Cultural, demographic, regulatory, and financial changes are
impacting the post-acute care marketplace like never before. Providers need to
navigate through an ever-changing list of obstacles and barriers simply to
deliver care to their clients. Although the road may seem tortuous and the
barriers insurmountable, there are tools to help providers understand the
operational landscape and how best to deal with the necessary “evils” of
providing the best-in-class care for some of our nation’s most vulnerable
people. These 10 tools position providers for success as the move toward a pay-for-
performance system becomes a reality.
Tool No. 1: MDS/CARE
The primary purpose of the Minimum Data Set (MDS) is to work
as a functional assessment tool for identifying and addressing potential
resident care problems and delivering an individualized care plan for the
resident. The purpose of the Resident Assessment Instrument is to develop a
care plan for each beneficiary and to provide services, in accordance with that
plan, that help the resident attain or maintain the highest practicable
physical, mental, and psychosocial well-being.
The CARE (Continuity Assessment Record and Evaluation Item
Set) tool was developed as part of the Post-Acute Care Quality Initiatives and
the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD) for standardized
use in both acute and post-acute settings for admission and discharge.
The CARE tool is meant to standardize assessment items based
on the scientific literature and experiences with the current mandated
assessment items in the Medicare payment system. These assessments include
IRF-PAI, MDS, and OASIS instruments, as well as items related to patient
severity, payment, and quality-of-care monitoring.
Within the CARE tool, two types of items exist: core Items,
which are asked of every patient regardless of condition, and supplemental items,
which are only asked of patients having a specific condition. This
standardization of language helps clinicians communicate acuity, treatment
needs, and outcomes with greater accuracy. The language also allows for
measurement of outcomes in physical and medical treatments while controlling
for factors that may affect those outcomes, specifically cognitive, social, and
Tool No. 2: PEPPER
Surprisingly, at the date of this publication, nearly 50
percent of U.S. skilled nursing facilities (SNFs) have not downloaded the 2015 Program
for Evaluating Payment Patterns Electronic Report (PEPPER) launched mid-April
of this year. PEPPER helps SNFs understand where they stand in relation to
other SNFs in their state, and nationally with regards to vulnerability for
investigation for improper Medicare payments. By understanding its “outlier”
status, PEPPER enables the SNF to prepare for investigation, to take corrective
actions, and to focus on areas of possible weakness.
By looking at six specific target areas (Therapy Resource
Utilization Groups (RUGs) with High Activities of Daily Living (ADL),
Non-therapy RUGs with High ADLs, Change of Therapy Assessment, Ultra-High RUGs,
Therapy RUGs, and 90+ Day Episodes of Care), the Centers for Medicare &
Medicaid Services (CMS) is able to determine whether or not “outlier” SNFs are
overcoding expenses (above the 80th percentile) or undercoding and
not delivering quality care (below the 20th percentile).
In addition to helping a facility be proactive, take
corrective action, and focus on areas of potential vulnerability, understanding
the PEPPER helps the facility to improve quality of clinical documentation and
educate the clinical staff. Data monitoring should be part of a facility’s
quality assurance improvement program.
Tool No. 3: Five-Star
In 2008, CMS enhanced the Nursing Home Compare public
reporting website (www.medicare.gov/nursinghomecompare)
to include a set a quality ratings for nursing care centers that participate in
Medicare or Medicaid. This website displays a nursing center’s “star rating” in
its Five-Star Quality Rating System for the public, enabling it to distinguish
itself between high- and low-performing nursing centers.
In February 2015, as part of the president’s executive action,
several changes in the ratings system took place. A staffing component and a
quality measure (QM) component were added, impacting ratings by potentially as
many as two stars. The staffing domain changed how three- and four-star ratings
are determined by preventing a four-star rating if both the “registered nurse
and all staffing” received a three-star rating, thus giving the facility an overall
The QM domain added new quality measures dealing with the
use of antipsychotic medications during short and long stays and reset the cut
points to achieve each star rating. Because the QM affects the final Five-Star Quality
rating, if the QM domain is one or five stars, facilities need to pay close
attention to this domain.
Achieving a Five-Star Quality Rating is no easy task. However,
by consistently auditing for MDS accuracy and verifying data, a facility can be
on its way to a bright future.
Tool No. 4: Bundled
Payments For Care Improvement Initiative
This innovative bundled payment model was launched in 2013. It
encompasses financial and performance accountability for episodes of care and
is included in the Affordable Care Act (ACA), which specifies a three-year demonstration project testing four
models of bundled payment within Medicare distributed by diagnosis-related
group (DRG) algorithms.
By 2014, 232 hospitals/providers were participating in the
Bundled Payments for Care Improvement (BPCI) Initiative. Currently there are
four broadly defined models of care linking payments for multiple services
beneficiaries receive during an episode of care. The four models are: Retrospective
Acute Care Hospital Stay Care Only, Retrospective Acute Care Hospital Stay Plus
Post Acute Care, Retrospective Post Acute Care Only, and Acute Care Hospital
Stay Only. In the first model, awardees agree to provide a standard discount to
Medicare from the usual Part A hospital in-patient payments. Models 2 and 3,
actual expenditures are reconciled against a target price for an episode of
care, and in Model 4 a lump sum payment is made to a provider for the entire
episode of care. DRGs are included in each episode, and there are 48 episodes that
can be chosen by participants.
Regardless of the BPCI model chosen, this new initiative
includes provider-led redesign and enhancements and re-engineered care pathways
using evidence-based medicine that result in standardized operating protocols,
improved care transitions, and coordination. Gainsharing among provider
partners may also become a reality with BPCI. Also, a number of other payment
reforms are being vetted—providers should be alert to the new payment models
Tool Number Five:
In January, CMS
initiated the Improving Medicare Post-Acute Care Transformation (IMPACT) Act to
improve the reliability of the data on Nursing Home Compare, to help nursing care
centers improve nationwide-focused survey inspections, payroll-based staffing
reporting, scoring methodology, timely and complete inspection data, and
additional quality measures.
The “impact” of the IMPACT Act is geared toward helping
patients compare outcomes across different care settings, thereby supporting
better choices and results for patients.
The act also funds a key improvement to nursing center oversight—the collection
of staffing data—looking at how nursing and other staffing levels “impact”
quality of care. Another element is the institution of more routine surveys of
hospice providers, ensuring that standards are met for the benefit and safety
of patients in end-of-life care.
Tool Number Six: Value-Based
Budgeted to save Medicare $2 billion over the next 10 years,
value-based purchasing was included in the Protecting Access to Medicare Act of
2014 (HR 4302). Also known as the “doc fix,” this one-year patch of the
sustainable growth rate was a value-based purchasing program for SNFs. By
targeting hospital readmissions, value-based purchasing establishes an
incentive pool for high-performing SNFs based on their reduction of hospital
readmissions. The secretary of Health and Human Services (HHS) will specify a
SNF all-cause, all-condition readmission policy by Oct. 1, 2015, and by Oct. 1,
2016, an all-condition, risk-adjusted, potentially preventable readmission rate
will be established.
A SNF readmission measure will include a performance
standard for SNFs, levels of achievement and improvement, and a scoring
methodology to create a ranking system. Medicare’s payment rates will be based
on performance scores starting in October 2018. The highest ranked SNFs will
receive the highest incentive payments, and the lowest ranked will receive the
lowest incentive payments. The lowest ranked 40 percent of SNFs will be
reimbursed less than they otherwise would be reimbursed without the SNF value-based
As of this publication, CMS will withhold 2 percent of SNF
Medicare payments starting Oct. 1, 2018, and redistribute 50 percent to 70
percent of the withheld payments back to the providers by way of incentive
payments. CMS will retain the remaining 30 percent to 50 percent of funds as
program savings. HHS will report the performance on readmission measures for
each SNF on Nursing Home Compare beginning Oct. 1, 2017.
Tool Number Seven:
This is the “Year of Compliance” within the profession. Compliance
will take center stage as regulations and changes continue to be implemented, creating
a paradigm shift of post-acute providers. P-R-E-P-A-R-E is an excellent way to
remember the seven elements of a compliance program:
1. Policies and
Procedures: Non-retaliatory policy, trusting atmosphere so staff feels safe to
disclose and promote commitment to compliance.
2. Reporting and
Investigating: Independent third party review and client attorney privilege.
3. Education and Training: The No. 1
reason for noncompliance is lack of training. It is important to develop a mandatory
facility compliance process, perform risk assessments by area, and make sure
the program is reinforced regularly.
4. Prevention and Response: Establish an anonymous system to seek
guidance and report violations; conduct fact-finding program before full
5. Auditing and Monitoring: Detect, prevent, and deter through a
formalized approach headed by a person with no vested interest in outcomes. Independent
third-party external auditing and internal monitoring become important tools
6. Responsibility/Compliance Officer and Committee Oversight: The compliance
officer and committee are responsible for developing, operating, and monitoring
the compliance program and report to the highest governing body or chief
Discipline, and Incentives: Investigate quickly and thoroughly, conduct root-cause
analysis, apply consistency with discipline, and hold the compliance officer
and management accountable.
As compliance becomes center stage, the P-R-E-P-A-R-E
approach helps build a program that is part of the fabric of everyday
Tool Number Eight: Therapy
structure of a rehabilitation department can either be an in-house operation or
contracted out. This department can significantly impact the reputation of the
facility and the patient outcomes necessary for quality care. As with any other
segment of the business, the principles that apply to operating a successful
nursing facility—maintain occupancy, give quality care, and manage finances—can
be applied to the management of a rehabilitation department as well.
oversight of a successful rehabilitation department has three categories:
Operational Elements: Staffing, space, signage, equipment, supplies, and marketing.
Clinical Systems: Restorative feeding, functional maintenance, restorative nursing, contracture
prevention, wound care, restraint reduction, and positioning.
Standards of Operation: Productivity, efficiency, revenue, payer mix, and expenses.
While the above three categories are not all-inclusive,
they do provide a road map to success. However, of the above subcategories, staffing always seems to
be the most difficult and the most important. In order to provide services
accordingly, it is imperative that the facility identifies the number of
therapists required to properly service the facility census.
Simultaneously, deriving the staffing mix between registered-
and assistant-level clinicians poses discussion and contemplation. The
determining factors include staff availability, cost, state-specific practice
acts, and therapist experience.
Tool Number Nine:
Focused Surveys: Dementia/MDS
The collaboration between CMS and Improve Dementia Care, a
public-private partnership established in 2011, has begun to transform how patients
with dementia receive care in nursing centers across the country. A program
focused on the unnecessary use of medications was piloted in five states. Based
on the results, CMS has revised the dementia care-focused survey process. CMS
also plans to apply the revised version in both traditional and QIS states.
In 2012, CMS launched the National Partnership to Improve
Dementia Care, an initiative to improve and expand the use of nonpharmacological
approaches to care and to reduce antipsychotic medication use in long-stay
nursing center residents. By late 2014, nursing centers in the United States
had achieved a 19.4 percent reduction in antipsychotic drug use.
MDS-focused surveys are also taking center stage with a list
of concerns with MDS coding. Triggers to the Quality Measure Report, including
pressure ulcers, urinary tract infections, antipsychotic drugs, falls with
major injuries, urinary catheters, and/or restraints may put the provider at
risk. In its initial pilot, CMS found an almost a 100 percent error rate.
Tool Number 10:
Sustainable Grow Rate (SGR) ‘Doc Fix’
After 17 “doc fixes” over the past 11 years, Congress
finally passed HR 2 to fix a broken payment system and put into place a number
of reforms that will create a more sustainable solution. Essentially, the doc
fix includes some therapy reforms, including a 33-month extension of the
therapy cap exception process (Dec. 17, 2017), which will allow providers to
continue delivering therapy if medically necessary, coded, and documented.
The fix also includes targeted relief from the arbitrary
Medical Manual Review process, creating a system that is targeted toward
providers with a high claims denial percentage and/or aberrant billing
patterns, to name a few.
There is also a 1 percent market basket update, meaning
providers will receive a 1 percent market basket increase, net of other
adjustments. In other words, post-acute providers, such as long term care and
inpatient rehabilitation hospitals, SNFs, and home health and hospice
organizations, will help finance the repeal, receiving base pay increases of
1 percent in 2018—about half of what was previously expected.
Change Is Necessary (And Can Be Good)
Health care is changing at an alarming rate. Providers are
experiencing change that will position the profession for the long haul, with a
change in demographics and the need for services. But, with the shift toward a
pay-for-performance system focused on value and on quality vs. volume,
providers must work now on quality outcomes, compliance, and improving the
customer experience to survive in the “new world” of health care.
Mastrangelo , OTR/L, LNHA, MBA is founder, president, and chief executive
officer of Harmony Healthcare, a leader in health care consulting, education
and training, and operations and talent management (www.harmony-healthcare.com/). Mastrangelo is an internationally known
and respected speaker and presenter.