| The Link Between Falls And Brain Activity | https://www.providermagazine.com/Issues/2017/June/Pages/The-Link-Between-Falls-And-Brain-Activity.aspx | The Link Between Falls And Brain Activity | <div></div>
<div><span><img src="/Issues/2017/June/PublishingImages/AngieSzumlinski.jpg" class="ms-rtePosition-1" alt="Angie Szumlinski" style="margin:5px 10px;" /></span>There has been some exciting research in the pursuit of identifying the root cause of falls. </div>
<div><br>A study recently published in the December issue of Neurology finds that people whose brains work the hardest when they try to walk and talk at the same time may have a higher risk of falling in the future than those who can do both with ease. The ability to multi-task is directly related to what is considered “executive function” and/or “dual-task performance.” What makes this truly exciting is that it appears to be the first study to link brain activity changes that precede behavioral changes to risk of falls.</div>
<div><br>In this study, researchers asked the participants to perform three tasks: walking at a normal pace, reciting alternate letters of the alphabet while standing, and reciting alternate letters of the alphabet while walking at a normal pace. They then measured the brain activity and oxygen levels in the frontal lobe of the brain and found oxygen levels rose when the brain worked harder. </div>
<div><br>Although more research is needed to identify interventions that may influence brain activity during complex walking conditions as a way to prevent falls, this study does identify changes in brain activity and oxygen levels, which is more scientific than anything being used today.</div>
<div><br>So what does this really mean in predicting a resident’s risk for falls in a proactive manner? People who are able to multi-task, including walking and talking at the same time, will likely fall less frequently than people who struggle with it. </div>
<div><br>Long term and post-acute care (LT/PAC) providers should take note. According to the Centers for Disease Control and Prevention, more than one in four seniors fall each year, and falls are a leading cause of death and disability in seniors.</div>
<h2 class="ms-rteElement-H2">Investigating the Resident’s History</h2>
<div>For LT/PAC providers responsible for evaluating residents at risk for falls, a first step to manage risk is to investigate. If little is known about the resident’s risk for falls, consider asking questions of the resident and/or family; be inquisitive about previous lifestyles and employment. </div>
<div><br>There are differences in brain activity and function for people who work in “change on a dime” dynamic positions versus positions requiring rote/single-thought process activities. </div>
<h2 class="ms-rteElement-H2">Going Beyond the Standard to Reduce Fall Risk</h2>
<div>Staff should also consider initiating standards for fall-risk identification and reduction such as balance and strength training, medication reviews, or checking for appropriate footwear. Then, think outside of the paradigm that clinicians are often caught up in. </div>
<div><br>For example, the “homelike environment,” “clutter-free environment,” and “therapeutic milieu” are all great additions to the care plan, but they may sound to some like “canned” interventions, and, sometimes, they are.</div>
<h2 class="ms-rteElement-H2">Be Sensitive to Distractions</h2>
<div>Say a resident at risk for falls ambulates in a common area that is distracting. To assess the person’s risk, consider what types of distractions might interfere with the resident’s ability to ambulate safely. </div>
<div><br>Noise, raised voices, other residents calling out, chair/bed alarms, door alarms, telephones ringing, overhead paging, clutter around seating areas, staff moving about with medication carts and supplies are all distractions that require the resident to multi-task while walking. </div>
<div><br>Even if the resident tries to “tune out” distractions, it isn’t always possible. It is likely the resident will listen to other conversations, respond to alarms sounding, turn to respond to their name being called, or will be required to step around items on the floor: This constitutes multi-tasking. </div>
<div><br>While these distractions may not affect everyone, these situations can increase the risk of falls if a person has difficulty processing multiple stimuli while walking. Being alert to these situations may assist in maintaining a calm, therapeutic environment with a decreased risk for falls for all residents.</div>
<h2 class="ms-rteElement-H2">To Maintain a Calm Environment, Be the Customer</h2>
<div>Some fixes can be quite simple. One thing that is critically important is for the management team to “be the customer.” Quietly visit resident care areas, common areas, activity rooms, dining rooms, and therapy gyms. Bring a critical eye, and be hypersensitive to noise levels and clutter. </div>
<div><br>The typical “rounds” don’t really identify these areas of risk, and many centers are so tuned into the day-to-day operations that these scenarios are considered the “norm.” </div>
<div><br>Then, observe the residents as they ambulate about the center. Observe for unspoken levels of stress, which is often presented as hesitancy while ambulating, turning their heads toward noise, attempting to respond to external stimuli, hand fidgeting, and reaching out to support themselves on furniture or walls. </div>
<div><br>If management observes a resident exhibiting these unspoken signs of stress or distress, consider referring the person to skilled therapy for evaluation. The therapist may assist in determining whether the resident would benefit from an environment with decreased stimulation. </div>
<h2 class="ms-rteElement-H2">Taking an Interdisciplinary Approach</h2>
<div>If needed, a resident who is at risk for falls could be identified for staff members. A color-coded arm band on the walker is one way to signal staff to be considerate of the resident’s need for a calm environment. The process of implementing any method of fall prevention should be interdisciplinary and requires education on the part of staff. More important, the outcomes would benefit the residents. </div>
<div>Consider these other ideas to help cut residents’ risks of falls:</div>
<div><ul><li>Request referrals for resident assessment and evaluation by skilled therapy staff to determine if there is a connection between distraction and poor balance/gait stability;</li></ul></div>
<div><ul><li>Create a list of residents who may be affected by distractions, noise, or clutter;</li></ul></div>
<div><ul><li>Establish a Performance Improvement Plan (PIP) through the Quality Assurance and Performance Improvement (QAPI) committee to develop a plan for decreasing noise and clutter throughout the center and/or identifying ways to assist the specific residents affected;</li></ul></div>
<div><ul><li>Review the plan with the full QAPI committee, adjust as needed, and establish an implementation plan;</li></ul></div>
<div><ul><li>Circle back and evaluate the plan through ongoing monitoring, auditing, and tracking and trending fall rates; </li></ul></div>
<div><ul><li>Review outcomes at the quarterly QAPI committee meeting and adjust the plan if needed; and</li></ul></div>
<div><ul><li>If the center has struggled with higher fall statistics, consider initiating a History of Past Non-Compliance to avoid regulatory citations.</li></ul></div>
<h2 class="ms-rteElement-H2">Keeping the Goal in Mind</h2>
<div>Although there is no magic formula to reduce falls and residents may continue to experience them, the goal is to identify the specific cause(s). This is usually very individual to each resident. Thinking about this study gives reason for pause, as many centers are a buzz of activity with different noises, alarms, and so on. </div>
<div><br>The impact of these seemingly harmless, “normal” noises on residents at risk could be significant, and centers may become “numb” to the noise. </div>
<div><br>Take the time to be the observer. Stop, look, and listen. Share resources with sister facilities, “mystery shop” different centers, and give constructive feedback. Remember, it may make the difference in resident outcomes, fall rates, quality measure results, star rating, and scope and severity of citations. </div>
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<div><em>Angie Szumlinski, NHA, RN-BC, RAC-CT, BS, is director at HealthCap Risk Management Services. She can be reached at Angie.Szumlinski@HealthCapUSA.com. </em></div> | A study recently published finds that people whose brains work the hardest when they try to walk and talk at the same time may have a higher risk of falling in the future than those who can do both with ease. | 2017-06-01T04:00:00Z | <img alt="" src="/Issues/2017/June/PublishingImages/caregiving1_t.jpg" style="BORDER:0px solid;" /> | Caregiving | Column |
| Myth-Busting Medicare for Long Term Care Skilled Services | https://www.providermagazine.com/Issues/2017/June/Pages/Myth-Busting-Medicare-for-Long-Term-Care-Skilled-Services.aspx | Myth-Busting Medicare for Long Term Care Skilled Services | <div></div>
<div><img src="/Issues/2017/June/PublishingImages/caregiving2.jpg" class="ms-rtePosition-2" width="309" height="261" alt="" style="margin:15px;" /><br><br>The guidelines for Medicare are lengthy and complex. Yet, understanding the inner workings of the Medicare program is necessary for providers to guide patients and their families through the maze of long term/post-acute care coverage. With any program, especially one that has been in existence for more than 50 years, it’s common for myths to develop over time. </div>
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<div>Below are eight Medicare myths and truths to keep in mind while navigating coverage for long term care skilled services.</div>
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<div><span class="ms-rteThemeForeColor-6-5"><strong>Myth #1:</strong></span> A resident with psychosis will not qualify for Medicare Part A skilled services.</div>
<div>Although most psychiatric services will not qualify as Medicare Part A skilled services, there are some instances when a resident will qualify when coming straight from the hospital, at least for a short period of time. </div>
<div><br>To help determine whether a resident qualifies, first determine if the stay in the psychiatric hospital meets the three-day qualifying hospital requirement. If it does, the next area to review is whether the care meets the requirements for skilled services under Medicare Part A.</div>
<div><br>The resident may need to have his or her medications adjusted; there is always the potential for an adverse drug reaction if any medications were changed or added. In addition, depending on the time spent in the hospital, there may have been some deterioration and the resident may receive physical therapy orders upon discharge from the hospital. Other areas to review include hearing, speech and vision, cognitive patterns, mood, behavior, functional status, and medications. </div>
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<div><strong class="ms-rteThemeForeColor-6-5">Myth #2: </strong>A resident may be covered for the first five days to observe and assess his or her condition.</div>
<div>The Centers for Medicare & Medicaid Services (CMS) does not specify a minimum or maximum time covered; however, administrative presumption of coverage may be an option. </div>
<div><br>Remember, though, that the use of the administrative presumption is reserved only for residents being directly admitted from a three-day qualifying hospital stay. In addition, this administrative presumption only covers up to and including the assessment reference date (ARD) if no skilled need is identified on the initial admission/readmission minimum data set (MDS). The regulation indicates that a resident can be in skilled care “until the condition of the patient is stabilized.” Typically, skilled care for observation and assessment lasts for a few weeks or less.</div>
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<div><strong class="ms-rteThemeForeColor-6-5">Myth #3: </strong>A new diagnosis triggers a new benefit period.</div>
<div>This is one of the most dangerous Medicare myths out there. It can impact not only resident care, but also customer service and can have a significant financial impact as well. The only way a resident can earn a new 100-day benefit period under skilled nursing facility (SNF) Medicare Part A is to complete a 60-day period of wellness. The calculation for earning a new benefit period is based on two criteria: determining when skilled services ended and counting days.</div>
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<div><span class="ms-rteThemeForeColor-6-5"><strong>Myth #4:</strong></span> All residents who are receiving tube feeding are always skilled and always will be skilled.</div>
<div>The caveat lies with the level of calories and fluid the resident is receiving via the tube. Residents who get 26 to 50 percent of their calories and 501 CCs of fluid per day via the feeding tube, or residents who receive 51 percent or more of their calories via the feeding tube, will automatically qualify for Medicare Part A benefits in a SNF. They are required to continue on Medicare to use a full 100-day benefit period until they drop below such levels on an MDS. </div>
<div><br>These levels will also continue to count as part of that spell of illness and prevent the resident from attaining the 60-day period of wellness to qualify for a new 100-day benefit period.</div>
<div><br>Residents who meet the caloric and fluid requirements will remain at a skilled level of care for a full 100 days, as long as they remain at those required levels. In addition, the resident will not qualify for a new 100-day benefit period unless he or she drops below the calorie and fluid levels previously identified for 60 consecutive days without any other skilled service in the SNF inpatient hospital stay or remains at those calorie and fluid levels identified previously but discharges to home with skilled services being provided in the home for 60 consecutive days.</div>
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<div><strong class="ms-rteThemeForeColor-6-5">Myth #5:</strong> As long as there is an inpatient hospital stay or Medicare Part A SNF stay within the last 30 days, the SNF can pick the resident back up on Medicare Part A.</div>
<div><br>Although this is partly true, the most important criterion using the 30-day transfer window is relating the reason for coverage back to the original hospitalization or a condition that arose during treatment. If the reason to pick the resident back up under Medicare Part A is completely unrelated to the original hospitalization or subsequent SNF stay, the criteria outlined in the regulation regarding the 30-day transfer rules are not met, and the resident should not be put back on Medicare Part A.</div>
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<div><strong class="ms-rteThemeForeColor-6-5">Myth #6: </strong>A resident on Medicare Part A in a SNF can never leave the SNF for an overnight leave of absence.</div>
<div><br>Often, a resident is unable to leave the SNF due to the complexity of the services being rendered. When considering an overnight leave of absence (LOA), consider the following: Can the resident safely be away from the SNF, and can the family or responsible party be taught to safely meet the resident’s needs while out of the SNF? Are the absences infrequent in nature and not for prolonged periods of time?</div>
<div><br>Consult with the resident’s physician to notify him or her of the LOA request and get some feedback from the physician’s point of view on whether the LOA is feasible. </div>
<div><br>For example, if a resident is able to leave the SNF on a weekly basis for an overnight visit, or if the resident leaves for prolonged periods of time three times per week to attend an off-site bingo game, it is doubtful that the practical matter criteria is being met. Remember, one of the four criteria related to meeting the skilled services requirement in a SNF is the practical matter criterion identified in Section 30.7 of the Medicare Benefit Policy Manual (Pub. 100-02).</div>
<div><br><strong class="ms-rteThemeForeColor-6-5">Myth #7: </strong>You never have to issue more than one notice regarding a Medicare stay at the same time.</div>
<div>If only that were a true statement. There are so many notices that it can be confusing to try to understand which notice is issued under what circumstances. To further complicate things, there are times when more than one notice will be issued at relatively the same time. Review Chapter 30, Section 261 of the Medicare Claims Processing Manual for instances when more than one notice may be required.</div>
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<div><strong class="ms-rteThemeForeColor-6-5">Myth #8: </strong>There is never an instance where no notice is required at the end of Medicare coverage.</div>
<div><br>When a beneficiary exhausts his or her 100-day benefit period in the SNF, there is no notice required. The Beneficiary Notification Initiative (BNI) process allows beneficiaries to be notified and gives them the ability to appeal decisions being made by providers in relation to their Medicare coverage. </div>
<div><br>The end of the 100-day SNF benefit period is not a provider decision, but rather a statutory end of coverage based on the Medicare guidelines, and there is nothing that the beneficiary can challenge or appeal. While no formal notice or form is required, it is recommended the beneficiary be informed about the end of the 100-day benefit period.</div>
<div><br>Long term care providers need a thorough understanding of Medicare’s guidelines so they can best serve their residents. Visit CMS.gov for the latest changes. And, keep in mind the eight Medicare myths. Doing so may save time and prevent missteps. <br></div>
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<div><em>Elizabeth McLaren is associate vice president of Health Services at Covenant Retirement Communities (CRC), the nation’s sixth-largest not-for-profit senior services provider. She oversees CRC’s 13 skilled nursing centers at 12 continuing care retirement communities in 10 states and is author of “Long-Term Care Skilled Services: How to Document for Proper Medicare Reimbursement.” She can be reached at Elizabeth_mclaren@covenantretirement.org. </em></div> | Eight Medicare myths and truths to keep in mind while navigating coverage for long term care skilled services. | 2017-06-01T04:00:00Z | <img alt="" src="/Issues/2017/June/PublishingImages/caregiving2_t.jpg" style="BORDER:0px solid;" /> | Caregiving | Column |
| Christian Mason: Caring Up the Ladder | https://www.providermagazine.com/Issues/2017/June/Pages/Christian.aspx | Christian Mason: Caring Up the Ladder | <div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><p><br></p>
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<p><img src="/Issues/2017/June/PublishingImages/ChrisMason.jpg" alt="Chris Mason" class="ms-rtePosition-1" width="143" height="156" style="margin:5px 15px;" />Talking with Christian “Chris” Mason about his career in assisted living is like reading a classic novel. It has an intriguing start and continues with a sequence of life events that connect and spark the next great chapter. At the end, the reader reflects on what has transpired, gaining an intellectual boost and a new appreciation for those who find great joy in caring for the elderly. <br></p>
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<p>Mason embodies personal and professional development. There’s Chris Mason the assisted living pioneer, with his own former community—Bridgewood Rivers in Roseburg—being one of the two that were the first communities in the state of Oregon to receive assisted living licensure. <br></p>
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<p>Then there’s Chris Mason the business owner, the father, and chair of the National Center for Assisted Living (NCAL). <br></p>
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<div>“I guess you can say that I’ve been in it since the beginning,” says Mason. “And that led me down the path I’m on.”</div>
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<h2 class="ms-rteElement-H2">An Early Start</h2>
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<div>But for Mason, his beginning started earlier. At 16, he witnessed his grandfather fall ill with cancer and receive care in a nursing center. “My grandfather and I were very close. I would visit him every day. And I missed him when he passed away,” says Mason. “I thought, ‘There’s got to be something that I could do to make a difference.’” </div>
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<div><br>That’s when he turned toward a career in therapy. While working as a certified nurse assistant at a center in northern Vermont, Mason studied therapy and applied mathematics. It was during these formative years that he learned that the family and care team must be in sync to provide the best care.</div>
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<div><br>Soon after, Mason realized he wasn’t finished learning just yet. He went back to school to become a nursing home administrator. His motivation: to be more effective at a higher level. <br></div>
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<h2 class="ms-rteElement-H2">Making Memories Count</h2>
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<div>At the start of his career as a skilled nursing center administrator, Mason was working in Montgomery, Ala. While many residents are memorable, one stands out in his mind—a young man named Don who was a former linebacker on the Alabama Crimson Tide football team. He had been in an automobile accident and was paralyzed from the neck down. </div>
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<div><br>“We got to become good friends,” recalls Mason. “We would sit and talk about things that meant so much to him. He was a big outdoorsman, he loved to hunt and go camping.</div>
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<div><br>“Here he was—this 275-pound man confined to a bed. It was back then when I thought I could conquer the world, so I made the decision that we were going to go camping.”</div>
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<div><br>Mason let all the residents know and had to plead with staff to come along. After finding a handicap-accessible site, Mason made the trip with other residents and staff, leaving behind a sign on the door that read: Gone Camping. “It rained the whole time we were there, but everyone had a great time,” says Mason. “And I’m proud to say it’s something we’re still doing, 30 years later.”</div>
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<h2 class="ms-rteElement-H2">Growing Up the Ladder</h2>
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<div>Over time, Mason grew within his company as administrator. “I had a knack for fixing things, and they noticed,” he says. The company’s directors sent him to communities that they would buy that were broken and had problems. Mason would work together with the team to figure out what the problem was, decide which staff were working out and which staff weren’t, and fix the flaws. </div>
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<div><br>When one of the owners started his own company, Mason joined as an operating partner. There he worked for several years until a new door opened. The head of the Oregon state government senior services department was doing a tour through the state to talk about giving seniors more choice and independence. </div>
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<div>Hearing the new direction, Mason jumped right in. He joined a small group of leaders and developed and built one of the state’s first assisted living communities. </div>
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<div><br>It wasn’t long before Mason set his sights on a new venture. “I watched the changes that were occurring in acuity and thought we had some gaps,” he says. “So I went out and started a software company.”</div>
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<div><br>And so Vigilan came to be. Mason honed his mathematics background and experience as an administrator to focus on time-based metrics. The company produced an acuity-based assessment tool that allowed customers to assess residents’ needs and to have the right people with the right skills in the right place at the right time. </div>
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<div><br>Mason’s insights into the world of caregiving gave him a boost to starting to build a company from the ground up. “Let’s say a resident needs assistance with bathing. It’s very different if it is standby assistance or total assistance,” he says. “Total assistance means you’re working at the staff member’s pace. Standby assistance means you’re working at the resident’s pace. In actuality, standby assistance takes more time. </div>
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<div>“It’s understanding how those elements affect a person’s choices and quality of care that really got me interested in building that company, so I worked on it for many years.”</div>
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<div><br>Today, Mason is president and chief executive officer of Senior Housing Managers. Located in Wilsonville, Ore., Senior Housing Managers operates assisted living, residential care communities, and nursing centers in Oregon and Washington. Following a servant leadership model, the company has never turned someone away. </div>
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<div><br>“We have a lot of low-income residents, a lot of Medicaid,” he says. “We’re never going to get rich at it, but we’re sure having a lot of fun taking care of people.”</div>
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<h2 class="ms-rteElement-H2">Looking Ahead </h2>
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<div>Being chair of NCAL has granted Mason an even larger sense of responsibility. His advice to providers is to embrace their role in meeting the demands and expectations for both millennials as workers and baby boomers as residents and patients. </div>
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<div><br>About 60 percent of Mason’s staff is millennial, including his own son, Carl. “I’ve learned the millennial perspective from him,” says Mason. “He works 12-14 hour days, but he wants to work them when he wants to work them. He’ll come in early and leave early for the gym at two o’clock, and then he’ll work at home later that evening.”</div>
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<div><br>And, just like millennials, baby boomers will have demands that providers must meet, simultaneously. </div>
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<div>A baby boomer himself, Mason can relate. “I’m a hard-core Boston Red Sox fan,” he says. “I want the paper, my coffee (Starbucks, latte, nonfat), and fresh flowers brought to my room. I want the score circled, and if the Red Sox lost, break it to me gently. </div>
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<h2 class="ms-rteElement-H2">Life-long Learner </h2>
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<div>Mason is currently seeking two PhDs: one in theology and the other in business administration with a focus in management and ethics. “My friends all say, ‘You’re 58 years old, what do you need to do that for?’” jokes Mason. “I’m intrigued. We’re about to hand the reins of leadership to the next generation. I look at that and think, ‘What is it that they need to know, what do we need to share?’”</div>
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<p>The motivations for individuals to volunteer and work takes priority for Mason, especially as the long term and post-acute care sector grapples with a caregiver shortage and seeks to attract new talent. In the coming months, he plans to survey about 4,000 health care leaders in the United States to ask what motivates them to donate time. <br></p>
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<p>“The volunteerism in millennials is about half of what it was with baby boomers,” says Mason. “We need to understand why. Whether it’s in work-related situations or volunteer situations, being able to understand that allows us to know what qualities are important to them so that we can then make sure that we are putting the right things out there to attract them.”</p>
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<h2 class="ms-rteElement-H2">Paving Career Pathways</h2>
For Mason, learning from other great leaders has deep value,
because best practices can be applied to day-to-day business.
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<p class="ms-rteElement-P">Take the learning organization concept, coined by Peter
Senge, author of the book “The Fifth Discipline: The Art and Practice of the
Learning Organization.” According to the book, this is an organization where
individuals continually expand their capacities to create the results they
truly desire, where new and expansive patterns of thinking are nurtured, and
collective aspiration is the norm. </p>
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<p class="ms-rteElement-P">“It’s really about the organization’s members transforming
themselves,” says Mason. “But if you go one step further, you have what I would
call a developmental organization.” </p>
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<p class="ms-rteElement-P">In LT/PAC, this organization
focuses on developing the three groups involved in an individual’s care: the
family, the resident, and the staff. Similar to a three-legged stool, says
Mason, “if those legs aren’t all in sync, and they aren’t all working together,
the stool will fall. And for staff, this means developing all employees, not
just those in management.” </p>
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<h2 class="ms-rteElement-H2">The Pyramid Program</h2>
<p class="ms-rteElement-P">It was with this concept in mind that Mason developed his
company’s pyramid program, which aims to attract the right talent and retain
that talent with professional development opportunities. “When you hire
someone, do you hire them for a job, or do you hire them for a career?” Mason
asks. “Millennials on average switch jobs less than every two years, but you
want them for longer.”</p>
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<p class="ms-rteElement-P">New employees benefit from mentor and career counseling from
the time that they are hired. <span> </span>They have
a career map that is planned out for them, and can reap benefits as they
progress up the ladder, says Mason. “If you are truly of the right mind and you
fit, here’s a wonderful opportunity for a career,” he says. “It’s all about continuity
and longevity when it comes to care.” </p>
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<h2 class="ms-rteElement-H2">Covering the Unexpected</h2>
<p class="ms-rteElement-P">The program works. About half of the executive directors
employed by Mason’s company started out as certified nurse assistants. It also
provides a way for staff to have their shifts covered, should an unexpected
event arise.</p>
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<p class="ms-rteElement-P">When an employee had to take off because her son fell and
broke her arm, she was able to choose from a list of individuals who were
cross-trained in the kitchen. A fellow staff member covered for her. “The
residents had a great meal,” says Mason. “The staff member that came in and
filled the role was happy to do that. At the end of the day, it was about that
continuity.” </p>
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<p class="ms-rteElement-P">Other benefits are that staff can learn new jobs, receive an
automatic merit increase when they complete training, and can be next in line
when job openings occur.</p>
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<p class="ms-rteElement-P">It can be a clear selling point to attracting the right
talent, Mason says. “If they are motivated and they want to learn and grow,
here’s a path.” </p>
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<p><br></p> | Talking with Christian “Chris” Mason about his career in assisted living is like reading a classic novel. It has an intriguing start and continues with a sequence of life events that connect and spark the next great chapter. | 2017-06-01T04:00:00Z | <img alt="" src="/Issues/2017/June/PublishingImages/ChrisMason_t.jpg" style="BORDER:0px solid;" /> | Management | Column |
| Eight Characteristics of an Efficient Finance Department | https://www.providermagazine.com/Issues/2017/June/Pages/Eight-Characteristics-of-an-Efficient-Finance-Department.aspx | Eight Characteristics of an Efficient Finance Department | <div></div>
<div>In the days of the Roman Empire, all roads radiated from the capital city of Rome. In the skilled nursing care center world, all paths to getting paid emanate from the finance department. Long term and post-acute care (LT/PAC) providers face innumerable challenges in what has become a perpetual quest for reimbursement. In myriad ways, a finance department can facilitate or impede that quest. This article will focus on eight critically important features of an efficient finance department. </div>
<h3 class="ms-rteElement-H3">1. The Dream Admission Packet</h3>
<div>The linchpin of most admission packets is the admission agreement. A fully signed and dated admission agreement that unambiguously outlines each party’s responsibilities, and has no unfilled-in blanks, is an adequate admission agreement.</div>
<div><br>But an efficient finance department’s admission packet is more than adequate. Its admission agreement is carefully drafted so the signer can face potential liability without either creating an impermissible third-party guarantee or requiring access as a precondition to a lawsuit. The best admission packet also includes an ironclad set of authorizations, so the days of depending on a recalcitrant son or unresponsive daughter to produce bank statements or turn over pension checks are over. </div>
<h3 class="ms-rteElement-H3">2. Timely Representative Payee Applications</h3>
<div>Good finance departments apply to become representative payees for every unmarried long term resident who receives Social Security benefits and needs assistance managing his or her funds. As representative payee, the nursing center administrator is able to receive the resident’s benefit checks and apply those funds to the resident’s cost of care. The resident need not be incapacitated, and the facility need not get the consent of the resident’s next of kin.</div>
<div><br>A quick look at the Social Security Administration’s website makes clear that the facility administrator is an appropriate representative payee for residents with compromised capacity who receive retirement or disability benefits. </div>
<h3 class="ms-rteElement-H3">3. Precautionary Medicaid Applications</h3>
<div>Responsible finance departments do not let their accounts get more than three months out without securing Medicaid as a potential payment source on the account. Precautionary Medicaid applications should be submitted on behalf of such delinquent residents even if the facility suspects the resident is ineligible, or the family objects, or financial documentation is missing.</div>
<div><br>Nursing centers have the legal authority to file applications for their residents, and there are Medicaid regulations that can make excess resources unavailable for eligibility purposes, exempt penalized transfers in cases of undue hardship, eliminate the need for spousal documentation, and bestow coverage on illegal aliens. </div>
<h3 class="ms-rteElement-H3">4. Getting Control </h3>
<div>While less successful finance departments let account balances grow while waiting for a child to bring in bank statements, a sibling to arrange a discharge, or a private attorney to apply for Medicaid, successful finance departments are proactive. If a resident has no payment source and the family is unresponsive, the facility can and should petition for guardianship or initiate a discharge for non-payment depending on the resident’s capacity.<br></div>
<div><br>Where a private attorney refuses to prove the status of an allegedly pending Medicaid application, the facility can and should file a precautionary application. </div>
<h3 class="ms-rteElement-H3">5. Good Record Keeping</h3>
<div>Medicaid appeals are won and lost depending on how well the finance department can document its efforts to secure the resident’s financial records, request assistance from the Department of Social Services, and meet Medicaid’s strict deadlines. </div>
<h3 class="ms-rteElement-H3">6. Arresting Growing Net Available Monthly Income (NAMI) Debts</h3>
<div>Every finance department knows the challenges of collecting NAMI far too well. While collecting back NAMI is important, responsible finance departments also take aggressive steps to stop NAMI debts from growing. Often using information from a resident’s Medicaid file, judges can issue orders redirecting pensions and/or freezing accounts into which NAMI is deposited. A Temporary Restraining Order can prevent misappropriation of the resident’s income during the pendency of a collection action. </div>
<h3 class="ms-rteElement-H3">7. Zero NAMIs</h3>
<div>Effective finance departments collect the full amount of medical assistance rightfully due and owing to every Medicaid recipient who resides in their facility. Securing every available zero NAMI budget is key to achieving this goal. Whether the budget adjustment is based on a viable bill, a pending guardianship, a court-ordered fee award, necessary medical expenses, or impermissible retroactive rebudgeting, pursuing these funds from Medicaid can help reduce a facility’s receivables. </div>
<h3 class="ms-rteElement-H3">8. Dealing with Decedents’ Accounts</h3>
<div>While new debt is always easier to collect than old debt, collecting on a decedent’s account is particularly challenging. Given the nature of the services rendered by skilled nursing centers, the resident population has a higher-than-average risk of mortality. Finance departments therefore have no choice but to recognize the possibility that a resident will pass before his or her account is brought current.</div>
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<div>In light of this reality, when finance departments refer cases for guardianship they should seek orders that include post-death powers. When they request Medicaid authorizations that generally lose effectiveness at death, they should simultaneously collect genealogical information to facilitate potential estate proceedings. A dedicated finance department will try to reduce NAMI debts owed by incapacitated residents to judgments in order to trump Medicaid’s post-death preferred creditor status. </div>
<h2 class="ms-rteElement-H2">Admission Procedures Can Help or Hurt</h2>
<div>Skilled nursing centers with stellar finance departments can still face intractable receivables due to shortcomings in their admission procedures. A frame-worthy admission agreement is of little value if on admission the resident’s representative is presented with the signature page without being afforded the opportunity to read the entire agreement and ask questions.</div>
<div><br>Likewise, even a consummate finance department will have a hard time securing payment on the account of a competent but uncooperative resident who is admitted with no financial information, no signed paperwork, and no involved community contacts.</div>
<div><br>Finally, an admission department that puts incoming residents into a short- or long-term box does a disservice to its finance department. Short-term residents frequently become long-term due to changes in their medical condition and/or family situation.</div>
<div><br>An expectation on the center’s part that the resident will voluntarily leave after a brief stay is not a permissible basis for an involuntary discharge. Whenever possible, new admissions should be treated as potential permanent placements.</div>
<div><br>More often than not, LT/PAC centers face different obstacles when it comes to getting paid. The problems could start with residents or patients who cannot assist in resolving their own payment problems. <br><br>Additional issues arise when the resident’s community contacts have no interest in helping the center get paid. The trouble can then reach crisis proportions when family members, who may be motivated by conflicting interests, obstruct the center’s efforts to secure reimbursement on a resident’s account.</div>
<div><br>To the extent skilled nursing centers need a helping hand to achieve solvency, an effective finance department is an invaluable support. But the admission department also has a significant, tactical role to play in the operation.</div></div>
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<div><em>Nancy Levitin, Esq., partner, and Jeffrey Neuman and Katie Barbieri, associates at Abrams, Fensterman, Fensterman, Eisman, Formato, Ferrara & Wolf, authored this article. They can be reached at nlevitin@abramslaw.com, jneuman@abramslaw.com, and kbarbieri@abramslaw.com</em>.</div> | In myriad ways, a finance department can facilitate or impede that quest. This article will focus on eight critically important features of an efficient finance department.
| 2017-06-01T04:00:00Z | <img alt="" src="/Issues/2017/June/PublishingImages/fianance-t.jpg" style="BORDER:0px solid;" /> | Finance;Management | Column |
| Navigating the New Rule: Changes to Quality of Care Regulations | https://www.providermagazine.com/Issues/2017/June/Pages/Navigating-the-New-Rule.aspx | Navigating the New Rule: Changes to Quality of Care Regulations | <br>At the core of changes to the Quality of Care regulations are two central themes: 1.) the need to care for more severely ill and frail elders, either during the post-acute period or during long term stays in nursing centers; and 2.) the Centers for Medicare & Medicaid Services (CMS) strategic shift toward person-centered care that explicitly weighs residents’ choices and preferences in all care decisions.<br><br>The revised regulations articulate a higher level of clinical competence and service and a more person-centered emphasis, reflecting how the role of nursing centers has evolved and is expected to continue evolving. <br><br>The overall Quality of Care domain (regulation 42 CFR §483.25) applies to all treatment and services provided to nursing center residents. The new regulations, however, have been enriched with greater specificity and rigor for all clinical services, with definite updates in the following areas:<br><br>(a) Vision and hearing<br>(b) Skin integrity<br>(1) Pressure ulcers<br>(2) Foot care<br>(c) Mobility<br>(d) Accidents<br>(e) Incontinence<br>(f) Colostomy, ureterostomy, or ileostomy care<br>(g) Assisted nutrition and hydration<br>(h) Parenteral fluids<br>(i) Respiratory care, including tracheostomy care and tracheal suctioning<br>(j) Prostheses<br>(k) Pain management<br>(l) Dialysis<br>(m) Trauma-informed care<br>(n) Bed rails<br><br>There are three central themes that appear throughout the revised Quality of Care regulation and the related Interpretive Guidance published by CMS. Treatment and care must be based on the following: professional standards of practice; the comprehensive, person-centered care plan; and residents’ choices.<br>This balancing of professional standards with resident perspectives from the person-centered care plan and resident choices acknowledges the focus on individuals and their preferences.<br><br>The concept of providing care in accordance with professional standards of practice is nothing new. However, balancing this with a comprehensive and person-centered care plan and ongoing resident’s choices requires all nursing center staff to ask and learn more about each person and the care decisions they would make in different circumstances.<br><br>Truly understanding a resident’s choices requires a more intimate level of communication than some providers may be used to.<br><br>For example, most providers understand the importance of conducting pain assessments to identify and minimize a patient’s pain and discomfort. But what about understanding whether a resident’s goals for pain management are being met? From the resident’s perspective, do the benefits of the pain treatment outweigh any side effects he or she may be experiencing, such as sedation? Some residents may choose to live with more pain in exchange for greater alertness, or avoidance of other side effects. Others may wish to consider alternative treatment options. <br><br>As mentioned in the <a href="/archives/2017_Archives/Pages/0217/Navigating-The-New-Rule-Person-Centered-Care.aspx" target="_blank">February 2017 Quality Forum</a> on person-centered care, applying a person-centered philosophy requires a take-charge approach to eliciting resident (or resident representative) input and concerns at every stage of care. This extends to each of the Quality of Care areas listed above. For each of those areas, a question to consider is whether the resident is truly empowered and engaged as an active partner in his or her care. | The revised regulations articulate a higher level of clinical competence and service and a more person-centered emphasis, reflecting how the role of nursing centers has evolved and is expected to continue evolving.
| 2017-06-01T04:00:00Z | <img alt="" src="/Articles/PublishingImages/headshots/AndyKramer.jpg" style="BORDER:0px solid;" /> | | Column |