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Using Payroll-Based Journal Data to Compute Nursing Hours<p>Starting in spring 2018, the Centers for Medicare &amp; Medicaid Services (CMS) began using Payroll-Based Journal (PBJ) data to determine each nursing facility's staffing levels for the Nursing Home Compare tool used in the agency's Five-Star Quality Rating System.&#160; Accurate reporting is essential to a fair rating.</p><h2>How PBJ Works</h2><p>The PBJ system provides the reported staffing hours for each quarter. These data, based on Minimum Data Set (MDS) assessments, are used for CMS staffing calculations and are the basis for a nursing facility's Five-Star Rating. There is an added complexity, since CMS adjusts the reported staffing hours before calculating the ratings.</p><p>The adjusted hours <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image002.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />H<sub>a</sub> for each staff type are given by using the formula&#58; <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image004.jpg" alt="" style="width&#58;1px;margin&#58;5px;" /><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas3.png" alt="" style="margin&#58;5px;" /> where H<sub>r</sub> <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image006.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />represents the reported hours. The adjustment is based on <em>h</em><img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image008.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />, the case-mix or expected nurse staffing hours per resident per day and the national mean <em>m</em> <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image010.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />of case-mix hours for all facilities. </p><p>The case-mix values are derived from STRIVE, which is a CMS Staff Time Resource Intensity Verification Study (2006-2007) that measured the average hours per resident per day for each staff type&#58; RN (registered nurse), LPN (licensed practical nurse) and CNA (certified nurse assistant) based on the associated Resource Utilization Group (RUG-IV) 66.</p><h2>Rating Methodologies</h2><p>The Rating Methodology Rules shown below in Table 1 (taken from Table 4) of the July 2020 CMS Technical Users Guide, “Design for Nursing Home Compare Five-Star Quality Rating System.&quot;&#160; <br></p><p><br></p><p style="text-align&#58;center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Table1.png" alt="" style="margin&#58;5px;" />&#160;</p><p style="text-align&#58;center;"><br></p><h2>Nursing Levels Categorized</h2><p>It is important to note that two separate staffing level ratings are published by CMS. </p><p>One rating is for RN Staffing, and the other is the Overall Staffing. As illustrated in the table above, RN hours greater or equal to 1.049 will result in a Five-Star RN Rating. The combined sum of RN + LPN + CNA greater than or equal to 4.038 will give an Overall Five-Star Rating.&#160; The combination of adjusted values that result in 5, 4, and 3 stars, respectively, are summarized in Table 2 below.</p><p><br></p><p style="text-align&#58;center;">&#160;<img src="/Topics/Guest-Columns/PublishingImages/2020/Table2.png" alt="" style="margin&#58;5px;" /></p><p style="text-align&#58;center;"><br></p><p>Harmony Healthcare International (HHI) has developed three simple algorithms to estimate the staffing levels necessary for a given Star Status. In the equations below, R, C, and L represent the RN, CNA , and LPN reportable nurse staffing hours per resident per day needed to guarantee a given Star Ratings Level. </p><p>The case mix hours symbol h is the expected hours per patient per day based on the composite of RUG-IV values over a quarterly time period. The quantity h is indirectly related to case-mix indices in a nonlinear manner and is distinct for each SNF. The symbol m is the mean of case-mix hours averaged over all SNFs.</p><p style="text-align&#58;center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas1.png" alt="" style="margin&#58;5px;" /><br></p><p><img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image017.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />Previous statistical data suggest that case-mix indices and adjustment factors vary very slowly over time for most facilities. Therefore, it is reasonable to assume that the values assigned in a given time period can be used to estimate the reported values in a subsequent time period to gain the desired star status. </p><p>As an example, consider the case-mix values for a given facility shown in Table 3 taken from the CMS Medicare Nursing Home Compare Website. </p><p><br></p><p style="text-align&#58;center;">&#160;<img src="/Topics/Guest-Columns/PublishingImages/2020/Table3.png" alt="" style="margin&#58;5px;" /></p><p>The calculations to attain a Five-Star rating for the case-mix data listed in Table 3 are as follows&#58;</p><p style="text-align&#58;center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas2.png" alt="" style="margin&#58;5px;" /><br></p><p>The same technique can be used to determine the reportable hours per patient per day for 4- or 3-Star Ratings.</p><p><em>Kris Mastrangelo, OTR/L, LNHA, MBA, is chief executive officer and president of Harmony Healthcare International. She can be reached at </em><a href="mailto&#58;Kmastrangelo@harmony-healthcare.com" target="_blank"><em>Kmastrangelo@harmony-healthcare.com</em></a><em>. James E. Smerczynski has been with Harmony Healthcare since retiring from Raytheon in 2012. He has an extensive background in integrated weapon system engineering that includes the Patriot Air Defense System, Advanced Lightweight Torpedo, and Hawk Missile System. Smercznynski has considerable experience in applied mathematics that directly applies to the probability and statistics analytics of the health care industry. He also does analytics for the startup software company Hopforce.</em></p><p>​</p>2020-12-14T05:00:00Z<img alt="James Smerczynski, Kris Mastrangelo" src="/Topics/Guest-Columns/PublishingImages/2020/SmerczynskiMastrangelo.JPG" style="BORDER&#58;0px solid;" />Quality;CMSSmerczynski, MastrangeloStarting in spring 2018, CMS began using Payroll-Based Journal data to determine each nursing facility's staffing levels for the Nursing Home Compare tool used in the agency's Five-Star Quality Rating System.
Innovative Training Program Open to Help Caregivers Combat COVID<p>​<br></p> <p><img src="/Topics/Guest-Columns/PublishingImages/1120_JaneDavis.jpg" alt="Jane Davis " class="ms-rtePosition-1" style="margin&#58;5px;width&#58;270px;height&#58;347px;" />I had little idea what I was getting into when I agreed to participate in an innovative pilot program to help nursing home administrators and frontline staff combat the spread of COVID-19.</p><p>But I was willing to try almost anything to prevent another wave of sickness, suffering, stress, and uncertainty like the one that hit our facility in April and May.</p><h2>All Are Welcome to Join</h2><p>Now that effort’s gone national. The AHRQ [Agency for Healthcare Research and Quality] ECHO National Nursing Home COVID-19 Action Network launched this month with training centers and nursing homes around the country joining new virtual communities of practice.</p><p>And, after participating in the pilot program, I’ve signed up again, because what the COVID-19 Action Network offers—not only education but mentoring and a peer community—is that valuable right now.</p><p>Working at nursing homes during this pandemic, so many of us feel like we’re carrying the weight of the world on our shoulders, with hardly any support. The stress takes a terrible toll. Even worse, because there’s so much still unknown about this virus, we worry that we’re missing things—things that could help keep our residents safe. </p><h2>Support and Mutual Respect</h2><p>Participating in the COVID-19 Action Network brought me to a new place—a place where I could share my perspective and experiences, where I could learn from the experiences of my peers, where I could hear new ideas and think differently. It was a place of collaboration and mutual respect where I didn’t just passively receive wisdom and best practices from the experts. I contributed my own, and it was valued.</p><p>And, perhaps most of all, it was a place where I felt supported. My staff and I were not alone—far from it. Being in the Network reinforced that we truly are all in this fight together.</p><h2>A Collaborative Approach</h2><p>The Network is led by three organizations&#58; the federal AHRQ, the Institute for Healthcare Improvement (IHI), and Project ECHO. Together, they created the initiative to prevent and reduce COVID-19 in nursing homes—not through regulation or compulsory programs but through voluntary, collaborative learning.</p><p>Here’s how it works&#58; Training centers across the country—mainly academic medical centers or large health systems—run virtual communities of practice on Zoom that are staffed by experts in infection control and gerontology. Staff from up to 35 nursing homes participate in these communities of practice.</p><p>Each Zoom session (there are 16) kicks off with a quick lecture on a topic like Personal Protective Equipment (PPE) use and then moves on to real-life case presentations that spark a lot of hands-on discussion and problem solving.</p><p>Everyone participates in the sessions. Everyone’s experience, observations, and questions are honored and valued. That’s what made it so different. We weren’t just there to learn. We were there to share with each other, and even teach each other—as well as the experts, who wanted to know about our on-the-ground experiences to inform their own perspectives.</p><h2>More Than Worth It</h2><p>After only one or two sessions, I was hooked. I didn’t want to miss a single session because of what I was learning, the support I was receiving, and the relationships I was building. After the 16-session program ended, I found myself missing it.</p><p>People sometimes ask me what it was like when the pandemic peaked this spring. I tell them I never experienced anything like it before and never want to again.</p><p>That’s why I “re-upped.” As a nursing home administrator, I want to do everything in my power to beat this scourge and protect our residents and our staff. I’ve learned that when we come together to learn with and from each other, we can create something powerful&#58; the knowledge and support to move forward and succeed.</p><p>We are not alone—and we shouldn’t be. I urge others to join the COVID-19 Action Network now.</p><p>To learn more about the AHRQ ECHO National Nursing Home COVID-19 Action Network, visit&#160;<a href="https&#58;//hsc.unm.edu/echo/institute-programs/nursing-home/pages/nursing-home-info.html" target="_blank">https&#58;//hsc.unm.edu/echo/institute-programs/nursing-home/pages/nursing-home-info.html</a>.&#160;</p><p><em>Jane Davis is administrator for Hyatt Family Facilities at Landmark Care &amp; Rehabilitation in Yakima, Wash. Starting out in assisted living in 1993, Davis has been a licensed nursing home administrator since 1998 with licenses in six states.&#160;She has practiced in Washington state, Texas, and South Carolina during her career. She can be reached at </em><a href="mailto&#58;Jane@hyattff.com" target="_blank"><em>Jane@hyattff.com</em></a><em>.</em></p>2020-11-23T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/nurse_computers.jpg" style="BORDER&#58;0px solid;" />Technology;COVID-19Jane DavisThe AHRQ ECHO National Nursing Home COVID-19 Action Network launched this month with training centers and nursing homes around the country joining new virtual communities of practice.
Mother-Daughter Team Makes Waves<p><img src="/Topics/Guest-Columns/PublishingImages/IMG_2217.jpg" alt="Kris Mastrangelo, Savannah James" class="ms-rtePosition-1" style="margin&#58;5px 20px;width&#58;295px;height&#58;429px;" />Kris Mastrangelo, OTR/L, LNHA, MBA, chief executive officer and president of Harmony Healthcare International (HHI), shares her journey of over 20 years in the long term health care industry. </p><p><strong><em>Provider</em>&#58; You have been quoted in the past saying, “I left what I thought was my dream job to start Harmony, and now this is the dream job.&quot; Why did you start Harmony? </strong></p><p><strong>Mastrangelo&#58;</strong> Initially, I began Harmony in 2001 to lessen my travel for work as I was on the road every week, and I had two young daughters—Savannah 2 ½ and Carissa nine months old. However, within two years of starting the company, the client base grew beyond the New England area, and it became apparent that travel would always be a part of my job.</p><p>As the company grew, so did the family, adding two more daughters, Alexandra the Great in 2003 and Mia in 2007. In addition to the travel, I noted that the work I was completing for nursing homes across the country was necessary and relevant as a third-party, unrelated vendor [versus being a department within the organization] to provide the client with unbiased, objective analysis and systems implementation.</p><p>Systems require oversight and refinement, and often companies are too close to the situation to see the necessary change or opportunity. Consulting to different organizations was vastly different from being a VP [vice president] in one organization. Consulting brought a deeper understanding and awareness of different ways to solve the same problem or opportunity. </p><p><strong><span><strong><em>Provider</em></strong></span>&#58; </strong><strong>&#160;</strong><strong>What did you see that was missing from the industry that Harmony could provide?</strong></p><p><strong>Mastrangelo&#58;</strong> HHI connects the dots between care and&#58;</p><ul><li><strong>C</strong>ompliance</li><li><strong>A</strong>uditing</li><li><strong>A</strong>nalysis</li><li><strong>R</strong>eimbursement</li><li><strong>R</strong>egulatory</li><li><strong>R</strong>ehabilitation</li><li><strong>E</strong>ducation </li><li><strong>E</strong>fficiency</li><li><strong>S</strong>urvey</li></ul><p>Back in 1998, the Medicare Part A reimbursement system transformed from a retrospective cost-based system to a prospective payment system (PPS). This was the first step in which the health care services rendered to the patient/resident directly impacted the rate of reimbursement.</p><p>Before 1998, clinicians virtually had zero fiscal responsibility. As an occupational therapist (OT), licensed nursing home administrator (LNHA), MBA, and, most importantly, the daughter of a mathematician/systems electrical engineer, I could translate the care [service delivery] into the numbers [reimbursement], a powerful combination back then. </p><p><strong><span><strong><em>Provider</em></strong></span>&#58; What do you wish you knew as a young entrepreneur that you know today?</strong></p><p><strong>Mastrangelo&#58; </strong>There is nothing that I wish I knew back then that I know today because every mistake is an educational experience on how not to do it next time. I am all about the journey. While I always have a sense of urgency to get the job done right, I know today that errors can make us better. </p><p>However, two concepts that do resonate&#58;</p><ol><li>If it isn't broke, do not fix it. Andy Turner, Sun Health Group, used to say that to us all the time. Yes, it is crucial to refine and improve, but don't blow up a system for a minor change. </li><li>Prioritization is a skill set. Knowing what requires your attention first is how you need to manage every day. Because, as an entrepreneur, there is always something on the to-do list. </li></ol><p><strong><em>Provider</em>&#58; How has your daughter becoming an entrepreneur in the health care industry changed your relationship? </strong></p><p><strong>Mastrangelo&#58;</strong> Savannah and I have always had a very close relationship and having her begin her career in the health care industry has only strengthened our bond. When Savannah was away for college, we talked every day. And this has not changed. Our conversations are endless, and we jump from subject matter to subject matter with excitement and curiosity. She retains complex, voluminous amounts of information while being able to distill and synthesize the subject matter…. with apparent ease. This affords everyone the benefit of her creations and ideas.</p><p><strong><em>Provider</em>&#58; Tuning in to your motherly intuition, is this the path you knew she would take, or did you imagine her in another field?</strong></p><p><strong>Mastrangelo&#58;</strong> I always knew that Savannah would be an entrepreneur. I didn't expect her to do it so quickly and so gracefully. She was on the path to be an OT during her freshman year of college. Two things happened.</p><ul><li>She decided, “for fun,&quot; to take a computer class the summer of her Tufts University freshman year into her sophomore year, and she loved it.</li><li>The OT profession was discussing the need for doctorate degrees for the trade. Savannah attended a rigorous, academically intense high school and wanted to get into the workforce before graduating college.</li></ul><h2><span class="ms-rteForeColor-10 ms-rteFontSize-3">Savannah James</span></h2><p>Developing a calculator to determine the reimbursement rates for patients in a long term health care facility may not be what a young mind dreams of creating when imagining the future. For Savannah James, daughter of Kris Mastrangelo, reimbursement, patient advocacy, and the complexities of ever-changing regulations have always been standard dinner table talk. The mother-daughter team is rare in the health care industry, let alone the technology field, with two generations mirroring one another's journey through entrepreneurship. <strong><br></strong></p><p><strong><em>Provider</em>&#58; Please describe Hopforce.</strong></p><p><strong>James&#58;</strong> Hopforce's mission is to optimize processes (via technology) in the health care industry. Our primary focus is the PDPM [patient-driven payment model] calculator, i.e., pdpm-calc.com, specifically designed for the long term health care industry and specific Medicaid Case-Mix States. In just a couple of clicks, the user can obtain the Medicare Part A or Medicaid Case-Mix reimbursement level by day and for the entire patient stay. </p><p>Simplicity in the calculator functionality is paramount; it was important that we make<span style="text-decoration&#58;line-through;"> </span>pdpm-calc.com (The PDPM Calculator), user-friendly for those who are less enthusiastic<span style="text-decoration&#58;line-through;"> </span>about technology. More importantly, Hopforce provides accurate data, reliable results, that are readily and efficiently displayed despite the dense and often confusing, multifaceted regulations. There are approximately 60,000 potential combination of HIPPS [Health Insurance Prospective Payment System] Codes for every Medicare Part A patient. The opportunity for miscoding or missing an element of care can result in colossal mistakes that impact the facility and patient care.</p><p><strong></strong><strong><em>Provider</em>&#58; What was the inspiration behind Hopforce?</strong></p><p><strong>James&#58;</strong> I have a background in computer science, software development, and psychology. During my education, I became passionate about optimization and reducing human error. I grew up with a family engrossed in health care, so discussions about what worked and what didn't work in the industry were daily dialogue. The notion of removing the inefficiencies that exist in current processes that are ripe for human error and improving patient care truly spoke to me. </p><p><strong><em>Provider</em>&#58; What has the feedback been like since you launched Hopforce?</strong></p><p><strong>James&#58;</strong> The reaction has been outstanding! Users provide ongoing feedback and say it has “improved the lives of MDS coordinators, decreasing their stress and enhancing their jobs' efficiency.&quot; </p><p><strong><em>Provider</em>&#58; Many startups are concerned about setbacks due to COVID19, quarantining, social distancing, and the restrictive nature of hospitals and long term health care facilities. How has this time helped or hurt Hopforce?</strong></p><p><strong>James&#58;</strong> There has been a massive surge in usage due to COVID because no one knew how to code for this, let alone code correctly, to receive proper reimbursement and use a new payment model. It was rewarding to offer a level of ease and assistance in helping the long term care facilities generate the information they needed to activate the funds for the most vulnerable population. Using a haphazardly written spreadsheet that does not give accurate data paired with COVID is disastrous for the facility and the patient. </p><p><strong><em>Provider</em>&#58; What are your aspirations for Hopforce as it grows? If you could describe the dream, barring any setbacks, what do you envision?</strong></p><p><strong>James&#58;</strong> My biggest dream for Hopforce is expanding into other realms of health care that need optimization and improvement. I would like to be able to facilitate them while pioneering how to protect the data. Further down the line, I want to develop software to assist health care disparities toward women and people of color. </p><p><strong><em>Provider</em>&#58; What is it like directly working with your mother? How has it changed your relationship?</strong></p><p><strong>James&#58;</strong> I have always looked up to my mom. To be in the arena, side by side, it is exciting to run with her and watch her operate. She is a genius and inspiring to watch her problem-solve. I am excited to offer what I do well and be able to play in the same stratosphere, especially in tech, which is so male dominated. I do not think that you see too many mother-daughter duos in the health care and tech field. It's exciting to be pioneering this today in the climate of our country.</p><p>Kris Mastrangelo, OTR/L, LNHA, MBA, is chief executive officer and president of Harmony Healthcare International. She can be reached at <a href="mailto&#58;Kmastrangelo@harmony-healthcare.com" target="_blank">Kmastrangelo@harmony-healthcare.com</a>. Her daughter, Savannah James, is founder of the PDPM calculator, Hopforce. Savannah James can be reached at <a href="mailto&#58;savannah.lee@hopforce.com" target="_blank">savannah.lee@hopforce.com</a>.</p><p>​</p>2020-10-01T04:00:00Z<img alt="" src="/Topics/Guest-Columns/PublishingImages/KrisSavannah.jpg" style="BORDER&#58;0px solid;" />ManagementMastrangelo and JamesKris Mastrangelo shares lessons learned from her first years as an entrepreneur and what it’s like cultivating a professional relationship with her daughter.
How Hands-on Nursing Home Ownership Works<div>At times, it seems appropriate to highlight the way in which nursing homes operate in the real world versus some of the misperceptions that can cloud the views of what we do in the long term and post-acute care profession.</div><div><br></div><div>A case in point is the idea that owners of skilled nursing centers are not involved or care about the residents who live in their buildings. Often, it seems, the larger the ownership group, the more talk there is of owners being focused on other things rather than the people who live in their communities.</div><br><p>I work for the Portopiccolo Group, and that idea could not be further from the truth,</p><p>Previously, I worked for several nursing home chains and when Portopiccolo/ClearView acquired Smith County Health and Rehabilitation in July 2019, I was unsure about what the changes would bring.&#160; <br></p><p>By that I mean, any previous acquisition I have been through as an administrator, the new owner overpromised when it came to lending support to meet the daily needs of the facility.</p><p>But, as I began to see the owner and the upper-level management in the building engaging the residents and staff, I gained some hope.&#160;Months later, I realized Portopiccolo Group had kept every promise they made.&#160;We did have everything we needed, and they did ensure the residents were our No. 1 priority.&#160; </p><p>Whether it be equipment, building renovations, supplies, operating cash, or good old moral support, we have it every day without fail.&#160; </p><p>There have been times in the past when I spent my own money on supplies that were needed. With this company, they are excellent at controlling waste, but not slashing.&#160;It doesn’t matter if it’s a resident wheelchair, or a kitchen fryer, or petty cash to buy the staff lunch, we always have it.&#160;</p><p>I see our owner and our executive operators quite frequently. For instance, just recently I witnessed our owner in a COVID-affected building talking to residents and staff to make certain they have everything they need, and that they were OK. He was doing the right thing when nobody was looking and putting his own health at risk to make certain his stakeholders know he cares for them. </p><p>I can’t put into words how proud I am to be a part of this company. I am grateful that even during this pandemic Portopiccolo Group is growing as a company because every building they buy is one more building full of residents and staff that will finally get the support and resources they need.&#160;They will be genuinely cared for by their owners and management team.</p><p><em>Alan A. Hall is administrator of Smith County Health and Rehabilitation, Carthage, Tenn.</em></p><p>​</p>2020-09-25T04:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/dr_staff.jpg" width="398" style="BORDER&#58;0px solid;" />Management;WorkforceAlan A. HallAt times, it seems appropriate to highlight the way in which nursing homes operate in the real world versus some of the misperceptions that can cloud the views of what we do in the long term and post-acute care profession.