Using Payroll-Based Journal Data to Compute Nursing Hours | <p>Starting in spring 2018, the Centers for Medicare & 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.  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://///Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image002.jpg" alt="" style="width:1px;margin:5px;" />H<sub>a</sub> for each staff type are given by using the formula: <img src="file://///Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image004.jpg" alt="" style="width:1px;margin:5px;" /><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas3.png" alt="" style="margin:5px;" /> where H<sub>r</sub> <img src="file://///Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image006.jpg" alt="" style="width:1px;margin:5px;" />represents the reported hours. The adjustment is based on <em>h</em><img src="file://///Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image008.jpg" alt="" style="width:1px;margin:5px;" />, the case-mix or expected nurse staffing hours per resident per day and the national mean <em>m</em> <img src="file://///Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image010.jpg" alt="" style="width:1px;margin: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: 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."  <br></p><p><br></p><p style="text-align:center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Table1.png" alt="" style="margin:5px;" /> </p><p style="text-align: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.  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:center;"> <img src="/Topics/Guest-Columns/PublishingImages/2020/Table2.png" alt="" style="margin:5px;" /></p><p style="text-align: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:center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas1.png" alt="" style="margin:5px;" /><br></p><p><img src="file://///Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image017.jpg" alt="" style="width:1px;margin: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:center;"> <img src="/Topics/Guest-Columns/PublishingImages/2020/Table3.png" alt="" style="margin:5px;" /></p><p>The calculations to attain a Five-Star rating for the case-mix data listed in Table 3 are as follows:</p><p style="text-align:center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas2.png" alt="" style="margin: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: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:0px solid;" /> | Quality;CMS | Starting 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:5px;width:270px;height: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: 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: 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: 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 <a href="https://hsc.unm.edu/echo/institute-programs/nursing-home/pages/nursing-home-info.html" target="_blank">https://hsc.unm.edu/echo/institute-programs/nursing-home/pages/nursing-home-info.html</a>. </p><p><em>Jane Davis is administrator for Hyatt Family Facilities at
Landmark Care & 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. She has practiced in Washington state, Texas,
and South Carolina during her career. She can be reached at </em><a href="mailto: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:0px solid;" /> | Technology;COVID-19 | The 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:5px 20px;width:295px;height: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>: 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." Why did you start Harmony? </strong></p><p><strong>Mastrangelo:</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>: </strong><strong> </strong><strong>What did you see that was missing from the industry that Harmony could provide?</strong></p><p><strong>Mastrangelo:</strong> HHI connects the dots between care and:</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>: What do you wish you knew as a young entrepreneur that you know today?</strong></p><p><strong>Mastrangelo: </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:</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>: How has your daughter becoming an entrepreneur in the health care industry changed your relationship? </strong></p><p><strong>Mastrangelo:</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>: 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:</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," 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>: Please describe Hopforce.</strong></p><p><strong>James:</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:line-through;"> </span>pdpm-calc.com (The PDPM Calculator), user-friendly for those who are less enthusiastic<span style="text-decoration: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>: What was the inspiration behind Hopforce?</strong></p><p><strong>James:</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>: What has the feedback been like since you launched Hopforce?</strong></p><p><strong>James:</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." </p><p><strong><em>Provider</em>: 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:</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>: 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:</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>: What is it like directly working with your mother? How has it changed your relationship?</strong></p><p><strong>James:</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: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: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:0px solid;" /> | Management | Kris 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.  <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. Months later, I realized Portopiccolo Group
had kept every promise they made. We did have everything we needed, and
they did ensure the residents were our No. 1 priority.  </p><p>Whether it be equipment,
building renovations, supplies, operating cash, or good old moral support, we
have it every day without fail.  </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. 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. </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. 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:0px solid;" /> | Management;Workforce | 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. |
What Drives PDPM | <span style="background-color:initial;">Like most people, there are days when it is tempting to kick back and reminisce about all the fun during long lost childhood days. Fond memories of long, and fun-filled, driving vacations—each and every summer—are still gleefully etched in memory. Those trips took weeks of planning and incorporated a variety of opinions from the entire family. However, when the dust settled, there was just one driver—the author’s father. </span><div><div> </div>
<div><span style="background-color:initial;"></span></div>
<div>After nearly two years of planning, the long term and post-acute care profession has embarked on its Patient-Driven Payment Model (PDPM) journey. Now that therapy is not the primary driver of reimbursement for skilled nursing facilities (SNFs) anymore, before one could say Interim Payment Assessment (IPA), thousands of therapists have job uncertainty. To come to grips with this somewhat expected, yet sobering reality, the burning question—what drives PDPM—needs to be answered first. </div>
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<h2 class="ms-rteElement-H2">The Right Amount</h2>
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<div>When introducing RCS-1, and then PDPM, the Centers for Medicare & Medicaid Services (CMS) realized that the therapy-centric, resource utilization groups (RUGs) based prospective payment system (PPS) was flawed and obsolete. Now, the main goal of PDPM has been to reimburse SNFs based on patient characteristics and complexity of care.</div>
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<div>Since therapy would cease to be the prime driver of SNF reimbursement under PDPM, most expected the therapy utilization to drop. However, CMS has declared that it reserves the option to audit providers when therapy is underutilized. So, what does all of this mean? How much therapy is the right amount? And who decides what is right?</div>
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<div>Firstly, PDPM means just that. It is a payment model driven by patient characteristics and complexity of care. It goes without saying that the care of patients in SNFs, in general, ought to include therapy. The goal for patient stays in SNFs is to optimize their functional status while providing all the necessary clinical and nursing care, so that they may transition to their homes or to other care settings at an opportune time.</div>
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<div>Granted, there will be patients who do not benefit from therapy as they may be too weak or too sick, but even they need to be reevaluated periodically to assess their candidacy for therapy.</div>
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<h2 class="ms-rteElement-H2">Don’t Forget Therapy</h2>
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<div>If providers do not do a good job in recognizing patients’ needs and stint therapy, one thing is bound to happen. CMS will audit and recover payments from those who are not providing adequate therapy to their residents. CMS has ready access to resident characteristics and therapy minutes provided through minimum data set (MDS) assessments. A quick audit could be accomplished by taking the various payments for physical, occupational, and speech therapy categories under PDPM—for individuals or a group of patients—and comparing them to the prevailing cost of actual therapy minutes provided, and/or prior utilization patterns under RUGs. </div>
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<div>If patients are demonstrating a high potential for improvement through their characteristics and functional scores, but are receiving suboptimal therapy, one may expect claim audits and survey citations. Under PDPM, CMS pays SNFs to provide therapy based on the anticipated need, as calculated by clinical characteristics and functional scores documented on MDS assessments, and not any longer by therapy minutes. </div>
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<div>In the absence of a published formula, how does one determine what is the “right” amount of therapy for each patient? Obviously, that has to be a collaborative determination by the clinical team and therapists, based on the patient’s characteristics and medical necessity. The clinical documentation should always be supportive of such a decision, and of any subsequent changes to utilization of therapy services. </div>
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<div>Adhering to the 25 percent cap on group and concurrent therapy may not be sufficient to prevent audits if patients are provided group or concurrent therapy while not meeting inclusion criteria for such options. If a patient truly does not need much active therapist engagement, consideration should be given to the use of Restorative Nursing Programs, which should enable quicker improvement in functional scores and perhaps a shorter length of stay, while providing an audit defense against stinting—if documented clearly along with medical necessity.</div>
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<h2 class="ms-rteElement-H2">Look to the Future</h2>
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<div>Will there be a shrinkage of the therapy workforce in SNFs? Yes, there likely will be, but it should not be a knee jerk response to a change in payment models, rather based on determination of need and utilization patterns. Since those standards are still being established in the industry under PDPM, across the board workforce reductions are premature and are bound to raise red flags for audit from regulators.</div>
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<div>Until a decision to reduce the workforce is obvious and unavoidable, perhaps asking the therapists to focus on the patient rather than the minutes every week is the right thing to do. Therapists could collaborate with nursing staff to revamp the Medicare Part B therapy program for long term care residents, while training SNF nursing staff to be effective partners in Restorative Nursing Programs.</div>
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<div>So, what drives PDPM? Is it the patient, or the payment? While initial reactions, such as changing therapy staffing in some centers, appear to suggest that payment is driving the change, the patient is the driver of the PDPM bus. Payment, no doubt, fuels the PDPM bus. </div>
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<div>If the journey is planned well—by charting a good path with accurate initial MDS assessments, there should be enough fuel to arrive at the destination. CMS acts as the gas station, and if providers encounter unexpected detours due to changes in patients’ conditions, IPAs will provide the additional fuel needed to get home. But it behooves providers to remember that gas stations can top off fuel, but not change drivers. The driver, for PDPM, is definitely the patient, and anyone who does not agree will be asked to get off the bus.</div>
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<div><em>Rajeev Kumar, MD, is chief medical officer at Symbria and secretary at AMDA—The Society for Post-Acute and Long-Term Care Medicine. </em></div>
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</div></div> | 2020-02-11T05:00:00Z | <img alt="" src="/Breaking-News/PublishingImages/150x150/RK.JPG" style="BORDER:0px solid;" /> | Policy | A medical doctor highlights the various issues driving PDPM. |
Meeting Challenges Head-on in Today’s Revenue Environment | <div> </div>
<p class="MsoNormal">The past few years have seen a record level of health care
facility bankruptcy filings, and if the first half of the year has shown anything,
it is that this trend is far from over. Ever-evolving challenges around
demographics, reimbursement, staffing, and operating costs present enormous
challenges for nursing centers and assisted living communities. </p>
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<p class="MsoNormal">With pressures mounting, both distressed and currently
operational facilities need to consider tactics to improve revenue and
efficiency. Having worked with dozens of health care businesses facing these
common pressures, there are clear avenues for facilities big and small. </p>
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<h2 class="ms-rteElement-H2B">Renegotiate Real Estate and Operational Costs</h2>
<p class="MsoNormal">Rent is a significant cost for many nursing facility operators,
and it is often set at a point in time when the organization enjoyed a higher
valuation. This makes it ripe for renegotiation and represents what is perhaps
the most immediate way to relieve financial stress on a nursing center. </p>
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<p class="MsoNormal">While it is true that no landlord will want to lower costs
off the bat, often times <span> </span>most are
amenable, understanding that reduced rent is still income. Even within the
larger operating company/property company financial structures, most of the time
rental or property leasing costs can be amended relatively quickly. </p>
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<p class="MsoNormal">Besides property costs, it is important to seek out other
areas where savings can be realized without compromising quality, such as food
vendor, pharmacy, or service contracts. This effort can positively impact the
bottom line. Perform assessments of the business to identify areas of
operations that could be improved, evaluate the return on overhead expenses, and
collect overdue accounts receivable in a disciplined way. </p>
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<h2 class="ms-rteElement-H2B">Code for Revenue Enhancement</h2>
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<p class="MsoNormal">Regulatory scrutiny of nursing centers has increased
dramatically both to ensure proper billing as well as satisfactory patient
care. Facilities are exposed to multiple audits of their patient care techniques
and billing procedures, and when issues are uncovered, the penalties and required
remedies can be taxing and expensive to implement.</p>
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<p class="MsoNormal">Staffing levels and direct patient care hours are among the
most highly scrutinized details, so some nursing center operators who cut
corners here do so at their peril—it is an expense that must be borne.</p>
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<p class="MsoNormal">Regulation around the minimum direct hours for patient care,
including certified nurse assistant (CNA) hours, places additional pressure on
the cost model by removing some of the decision-making autonomy management
staff would otherwise have on labor costs. This aspect is particularly
challenging because clinical staff in nursing centers—and in particular CNAs—typically
have high turnover due to low pay for the performance of a very difficult job,
both mentally and physically. </p>
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<p class="MsoNormal">One way to alleviate these pressures is to place emphasis on
recording and billing for all services rendered, and to implement best
practices in doing so. Develop proper coding protocols to maximize realizable
reimbursement rates so that that the facility is paid for all provided services,
even when operating in a reduced rate environment. </p>
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<p class="MsoNormal">When rising labor costs are already a concern, it might seem
counterintuitive to add extra coders to drill down into the details of
recording and billing. However, in the long run, effectively managing the
nitty-gritty details will make audits a much less stressful time for all
involved. </p>
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<h2 class="ms-rteElement-H2B">Market to the Right Audiences</h2>
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<p class="MsoNormal">Compared to residents that previously entered nursing centers
in moderate to good health, the average entrant today is older and sicker. At
the same time, hospital systems are increasingly referring patients within
their own networks, and preferred provider networks are referring to fewer
nursing centers. This all adds up to higher cost of care per resident.<span>  </span></p>
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<p class="MsoNormal">As the center faces these increased costs, it can be tempting to focus
all energy on private payers, who are attractive admissions due to their higher
reimbursement rates. However, today’s high deductibles and heavy patient
responsibility have decreased the market presence of private payers. The
Centers for Medicare & Medicaid Services (CMS), on the other hand, may have
lower rates of reimbursement but offer a growing pool of potential patients
backed by a payer that is guaranteed to pay its bills. As long as a reasonable
payer mix among residents can be maintained, accepting more Medicaid patients
can be a sustainable way to fill beds.</p>
<p class="MsoNormal">With both types of patients in mind, operators need to focus
proactively on referrals from hospital systems, assisted living facilities, and
preferred provider networks. Mandates vary from state to state, but most
assisted living facilities are required to discharge patients when their care
requires more than a one to one patient to professional ratio. </p>
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<p class="MsoNormal">At the same time, it is important to examine how to cost-effectively
reach and educate discharge planners at other health care facilities and
agencies, as well as families and other decision influencers. It can be hard to
consider investments in marketing when facing financial strains, but spending
smartly on radio, newspaper, or digital advertising can pay dividends in driving
new inquiries. Examine the competition’s pain points and market the facility as
an alternative solution. </p>
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<p class="MsoNormal">In addition to referral-focused outreach, it is important to
reach the wider community to raise awareness of services with a positive
message about the facility. Patients today have access to extensive research
and reviews when making choices about long term care, so it is imperative to
improve the facility’s CMS Five-Star Rating. The evaluation process is a bit
long—one year—but investing in care levels to enhance quality of care and
quality of life for all patients and residents will also help ensure a good Five-Star
Rating, which is a must to secure future organic inbound traction. <span> </span></p>
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<p class="MsoNormal">Some of these tactics can be led by operations, marketing, finance,
or legal teams. Those providers that are more complex and are further along in
the distress cycle may require outside expertise to lay out options and viable paths
forward. In the end, doing what is best for the health and well-being of
residents and patients often proves to be the most beneficial for the facility in
the long run as well. </p>
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<p class="ms-rteElement-P"><a href="https://www.carlmarksadvisors.com/team/marc-pfefferle/" target="_blank"><img src="/Topics/Guest-Columns/PublishingImages/MarcPfefferle.jpg" alt="Marc Pfefferle" class="ms-rtePosition-1" style="margin:5px 10px;width:70px;height:70px;" />Marc Pfefferle</a>,
partner at Carl Marks Advisors, has more than 30 years of financial and
operational restructuring experience. He serves in roles as senior advisor or
interim executive to companies in transition or in need of substantial
performance improvement or debt restructuring. He has served as CEO, CRO, or
equivalent leadership positions at 15+ companies, competing in a variety of
industrial, service, consumer, health care, and retail market segmen<span><span>ts. He can be reached at </span></span><a href="mailto:mpfefferle@carlmarks.com" target="_blank">mpfefferle@carlmarks.com</a>. <a href="https://www.carlmarksadvisors.com/team/jeffrey-pielusko/" target="_blank"><img src="/Topics/Guest-Columns/PublishingImages/JeffPielusko.jpg" alt="Jeff Pielusko" class="ms-rtePosition-1" style="margin:35px 10px;width:70px;height:70px;" /><br><br>Jeffrey
Pielusko</a>, director at Carl Marks Advisors, has over 10 years of financial
and operational restructuring and investment banking experience. He serves as
both company and lender advisor in evaluating and executing financial and
operational restructurings. He can be reached at <a href="mailto:jpielusko@carlmarks.com" target="_blank">jpielusko@carlmarks.com</a>.</p>
<div>
</div> | 2019-07-29T04:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/carlmarks.jpg" style="BORDER:0px solid;" /> | Management;Finance | Ever-evolving challenges around demographics, reimbursement, staffing, and operating costs present enormous challenges for nursing centers and assisted living communities. |
As Nursing Shortage Looms, Policymakers Step In | <div>Nurses are a critical part of health care and make up a large section of the health profession, including the senior living sector. According to the <a href="https://www.ncbi.nlm.nih.gov/books/NBK493175/">World Health Statistics Report</a>, there are approximately 3.9 million nurses in the U.S. and it is estimated that 1.2 million additional nurses will be needed by 2020. According to the <a href="https://www.nursingworld.org/practice-policy/workforce/%29%2c">American Nurses Association (ANA)</a>, a national organization representing 4 million nurses in all 50 states and U.S. territories, there will be more registered nurse (RN) jobs available through 2022 than any other profession in this country. </div>
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<div>However, many of those positions will remain vacant. It’s no secret that the U.S. is facing a serious nursing shortage. Many senior living communities are already experiencing it in the form of fierce competition when communities adding nursing staff. Such competition is especially present with during vacancies of nurse leader positions.</div>
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<h2 class="ms-rteElement-H2">Turning Away Nursing Students</h2>
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<div>According to the <a href="https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage">American Association Colleges of Nursing Report on 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing</a>, U.S. nursing schools turned away more than 75,000 qualified applicants from baccalaureate and graduate nursing programs in 2018. Going back a decade, nursing schools have annually rejected around <a href="https://money.cnn.com/2018/04/30/news/economy/nursing-school-rejections/index.html">30,000 applicants</a> who met admissions requirements.  </div>
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<div>Why is this happening? While there is a large and growing number of nursing students, there is a lack of instructors to educate them. <span style="background-color:initial;font-size:13.6px;">I</span><span style="background-color:initial;font-size:13.6px;">n order to teach nursing, one must first become at a minimum a registered nurse (RN) with several years of work experience. Most nurse educators complete a Master's degree in nursing education, although a doctorate is required to teach at many universities. These requirements, plus the fact that a nurse practitioner can earn $97,000 compared to an average salary of $78,575 for a nursing school assistant professor, according to the American Association of Nurse Practitioners, add to the nursing shortage.</span></div>
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<h2 class="ms-rteElement-H2">Dropouts and More</h2>
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<div>Other factors contribute to the nurse shortage. Nursing school is rigorous considering the coursework, reading for homework, and clinical work. For some, it is more challenging than expected, especially when it comes to the clinical work. It is one thing to study course materials and another when having to interact and provide hands-on care for patients. The reality of what nursing entails can dismay some students, causing them to dropout. </div>
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<div>Another factor has to do with the demographics of the current workforce. The nursing workforce is aging just like the population they serve. Currently, the U.S. has the highest number of Americans over the age of 65 than any other time in history. Baby boomers are retiring to the tune of 10,000 per day, and this number includes nurses. </div>
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<div>As the population ages, the need for health services increases. Today, the older population is living longer and consequently, requires more health care and nursing services. Nurses are stretched to the max since the supply of nurses no longer meets the demand.</div>
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<div>Nurses can experience burnout. Burnout is categorized as <a href="http://www.nationalnursesunited.org/news/beating-burnout-nurses-struggle-physical-mental-and-emotional-exhaustion-work">physical, mental and emotional exhaustion</a>, according to National Nurses United. Disengagement often follows. Burnout can also lead to dulled emotions and detachment, which can negatively affect patients. What is causing burnout? Long shifts, overextension due to the nursing shortage, high-stress environments, and coping with illness and death are some factors.</div>
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<h2 class="ms-rteElement-H2">Legislatures Taking Action</h2>
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<div>Recently, the author had an opportunity to speak with a professor at a nursing school who has 25 years of nursing experience in a clinical environment, five years of experience as a nurse educator in a clinical environment, and five years of experience as an educator in an academic environment. This professor stated that there is a push in many states for legislatures to address the nursing shortage immediately. In one state in particular, Arizona, recently passed <a href="https://www.aznurse.org/page/PPNursesList" target="_blank">two bills</a> in this category, S1524 and S1354.</div>
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<div>Bill S1524 calls for a working group to problem solve the nursing shortage. The bills seeks to bring together representatives via from all universities and colleges with a nursing program, members of healthcare organizations, and the Department of Health Services in order to establish a long-term plan and pilot program to address the nursing shortage. </div>
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<div>Bill 1354 provides $10 million to the Arizona Department of Health Services to create a grant program for assistance to universities and community colleges for registered nursing and advanced practice nursing programs. The bill also calls for assistance to health care institutions to develop and operate programs using retired physicians and nurses to provide guidance to new graduates of medical and nursing programs.</div>
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<h2 class="ms-rteElement-H2">Recommendations for Schools</h2>
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<div>How can schools attract the best nursing instructors? According to the professor, some suggestions mentioned were attracting more nursing instructors with a salary comparable to that of a nurse in a clinical setting, attracting new educators by paying for their advanced education degree required, and adding more simulated clinical experiences since booking real hospital settings has become very competitive. In a typical hospital setting, there could four or five schools coming in on one day to perform clinicals, and the space is at a premium. </div>
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<div>However, expanding class size is not the answer. “When class sizes increase, we can’t give each nursing student the individual attention they need to be the best at their profession which is ultimately, providing top notch patient care,” says the professor. </div>
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<h2 class="ms-rteElement-H2">The Case of Florida</h2>
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<div>While the nursing shortage is being felt across the U.S., some states are hurting more than others. Florida anticipates that there will be nearly 114,000 openings for registered nurses from 2018 through 2023. The Florida Department of Economic Opportunity lists nearly 3900 of those openings within Manatee and Sarasota counties alone. </div>
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<div>The nursing crisis was brought to the attention of Florida policymakers. In Feb. 2019, technical schools lobbied Florida state legislators to allow Florida technical schools and centers to provide transition programs. Students who complete the licensed nursing program would be able to continue their education. The move would create more opportunities for students to take the state exam and become registered nurses. As a result of their lobbying, <a href="https://www.flsenate.gov/Session/Bill/2019/381/?Tab=BillHistory" target="_blank">Florida House Bill 381</a> was introduced and filed.</div>
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<div>Unfortunately, the bill did not make it out of its respective committees and will not pass this year to become law. Even though the bill did not advance in 2019, it may resurface in 2020.</div>
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<div><em>Julie Rupenski is the Founder, President & CEO of </em><a href="https://www.medbest.com/"><em>MedBest</em></a><em>. She has gained national recognition for providing top talent solutions exclusively for the senior living industry. </em><span style="background-color:initial;font-size:13.6px;"><em>J</em></span><span style="background-color:initial;font-size:13.6px;"><em>ulie is a seasoned recruiter at filling c-suite, vice president, regional, and property level positions. She has an in-depth knowledge of the senior living industry since she previously worked in operations for both senior housing and senior living. </em></span><span style="background-color:initial;font-size:13.6px;"><em>Julie earned her degree in Gerontology at the University of South Florida, Tampa, Fla. She can be reached at jrupenski@medbest.com or 727-526-1294.</em></span></div> | 2019-05-05T04:00:00Z | <img alt="" src="/Breaking-News/PublishingImages/150x150/JR.png" style="BORDER:0px solid;" /> | Quality;Management | While several factors contribute to the country’s nursing shortage, state legislatures are taking steps to address them. |
Honoring 500 Heroes in 47 Ways | <p class="ms-rteElement-P">Every autumn, Centers Health Care, which operates 47 long term and post-acute care centers in New York, New Jersey, Rhode Island, Missouri, and Kansas, gears up to do something special for veterans for Veterans Day. Nearly 500 veterans either reside or are employed at 47 Centers Health Care centers, and two new Midwest locations in Topeka and Wichita, Kan., will soon care for more veterans. </p>
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<div><p class="ms-rteElement-P">For many years, the marketing department would create a certificate for veterans and host a photo day with families, friends, staff, and other residents. A ceremony would include a dedication cake, music, and a special toast to the veterans. Some facilities even offered live music. For those veterans who may be too weak or ill to be part of the day’s ceremony, they are honored with a pho<span>to and cake brought to their room.</span></p></div>
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<div><p class="ms-rteElement-P">Recently, Centers Health Care decided to go beyond certificates and cake. Each facility now displays a “Wall of Honor,” which is enshrined and dedicated to the facility’s veterans. The wall includes a poster of all the military branches, a wood display case with a veteran certificate personalized for that facility, a flag that was flown over the U.S. Capitol Building in Washington, D.C., and framed headshot photos of each resident veteran. </p></div>
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<h2 class="ms-rteElement-H2">A Team Effort </h2>
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<div>While doing a “Wall of Honor” isn’t anything new, constructing 47 of them was a big achievement for Centers Health Care. With a combination of the recreation, marketing, and public relations departments, all Walls of Honor were completed by late October. How the staff made this happen had much to do with meetings, creativity, and execution. </div>
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<div><span class="ms-rteFontSize-1">The Wall of Honor at Cooperstown Center. Cooperstown, NY. </span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">Photo: Courtesy of Centers Health Care</span><br><br></div>
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<div>In June, the first meeting took place with the heads of marketing and public relations brainstorming something extraordinary that would make each facility proud of their veterans. The idea of having a Wall of Honor was decided on but it was still in its infancy stages. Staff knew there would be (1) a framed poster with a logo of each military branch on that poster, along with a recognition quote from the company to its veterans and (2) photos of each veteran which would list their name and branch of service. </div>
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<div>But there needed be something else, something that would put it over the top. Instead of the annual saluting of the flag that takes place across each facility, the team decided that a special flag for each facility would come from each state senator where the facility is located. The public relations department started working with each senator and coordinated 47 special American flags that flew over the U.S. Capitol in Washington, D.C. (one for each facility), 47 dedicated certificates, and wood display cases. </div>
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<h2 class="ms-rteElement-H2">Putting it into Action</h2>
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<div>In August, a second meeting occurred with the marketing, public relations, and recreation teams. The teams created a timeline and marked Oct. 31 as the day each facility would receive the framed Wall of Honor poster, the individual veteran framed photo, a framed logo of their prospected facility, and the framed flag, and senator certificate. Tasks were divided and the marketing department was to create the framed poster, framed individual veteran photos, and framed facility. </div>
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<div>Public relations would compile each flag and certificate and have the flag properly folded in a triangle. Both items would be placed into the display case. The public relations team had a series of conference calls to reinforce the task at hand and determine the invitees from each location. The team determined who would head up the Veterans Day ceremony, preferably someone from a local American Legion. </div>
<div style="text-align:right;"><div style="text-align:center;"><img src="/Topics/Guest-Columns/Documents/WOH%203RS.jpg" alt="WOH 3RS.jpg" class="ms-rteImage-1" style="margin:5px;width:229px;height:357px;" /> </div>
<div style="text-align:left;"><span class="ms-rteFontSize-1">Veterans and staff member Joseph Wright is honored by Administrator David Liff at Hope Center in the Bronx, NY.</span></div>
<div style="text-align:left;"><span class="ms-rteFontSize-1">Photo: Courtesy of Centers Health Care.</span></div></div>
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<h2 class="ms-rteElement-H2">Challenges </h2>
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<div>Recreation departments in all Centers facilities invited members of the local American Legion, Veterans of Foreign Wars (VFW), and local law enforcement to attend the events and present the flag and personal certificates to the residents. Each facility’s recreation director spent many hours calling, scheduling, and confirming the event date. In some cases, confirming the guest of honor happened on the last day.</div>
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<div>Each center aimed to have at least one distinguished guest of honor to lead the ceremonies. The guest would say a few words, hand the certificates to each veteran, and distribute the cased flag to the resident and staff veterans. </div>
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<div>Each center was also challenged to brainstorm what other features each event would include. For example, at Washington Center in Argyle, New York, the event also included patriotic singing by the Argyle Central School Chorus. Another example took place at Hammonton Center in Hammonton, New Jersey, where a bagpiper performed.</div>
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<div>Finding the Right Spot</div>
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<div>While most facilities had the wall specified either in their dining room, main hallway, reception area, or activity room, some designated the wall to a special area where families and friends would view it out of the way from the regular foot traffic. Each facility is different, and each administrator is different. </div>
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<div>One of the most beautiful aspects of the Veterans Wall of Honor campaign was the coming together of veterans from the American Legion and VFW posts as they honored their elder fellow veterans. Some saluted one another, many shook hands, and some even embraced with hugs and tears. </div>
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<div>In addition to veterans coming together, activities and recreation staff throughout many of Centers’ facilities, discovered a new side of a friendship. For example, at Schenectady Center in Schenectady, NY, Kristen Pidgeon, recreation director, and Julianne Scopa, assistant director, got even closer as colleagues.</div>
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<div>“Veterans Day is always a very emotional day at the Schenectady Center,” says Pidgeon. “I have often felt the brunt of the work on me, so it was really nice to have someone to share that with. This was a huge undertaking in our large facility and I really couldn’t have done it without Julianne. We make an amazing team.”</div>
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<div>For the author, seeing the veterans being honored by their own is something that will never be forgotten. This was seen first hand at the Beth Abraham Center ceremony in the Bronx, NY as three American Legion personnel saluted and embraced one another after the resident veterans received their certificate. <em></em></div>
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<h2 class="ms-rteElement-H2">Lessons Learned</h2>
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<div>Two lessons emerged from the Walls of Honor project. The first is start early and the second is get an early start. To start early, it is best to begin planning five months in advance. Veterans Day falls on Nov. 11, so starting in May or June is ideal. </div>
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<div>To order a flag that has been flown over the U.S. Capitol, start the request via the center’s state senator. It can take two months to receive it and it will typically not be pre-folded. A local American Legion Post may be able to help with folding. </div>
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<div>The second lesson, “get an early start,” refers to the team. Get an early start with the team by assembling it early, including the marketing and recreation director. Encourage everyone to think five to six months out. No matter the number of facilities involved, the team needs to identify and tackle the main challenges head on and early. </div>
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<div>Keep in mind that local American Legion and VFW offices can take some time to respond because the members are retired and phones are typically manned only part-time. Do not get discouraged and keep on trying. Persistence pays off.</div>
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<div>All things considered, get a heartwarming vision of what should be achieved to honor the great veterans at the facility. Communicate that version with the staff and work together to make it happen. The veterans at Centers Health Care loved being recognized. Whether they are residents or staff, veterans are heroes and very special people in the country. </div>
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<div><em>Jeff Jacomowitz is an award-winning public relations professional and journalist and currently the public relations director at Centers Health Care, with more than 47 nursing homes and rehabilitation centers in the country. As a contributing writer for The Patch, Jeff specializes in health care and medicine. He can be reached at: jjacomowitz@centershealthcare.org. </em></div> | 2019-04-26T04:00:00Z | <img alt="" src="/Breaking-News/PublishingImages/150x150/JeffJacomowitzRS.jpg" style="BORDER:0px solid;" /> | Management | A provider shares lessons learned from a new project to honor veterans. |
Certified PA-Cs Integral to Expansion of Palliative Medicine | <span style="background-color:initial;">Sometimes, just sitting with a patient, having a conversation, or touching their hand emits more healing power than any prescribed medication. These gestures are especially valuable for patients battling long-term chronic diseases and illnesses. As care providers, these expressions of comfort can fall under the umbrella of palliative care, which treats the whole person by nourishing the mind, body, and spirit.</span><div><div> </div>
<div>However, patients and even some providers may be unaware of what palliative care is and how it works. This article aims to provide information about certified physician assistants (PA-Cs) and their expansion into long term and post-acute care LT/PAC. </div>
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<div>Palliative care programs have experienced tremendous growth and change over the past few years, from the types of programs offered to who delivers that care. As the specialty continues to evolve, one notable trend is the entrance of PA-Cs into the palliative care arena, including LT/PAC settings. The nation's PA-Cs are valuable assets within palliative care programs because, like physicians, they deliver frontline care. PA-Cs diagnose, develop the care plans, order diagnostic tests, prescribe medication, and counsel patients about treatment options and what to expect in the future. </div>
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<h2 class="ms-rteElement-H2">New Developments</h2>
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<div>A recent amendment made to HR 1284—Medicare Patient Access to Hospice Act of 2017— now recognizes PA-Cs  as a “distinct and important part of the hospice interdisciplinary team with the ability to provide care to terminally ill Medicare patients.” </div>
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<div>This allows PA-Cs to effectively serve as the attending physician for hospice patients, according to the National Hospice and Palliative Care Organization. It also loosens limitations on PA-Cs who now have an unencumbered opportunity to extend palliative care services and help address workforce shortages in LT/PAC. </div>
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<div>Another development that enhances the PA-C workforce is HR 1676—Palliative Care and Hospice Education and Training Act— passed in August 2018. This approves grants to enhance educational programs, research, and workforce development in palliative medicine. These grants are designed to improve the education of PA-Cs in palliative care, support continuing education programs, and encourage PA-Cs to teach or practice palliative medicine through incentive programs. </div>
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<h2 class="ms-rteElement-H2">Meeting Demographic Demands</h2>
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<div>These are developments that will affect the PA-C workforce in a positive way.  However, access to palliative for patients remains inadequate. </div>
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<div>According to the legislation in HR 1676, over the next 20 years there will be no more than a 1 percent growth in the physician workforce, while patients eligible for palliative services will increase by over 20 percent. <br><br></div>
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<div>What’s more, according to a 2014 Institute of Medicine report, a rapidly aging population coupled with large numbers of patients taking advantage of hospice—more than 1.5 million patients annually means expansion of PA-C practice in hospice and palliative settings is timely.</div>
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<h2 class="ms-rteElement-H2">Filling a Gap </h2>
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<div>The nation’s more than 123,000 certified PA-Cs  can address the access issue and fill palliative care gaps in LT/PAC. While it is projected that there will be a shortage of 18,000 palliative care providers over the next few years, there has been close to 50 percent growth in the PA-C profession over the past decade.</div>
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<div>And with the legislative amendment (HR 1284) that allows PA-Cs  to practice in hospice and palliative care, there will continue to be a rise in palliative care PA-Cs  as the subspecialty grows and the ranks expand. PA-Cs will be integral in the growth of these services because they are highly qualified care professionals who can provide life-saving diagnostic and therapeutic services. Additionally, collaboration with physicians has been a hallmark of PA practice since the profession’s inception, and this continues in palliative medicine. </div>
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<div>The greatest value proposition is the compassionate care PA-Cs can provide as patients and families cope with the physical, psychological, and emotional toll of medical treatment. In addition, PA-Cs expand health care access to patients, offering appointments sooner and spending additional time to educate and counsel patients. </div>
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<div>It is important to note that all PA-Cs can administer palliative care, not just those employed in specialized palliative care centers. PA-Cs in emergency medicine, hospital medicine, and LT/PAC, among others, often treat patients who concurrently need the effective benefits of specialized programs, or coordinate closely with members of the palliative care team. This involves developing meaningful relationships with patients and their families, managing intractable symptoms, and coordinating additional care or the transfer of patients to LT/PAC centers. </div>
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<div>Two-way communication is also essential to ensuring strong palliative care programs in LT/PAC. PA-Cs can lead such efforts by educating and answering patient as well as family questions and concerns about their illness and course of care. During consultations, PA-Cs can talk with patients about what they understand about the disease process, help them vocalize what is an acceptable quality of life based on their values and priorities, and coordinate obtaining the support they may need. </div>
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<div>Today, certified PA-Cs are mainstream in the LT/PAC workforce, providing care in settings ranging from rural centers to the nation’s largest long term care systems. PA-Cs are well qualified for the role. Like physicians, they commit to lifelong learning through continuing medical education and maintain certification through a rigorous process that includes assessments every 10 years. They also work on interdisciplinary teams, better enabling high-quality, patient-focused care. </div>
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<div>Additionally, certified PA-Cs are educated in the core areas integral to the delivery of palliative care, including patient and family communication skills. Their education focuses on interdisciplinary collaboration and teamwork in the delivery of care that can alleviate the burdens caused by provider shortages and increase access to the more than 6 million people in the United States who could benefit from palliative care services.</div>
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<div>Legislation like HR 1676 further advances the role of PA-Cs in palliative care by funding programs that will prepare students in direct and related areas of medicine, support continuing education programs, and encourage more PA-Cs to teach or practice palliative medicine through career incentives. </div>
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<div>With the aging of the population and more people living with chronic diseases, experts anticipate demand for quality palliative care programs to grow substantially in the next decades. With more PA-Cs choosing to specialize, they will certainly play a greater role in the care of seriously ill patients, like those in LT/PAC settings, in the years to come. The PA-C profession continues to proliferate, adding 8,000 newly-certified PA-Cs  to the workforce every year.</div>
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<div><em>Dawn Morton-Rias, Ed.D, PA-C is president and chief executive officer of the NCCPA, the only certifying organization for physician assistants (PA-Cs) in the United States. The PA-C credential is awarded by NCCPA to PA-Cs who fulfill certification, certification maintenance, and recertification requirements. NCCPA also administers the Certificate of Added Qualifications program for experienced Certified PA-Cs practicing in seven specialties. For more information, visit </em><span style="background-color:initial;"><i>https://pasdothat.net/. </i></span></div></div>
| 2018-10-04T04:00:00Z | <img alt="" src="/Breaking-News/PublishingImages/Dawn%20Rivas%20for%20web.jpg" style="BORDER:0px solid;" /> | | Certified physician assistants, also known as, (PA-Cs) are expanding into long term and post-acute care settings. |
The Power of Going Mobile | <div>Mention the word “mobility” in the context of senior living, and some people might think of group exercise or physical therapy. Today, mobility has another important meaning for senior living organizations: the opportunity to deploy innovative mobile solutions for staff members. These solutions represent an increasingly important way to address key trends—namely, increasing resident age and acuity rates alongside growing challenges related to staff recruitment and retention. </div>
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<div>There’s no question that mobile devices and apps have become ubiquitous at home and in the workplace. In fact, according to the Pew Research Center, 95 percent of Americans now own a cellphone. More than three-quarters own a smartphone—a marked increase from Pew’s first survey of smartphone ownership in 2011, when just 35 percent of Americans had these devices.</div>
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<div>Meanwhile, the IQVIA Institute for Human Data Science recently reported that there are now 318,500 health-related mobile apps—doubling from 2015 to 2018.</div>
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<div>Mobile devices and apps present a real opportunity for senior living communities to improve efficiency and service to residents. They offer a number of advantages over current techniques:  </div>
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As with any technology, achieving favorable results with mobile solutions requires more than simply buying an app. Communities can increase the odds of success by taking a strategic approach to mobility. </div>
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<div>Mobile applications require a communications infrastructure to relay information to and from devices. While it is possible to use cellular service, this is not a cost-effective option in most cases. The alternative is a Wi-Fi network, which many communities are already investing in to meet residents’ needs as well as administrative requirements. <br></div>
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<div>As communities deploy these networks, they should consider uses such as staff communication via mobile applications or voice over IP (VoIP) phones. The key requirement is reliability to ensure uptime for residents and staff. These investments in Wi-Fi serve as a solid foundation for mobile solutions.</div>
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<div>Mobile applications have a big impact on the workflow of frontline caregivers. Using pilots helps “kick the tires” of the technology and build positive momentum within care teams. Demonstrating reliability is especially important for the introduction of apps that replace another form of communication, such as a pager system for receiving alerts. Though much more limited than a mobile app, a pager system is a known and trusted communication tool for caregivers. A pilot helps prove that the new app is just as reliable. </div>
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<div>Any organization planning to deploy a large number of mobile devices needs a way to manage and control them. Standardizing on one device helps greatly with this. The choice will be influenced by a number of factors, including cost, size, battery life, and operating system. The relative importance of each of these factors will be different for every organization, but there is such a wide range of options available that the right fit is almost certainly available.</div>
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<div>The other essential component is a mobile device management (MDM) platform. This software tracks the “who” and “where” of devices. It also helps in automating device and app updates while restricting staff members’ ability to load unauthorized apps onto their mobile devices. All of that is critical to ensuring the reliability and security of mobile devices and apps.</div>
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<div>Having these enterprise standards supports operational efficiency. Even more important, it helps ensure that these devices will perform as intended.</div>
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<div>Mobile applications are replacing older ways of doing things, and they offer far more features and functions. Training for both frontline users and executive leadership is therefore essential to ensure adoption and to get maximum benefit from the investment. The application itself is not the real concern. For this, comparatively little training is required—especially among the younger “digital natives” within the workforce. </div>
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<div>The bigger impact of a mobile solution is on workflow. Consider the move from a pager system for handling alerts from a resident safety solution such as a nurse call or wander management system. For frontline workers, documenting response now happens on the spot. Over time, caregivers will come to appreciate added functionality such as being able to communicate via text messages and having a convenient, at-a-glance view of calls for help, but it does change ways of working.</div>
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<div>For executives, it introduces a new set of data and analytic tools to measure and monitor performance and dig into each resident’s behavior and evolving needs. A weekly follow-up with administrators and end users is helpful to address any issues, while ensuring that they are making the most of the solution’s features.</div>
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<div>While there are certainly plenty of technical and process steps that must be completed to support a successful mobile deployment, it is important to stay focused on what really matters: the outcomes these solutions produce for residents and, by extension, the business. </div>
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<div>Going mobile can help drive greater efficiency, higher-quality care, and richer data-driven insights. For example, the impact of a facility’s management app for technicians to help them focus on the most pressing maintenance needs can be assessed by a before-and-after comparison of the average time it takes to complete a task.</div>
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<div>Sometimes, however, a mobile app makes possible entirely new ways of seeing performance, as with an app to manage resident alerts. Most communities measure the response time: the time between the activation of the alert by the resident and the clearing of the alert by a staff member. Using an app makes possible a different metric: the encounter time. The caregiver “checks in” when they arrive to help a resident and “checks out” when the encounter is complete—this could be quite some time after the alert is cleared. </div>
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<div>When combined with notes on the encounter entered via the app, this gives administrators visibility to how much time is being spent in these interactions both at the community and caregiver levels. The data can be invaluable in informing staff management, as well as resident care planning.</div>
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<div>Building a strong technical, operational, and cultural foundation for mobility positions any senior living organization to benefit from emerging innovations, such as the next generation of mobile devices for health monitoring. These devices can help keep an eye on a host of vital signs, including blood pressure, heart rate, and hydration. Some alert not only staff but also a resident-designated relative or friend to receive alerts. </div>
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<div>Even more valuable than deploying individual apps is creating a strategy for integrating them. Bringing together data gathered through emergency call systems, care systems, electronic medication administration records, and wearable devices can empower communities to create—and analyze—a more complete picture of resident health, care needs, and performance in addressing those needs over time.</div>
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<div>These groundbreaking mobile technologies are already in use at many communities. For senior living, the future is mobile—and it’s happening now. </div>
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<div><em>Tony Villone is senior director, IT operations, at Senior Resource Group in San Diego. He can be reached at tvillone@srg-llc.com or 858-314-1725.</em></div>
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</em> | 2018-09-14T04:00:00Z | <img alt="" src="/Monthly-Issue/2018/August/PublishingImages/Tony%20Villone%20for%20web.jpg" style="BORDER:0px solid;" /> | Management;Technology | Communities can increase the odds of success with mobile solutions by taking a strategic approach. |