPM), resident outcomes will be key to avoiding medical review, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training session, Patient-Driven Payment Model: What Is Changing (and What Is Not). Note: Find the session slides here.
The goal of PDPM is for SNFs to provide value-driven care, said officials. “Fundamentally, it comes down to a balance. A high-value and efficient provider is one that is able to achieve high-quality outcomes at low cost.”
CMS measures SNF quality of care in three main ways:
The SNF QRP;
The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program; and
The Five-Star Quality Reporting System on Nursing Home Compare.
Providers may soon have a little more room to maneuver in their Quality Assurance and Performance Improvement (QAPI) programs thanks to the recently published Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency Proposed Rule. However, the Centers for Medicare & Medicaid Services (CMS) doesn’t seek to change the core regulations that lay out required performance improvement activities, including performance improvement projects (PIPs). The bottom line: PIPs are here to stay, and directors of nursing services (DNSs) need to make sure their teams optimize them, says Linda Winston, RN, MSN, BS, QCP-MT, DNS-MT, RAC-CT, a nurse consultant based in Norwich, NY.
What CMS wants to change
CMS proposes to again revise the Medicare/Medicaid conditions of participation (CoPs) by removing a significant chunk of the prescriptive requirements (i.e., the subparts) in the Phase 3 QAPI regulations that the agency originally designated for implementation this November 28.
The CASPER Reporting application in the QIES ASAP system offers providers an array of Skilled Nursing Facility Quality Reporting Program (SNF QRP) reports that providers can use in conjunction with the traditional MDS 3.0 CASPER reports to both monitor the MDS and drive quality improvement, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 13 SNF QRP training session, SNF QRP Reports/Enhancements and Case Study. Note: Find the session slides here.
Officials offered the following insights about how providers can use key reports:
SNF QRP QM reports
CMS provides two SNF QRP QM reports that provide a snapshot of facility performance data. “These reports are available on demand prior to public reporting of the measures, and providers can specify the reporting period of their choice and obtain aggregate performance data for the current and past three quarters,” explained officials. “The assessment-based reports are refreshed monthly, and the claims-based data are refreshed annually. Keep in mind that depending on the report you run, the current quarter may only have partial data.”
It can start out as little things. Something doesn’t feel quite right. The environment around you feels hushed or hostile. And then you become the target.
That was the experience for a nurse who was bullied for eight years by another staff member in her facility. She was about to walk away quietly and quit her job, like so many had before her, feeling like she could not do anything about her situation other than remove herself from it. But just in time, she found the strength she needed to keep going and to share her voice.
Although she would like to remain anonymous (we’ll refer to her as Nurse A), she wanted to share her story so that, if you are experiencing workplace bullying, you can learn how to overcome it, to move forward, and to start healing.
Under the Patient-Driven Payment Model (PDPM) that goes into effect this October 1 for the Skilled Nursing Facility Prospective Payment System (SNF PPS), restorative nursing plays two key roles, just as it did under RUG-IV:
1. It is a qualifier for two payment classification categories in the nursing component of PDPM:
a. Behavioral Symptoms and Cognitive Performance, and
b. Reduced Physical Function.
Note: See the chart at the end of this article for an overview of restorative nursing’s role in the nursing component of PDPM.
2. It also can serve as the daily skilled service required to meet a skilled level of care for Medicare Part A patients (e.g., upon admission when skilled therapy isn’t medically necessary, in conjunction with skilled therapy that doesn’t meet the daily requirement, or after the patient is discharged from skilled therapy). Section 30.6, Daily Skilled Services Defined, in Chapter 8, “Coverage of Extended Care (SNF) Services Under Hospital Insurance,” of the Medicare Benefit Policy Manual offers insights into its role as a daily skilled service:
“In instances when a patient requires a skilled restorative nursing program to positively affect his functional well-being, the expectation is that the program be rendered at least 6 days a week. (Note that when a patient’s skilled status is based on a restorative program, medical evidence must be documented to justify the services. In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)”
Effective November 28, at least one designated infection preventionist who meets specific education, training, and time requirements must be responsible for the infection prevention and control program in every Medicare- and/or Medicaid-certified skilled nursing facility/nursing facility (SNF/NF). One of those responsibilities is to be a member of the quality assessment and assurance (QAA) committee and to regularly report to the committee about the infection prevention and control program.
The underlying requirement in §483.40 of the Code of Federal Regulations (CFR) for F740 (Behavioral Health Services) feeds into multiple facets of the care process—and multiple additional F-tags:
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
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