​Long term care providers have been sitting on the edge of their seats waiting for the next change, holding on tight for the ride. Recent hot topics include resource utilization group (RUG) “recalibration,” recovery audit contractor (RAC) auditors, payment bundling, pay for performance, and new quality measures. 

The question is, “In the meantime, how can we ensure quality care and balance it with maximum reimbursement?” The staple of any effective quality improvement program can be summed up in one word: collaboration. 

Authentic collaboration changes how we communicate and mine opportunities to improve. The bonus to the process of collaboration is that blending the team’s perspectives can change the care culture, resulting in better survey outcomes and maximized reimbursement.

Lead And Educate

Operational collaboration revolves around leadership and communication. Commonly, operations may be the first to hear about regulatory changes. As regulations change, so will the processes. But when communication fails to reach the frontline staff, it can lead to noncompliance, and noncompliance leads to care concerns and reimbursement implications.
People are more likely to be compliant when they know “why” they are expected to change the process. Thus, leadership now involves more than holding the knowledge and setting expectations. It involves sharing the knowledge and empowering compliance.
Don’t worry, history has proven that with the Centers for Medicare & Medicaid Services (CMS) in the picture there is always something new to learn just around the corner, so operations will always have something to share.
Leading and educating the team in the direction of industry trends is more important now than ever. From compliance to revenue, effective operational processes are the key to professional and cultural growth through facilitation of collaboration.

The Clinical Component

Clinical collaboration begins with looking at the root causes of clinical concerns and ensuring quality during the quality indicators and quality measurements (QIQM) blackout period. Depending on quality indicator reports has been a reactive approach for many providers, and the QIQM blackout period presents an opportunity for examining the effectiveness of current processes before negative outcomes occur.
There are three simple strategies for identifying clinical collaboration opportunities: Nurse Assistant Activities of Daily Living (ADL) Interpretation, Nursing and Resident Conditions, and Nursing Medicare Documentation. Once a provider examines the root cause of these systems’ concerns, the improvement plan can be developed and implemented:
  • Nurse Assistant ADL Interpretation: One of the most common issues is the understanding between the difference of weight-bearing assistance and non-weight bearing assistance, resulting in inaccurate coding.  Using the “palms up, palms down” scenario may explain some of the coding inaccuracies.  Through observations of five residents during chair-to-wheelchair transfer, the following was observed each time: The nurse assistant, with palms down, picked up the resident’s legs to place them on the wheelchair leg rests and coded this as non-weight bearing assistance stating, “My palms were down.” The one point difference in the ADL score was the difference between an RUB versus an RUA, about $127 per day, per resident. On a five-day MDS, which pays for days one through 14, the total lost revenue for this facility in their core based statistical area was $8,897. Another observation revealed two nurse assistants repositioning a resident in bed while the resident grabbed and held on to the siderail. The resident was able to grab the siderail and hold on but not hold her body over, so one of the nurse assistants pulled and held the resident over until the other positioned the pillows. The nurse assistant replied, “My palms are down.” There goes another $127 a day. The only way to determine if there are valid coding interpretation concerns is to actually observe the ADL and coding activity. The collaborative effort, therefore, is to facility the nurse assistants in developing their own ADL documentation, after ADL re-training.


  • Nursing and Resident Conditions: There is always an opportunity to improve the skills of the nursing staff. When an MDS coordinator codes a condition such as a significant weight loss on a quarterly, this should not be a surprise. Surely someone noticed the resident was losing weight or experiencing a decrease in appetite during the 12-week period. The nurse assistants would have noticed loose clothing, the management staff would have noticed changes in appearance during rounds, the nurses in the dining room would have noticed the resident was not eating, the charge nurse would have noticed changes in appearance during med pass, and the dietary staff would have noticed the meal trays returning uneaten. A facility with multiple hospital re-admissions may want to look at the last 90 days of transfers to the hospital and then compare it with the clinical documentation. Most residents do not just wake up with a urinary tract infection or pneumonia needing hospitalization. There are signs and symptoms leading up to that point that would have been observed, communicated to the physician, and an intervention initiated with follow-up. All of this should have been documented. If the documentation does not reflect what led up to the transfer, it may indicate an opportunity to train nurses on assessment and documentation skills and to train nursing assistants on observation and communication skills.The collaborative effort here should be exploring how clinical concerns are communicated, asking the care team about their obstacles, and encouraging them to share what their clinical weaknesses are.


  • Medicare Documentation: Pertinent charting to reflect the ongoing need for skilled services is essential. Simply following a guideline sheet may not be sufficient since the nurse may be inclined to rely on the guidelines, thus eliminating using critical thinking skills. Knowing that the resident is being skilled for physical therapy from left-sided weakness related to a stroke is not enough. If this resident also suffers from chronic obstructive pulmonary disease and chronic heart failure, which may impact the resident’s progress towards the physical therapy goals, the nurse will need to know how to assess and what to document in all these areas. The care plan should reflect all the interventions and the documentation would prove the interventions are in progress. Documentation skills are dependent on skillful clinical assessment and knowledge of disease management, as well as knowledge of the three categories of skilled services. A basic skills set may include assessing respiratory status, fluid balance, diabetes management, and surgical site management. This list is not all-inclusive. The CMS categories of skilled services include: Skilled Nursing and Skilled Rehab (management and evaluation of the care plan, observation and assessment, teaching and training); Direct Skilled Nursing; and Direct Skilled Rehab. CMS defines and offers examples of each of these categories, which can be found in the Medicare Benefit Policy Manual, Chapter 8. Collaboration calls for asking the nursing staff to experiment with different documentation formats. A simple uniform format, such as PIE (Problem, Intervention, Evaluation), can assist with maintaining compliance and with critical thinking skills.  In addition, moving the care plan section of the medical record closer to the nursing notes section can increase the tendency to refer to it when documenting. Documentation should clearly reflect what the skilled need is and which skilled services are being rendered.

The Therapy Component

There is often insufficient communication between clinical and therapy that can result in the unmet needs of residents and insufficient documentation to prove the necessity for skilled care.
An achievable goal would be to begin to incorporate a few components of a “triple check” process, preferably during the Medicare meeting, to ensure effective communication and pertinent documentation.
During this process, and prior to the Medicare claim being submitted, the following activities, at a minimum, should be performed between the therapy and clinical teams:
  • Medicare claims (UB-04): Ensure that service dates, RUGs, and qualifying stay dates, match the MDS. The principle diagnosis should reflect the main reason for skilled care, and the secondary diagnoses, supportive of the principle diagnosis, should be listed on the MDS in section I. 
  • Therapy documentation: Minutes on the log should match the MDS and the plan of care, and the treatment plan must be complete and accurate.
  • Clinical documentation: Ensure that daily documentation is related to the skilled need, certifications are signed and dated, diagnosis on the claim and in the MDS are documented and signed by the physician, and pertinent interventions are on the care plan.
The message is clear. Expectations have reached a new level of provider performance, from management to frontline staff. Facilities can take advantage of the current landscape through collaboration between operations, clinical, and therapy.
Building an operational collaborative culture will ensure success in both quality outcomes and the revenue cycle.
Frosini Rubertino, RN, C-NE, CDONA/LTC, executive director and founder of TrainingInMotion.org, Bella Vista, Ark., has more than 30 years of experience in the health care industry and received her executive management training from the Weatherhead School of Management at Case Western Reserve University and her Continuous Process Improvement training in Cleveland, Ohio. Rubertino is an Eden Alternative Mentor and Educator and the author of the QIS Mock Survey Guide and the Complete Guide to Long Term Care Medicare Billing.  She can be reached at (479) 366-1074 or at frosini@TrainingInMotion.org.