Historically, Medicare populations have been managed the same way as long-term  populations. In staff members’ eyes, there may be no significant distinction between the services they deliver (other than the charting requirements), even though the Medicare population is post-acute, requiring more knowledge and skills to manage their conditions.
In addition, post-acute residents are not usually seen by nursing staff any more frequently than other residents. What’s more, there is sometimes internal conflict surrounding the incentive to transfer out, reaping the rewards of the three-night qualifying stay for reimbursement purposes, as opposed to treating within the facility and preventing a hospital readmission.

Incentives On The Horizon

Avoidable readmissions cost Medicare an estimated $12 billion each year. One thing is clear—there will soon be incentive to improve the management of post-acute conditions of skilled nursing facility (SNF) Medicare beneficiaries through the Centers for Medicare & Medicaid Services (CMS) Nursing Home Pay for Performance initiative. The initiative includes staffing, quality measures, survey inspections, and potential avoidable hospitalizations.

Even the Quality Improvement Organizations (QIOs) are on board. The CMS Care Transitions program, implemented through the QIOs, focuses on improving the process of care at the system level for specific conditions that lead to rehospitalizations.

It’s never too early to begin improving systems to deliver better post-acute care. Following are some steps to polish up a facility’s Medicare system,yielding improved care management and decreased rehospitalizations.

Tighten up the Medicare admissions process.

  • Include the hospital care plan in the inquiry information; the care plan should follow the patient.
  • Review the paperwork, and interview the patient and family to identify all conditions that may impact recovery. For example, if the primary reason for admission is therapy, there are surely other conditions and comorbidities that can impact the outcome of the therapy goals, such as congestive heart failure, chronic obstructive pulmonary disease, and diabetes. These conditions must be managed by nursing at the same time therapy is treating for the post-acute condition.
  • Prior to actual admission, or on admission, explain the Medicare coverage criteria to the patient and/or significant other. Don’t assume that the hospital discharge planner has already done this.
  • Have one designee make a visit to the resident and/or a phone call to the significant other no longer than 48 hours post admission to communicate the care plan, explain the skilled service, and any other information. This is a collaborative approach to the patient’s care experience. Let this designee be the “go-to” person for the family.

Hold weekly Medicare meetings.

  • Document progress made.
  • Use this meeting as an opportunity to ensure that certifications are signed, orders for services are written, and progress toward goals is checked.
  • Identify training needs.
  • For nursing skills, review documentation for the last six hospital readmissions to determine if issues were addressed during the early symptoms. People don’t just wake up with a urinary tract infection or pneumonia needing hospitalization. There are signs and symptoms that would have been communicated along the way and interventions implemented, which would be reflected in the nursing documentation.
  • Ask nurses what they feel their weaknesses are (skills and conditions), anonymously.
  • Stress early recognition of complications and appropriate interventions to both nurses and nurse assistants. Implement documentation and communication training that supports critical thinking skills. Often, skilled documentation will say, “Call light within reach. No complaints of pain. Seeing therapy for skilled services.” This type of documentation does not support a skilled need.
  • Conduct an experiment: Ask the nurses which patients are on Medicare Part A. The nurses will certainly know which residents are Medicare Part A because they chart on them every day. However, many do not know what specific skilled services are required by the patient. Use this exercise as an opportunity to educate nurses about Medicare Part A residents.
  • Teach nurses the three categories of skilled coverage: skilled nursing or rehab (management and evaluation of the care plan, observation and assessment of a changing condition, teaching and training); skilled nursing (IVs, dressing changes, enteral feedings); and skilled rehab (physical therapy, occupational therapy, speech-language pathology).
  • Focus on the quality of the documentation, not the quantity. Designate one person to check the quality of documentation as it relates to the skilled service and other pertinent conditions. This is best done during a daily nursing start-up routine.
  • Include categories of skilled service, the specific service for the category, and reason for skilled service in the documentation guidelines.
  • Use a simple documentation format to promote critical thinking skills (for example, PIE—problem, intervention, evaluation). Even if the resident is only receiving therapy services, interventions for conditions that may impact the therapy outcome must be documented. 
If there is a review of a therapy claim that results in a denial of payment, at least there is a chance that payment will be reduced to a lower nursing resource utilization group if nursing documentation supports it. Without the additional nursing documentation, the claim will most likely be denied in its entirety.
  • Let the minimum data set (MDS) coordinator facilitate the training of the MDS team. By now, it is obvious that the MDS 3.0 system cannot be conducted as it was with MDS 2.0. There must be a collaborative team in place that is trained to understand the coding guidelines and its implications on care and revenue. The team must be unique, the best athletes for the job, different from the standard “cookie cutter” team of pre-October 2010 that included department heads from each department.
There are now several assessments performed in the MDS process (Start of Therapy, End of Therapy, End of Therapy Resumption, Change of Therapy).

Setting the Assessment Reference Date is now a collaborative effort, just as it is when determining the need to conduct a Significant Change in Condition assessment. The MDS coordinator must communicate daily with therapy to stay on top of the Change of Therapy observation window.

Utilize INTERACT II tools.

  • “Stop and Watch” for nurse assistants is an easy tool to communicate subtle changes in condition so that early interventions may be implemented.
  • “Care Paths” help guide the nurse in assessing and managing several conditions, promoting critical thinking skills.
  • The “SBAR” communication tool helps nurses organize their information prior to contacting the physician. It includes the situation, background information, assessment/appearance, and the request.

Conduct daily rounds.

  • Include frontline charge nurses and nurse assistants and take the medical records along to review the documentation and care plans. In addition, it’s a good opportunity to interact with residents and families along the way.

Triple-check claims before sending.

  • This includes therapy, billing, and nursing. At a mini-mum, nursing should check the accuracy of the certifica-tions, documentation, diagnoses, and MDS coding; billing will ensure the claim reflects the appropriate diagnoses, billing dates, and additional codes; therapy will review its documentation to ensure it supports medical necessity and that the appropriate medical and treatment diagnoses are utilized.
  • Implement a discharge planning program.
  • Use teach-back approaches, and document the successful return demonstrations.
  • Train residents in management of their conditions and when to contact the physician or seek help. Community resources and contact numbers are essential.

Keep Up With Regs And Practices

Designate one person to inform the rest of the team and update policies and procedures as necessary. This individual should be well trained in Medicare regulations and know who the sources of authority are for regulatory changes.

Finally, consider purchasing software that is user friendly, customizable, and able to address multiple care settings. Point-of-care data capture, claims editing, and MDS scheduling are recommended features to look for.
Frosini Rubertino, RN, is the founder of TrainingInMotion.org, a regulatory specialist in long term care, and author of a new book, “Carmelina: Essential Nursing Systems for Long Term Care.” For more information on Medicare workshops or other services, go to www.TrainingInMotion.org or e-mail Frosini at frosini@TrainingInMotion.org.