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.
AHCA/NCAL Gold Quality Award Achievers Talk Strategy, Sacrifice<p>​A quartet of providers has received the preeminent Gold National Quality Award designation from the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) for 2020 and was honored for their achievement during the association’s annual convention, which ran on a virtual basis through the month of October.</p><h2>Starting With Bronze</h2><p><img src="/Monthly-Issue/2020/December/PublishingImages/Treutlen.jpg" alt="Treutlen Health and Rehabilitation" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;232px;height&#58;303px;" />Jane Martin, RN, director of nursing, Treutlen Health and Rehabilitation, Soperton, Ga., says for her 50-bed facility in rural Georgia, the latest attempt to achieve Gold started five years back when the organization earned Bronze from AHCA/NCAL, then Silver in 2017.<br></p><p>“That is when we decided to go for the Gold,” she says. “We [earned] a site visit last year, and then this year got the Gold award.”<br></p><p>Going for the top honor and going for the Bronze or Silver are worlds apart, Martin notes. “The Gold is so much different, and you really need to dedicate time to it.” This work includes copious writing down to report quality-based outcomes for residents, since getting positive results is what the award process is all about, she says.<br></p><p>“Probably the most difficult things is collecting the data. Everything has a different measurement time frame, so I really rely on LTC Trend Tracker [from AHCA/NCAL], NursingHome Compare… You need to know all of these data today on a regular basis.”<br></p><p>Once all the hard work resulted in the Gold, Martin says sharing the good news, in a COVID-sensitive manner, was a great feeling for staff and residents alike.<br></p><p>“We were in a huge open area when we told them, and it was a lot of yelling through masks,” she says. “It was kind of sad that we could not hug or have family there, but we did our best.”<br></p><p>As for what she would tell fellow providers about the award program, Martin says facilities should do it; even though it is not easy, it is well worth it. “We all learned so much through the process, and there were so many little things along the way, it has changed the way we live and work here.”</p><h2>Driven by Necessity</h2><p><img src="/Monthly-Issue/2020/December/PublishingImages/Burgess.jpg" alt="Burgess Square Healthcare and Rehab Centre" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;414px;height&#58;308px;" />Kristin Thrun, administrator, Burgess Square Healthcare and Rehab Centre, Westmont, Ill., says her nursing home got into the quality award world because back in 2012 when accountable care organizations and other value-based care entities emerged in her area, it became imperative for her facility to set itself apart.<br></p><p>“The focus became even more pronounced on overall performance outcomes and quality measures, and becoming part of the AHCA/NCAL award process helped us to do this in a systematic way,” she says.<br></p><p>After receiving some local awards for their work with residents, the facility earned Bronze from AHCA/NCAL in 2017 and then eyed going for Gold after that.<br></p><p>“I think the biggest challenge is continuing to push forward in terms of meeting the criteria and putting our programs in place and sustaining them despite the external challenges brought on by things like changes in payment models [Patient-Driven Payment Model] and keeping pace with those,” Thrun says.<br></p><p>An example she gives is the challenge it was to make the systemic change on medication reconciliation when a resident moved from the hospital to the nursing home. <br></p><p>“We worked with the hospital to change the process and reduce errors tied to these transitions of care and created a pharmacy position that just does admission reviews for new patients coming in,” she says.</p><h2>New Skills Help Staff Adapt</h2><p><img src="/Monthly-Issue/2020/December/PublishingImages/Applewood_cupcakes.jpg" alt="Applewood Center" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;262px;height&#58;383px;" />The third achieving group says its journey to Gold began 18 years ago, according to Gail Cushing, RN, executive director, Applewood Center, Winchester, N.H.<br></p><p>“It has been a long journey for sure, but we continued to forge on throughout the time, but it did not prevent us from getting to where we wanted to go,” she says.<br></p><p>The greatest thing about the Gold process, Cushing says, is that it gave Applewood Center and its staff new skill sets to be able to adapt to new demands. “We can take new problems and adapt very quickly. An example is with COVID-19; I have said handling the pandemic was made more manageable because we went through a dress rehearsal with the Gold awards.”<br></p><p>For her, the award application has taught her and her people to communicate better, get feedback, educate, teach, and fix pitfalls. One example is that during the pandemic, her staff came up with a way to clean their goggles when there was no water source in an area where people were working.<br></p><p>“The whole Gold process is a concept really that provides a facility&#160;with new means to achieve success, and the more you practice, the better you become and the more ingrained it all becomes,” Cushing says.</p><h2>Pride for the Gold</h2><p><img src="/Monthly-Issue/2020/December/PublishingImages/Heritage_EuniTami.jpg" alt="Heritage of Bel-Air" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;351px;height&#58;237px;" />Katie Frederick, administrator, Heritage of Bel-Air, Norfolk, Neb., started out talking about the end game of achieving Gold, which was the joy she, her 160-strong staff, and residents felt at accomplishing so much. Even though the pandemic has made a true celebration difficult, she says the pride all in the community feel about making Gold is real.<br></p><p>For her, making changes to be more efficient and better at evaluating results and outcomes is the lasting impact going through the award process will have.<br></p><p>“Evaluating and learning are what this has all been about. And, really getting better at communicating, listening to each other, and putting ideas into practice. That has all worked for us,” Frederick says. <br></p>2020-12-01T05:00:00Z<img alt="" src="/Monthly-Issue/2020/December/PublishingImages/1220_gold.jpg" style="BORDER&#58;0px solid;" />Quality AwardsPatrick Connole​A quartet of providers has received the preeminent Gold National Quality Award designation from AHCA/NCAL for 2020.
Communities Celebrate National Assisted Living Week<p>Held annually since 1995 and kicking off on Grandparents Day, National Assisted Living Week (NALW) was recognized during the week of Sept. 13-19 this year.<br></p><p>This annual observance, sponsored by the National Center for Assisted Living (NCAL), provides a unique opportunity for residents, their loved ones, staff, and volunteers to recognize the role of assisted living in caring for America’s seniors and individuals with disabilities.<br></p><p>During NALW, assisted living communities around the country are encouraged to host events and activities to celebrate the residents they serve.<br></p><h2>Caring is Essential</h2><p>Along with their sister nursing homes, assisted Living communities have been hit hard by the COVID-19 crisis. Despite the devastating stories of loss and social isolation many residents have experienced due to COVID-19, there are also many heartwarming stories about the dedication and compassion of staff members devoted to protecting the residents in their care. &#160;<br></p><p><img src="/Monthly-Issue/2020/November/PublishingImages/1120NALW_BerthaBunny.jpg" alt="Betty Bunny" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;255px;height&#58;255px;" />To acknowledge this commitment, NCAL announced in June that this year’s theme for NALW would be Caring is Essential. Perhaps more relevant now than in any year before, this theme highlights the role of essential caregivers in assisted living—the certified nurse assistants, nurses, food service workers, volunteers, and others—for their unwavering commitment and hard work.<br></p><h2>Honoring Residents</h2><p>While not all senior living facilities were able to celebrate the week, many communities adapted activities and found new and creative ways to honor both staff and residents during NALW. <br></p><p>Through social media posts, pictures, and videos, they shared their NALW stories. Many events were imaginative and fun, such as facemask fashion shows, tattoo and dress-up activities, fall farmer’s markets and pie-throwing contests, window visits from dairy cows to owls, and ice cream truck deliveries.<br></p><p>Other events focused on community connections such as adopt-a-grandparent programs and special messages, posters, and videos from local school children.<br></p><h2>Ingenuity Reigns</h2><p>In previous years, residents of Somerby Franklin Senior Living, Franklin, Tenn., were invited to the Moore Elementary School for a performance. As this was not possible due to COVID, teacher Amber Anderson encouraged her second-graders to create messages of love on posters to “add cheer into the residents’ hallways, rooms, and hearts.”<br></p><p>Connections were also made via community caravans and window visits, in some cases through specially constructed transparent visiting booths. One family even brought a forklift to raise family members to the residents’ windows on the second floor.<br></p><p>Perhaps the most amazing of all were the innovative “hugging devices” constructed in several facilities. These specially designed plastic curtains enabled residents to safely receive a warm embrace from their loved ones.<br></p><h2>Recognizing Staff</h2><p>Honoring assisted living staff members also took many forms during NALW, from pizza parties and cook-outs to dress-up days, dance contests, and games. The week also offered an opportunity for residents to express their appreciation for staff members through notes, cards, and videos with heartfelt messages of gratitude.<br></p><p>At Chandler Park Assisted Living, caregivers received a special video from residents thanking them for their work and proclaiming staff members “a blessing” and “an essential part of their lives.” Similar messages of thanks for essential caregivers came from administrators, local leaders, and government officials.<br></p><p>In many communities, staff members were presented with special goody bags, fun treats, prizes, t-shirts, and other tokens of appreciation.<br></p><h2>Honoring Those Lost to COVID<span><span><img src="/Monthly-Issue/2020/November/PublishingImages/1120NALW_JulieScott.jpg" class="ms-rtePosition-2" alt="Julie Scott, Omni West" style="margin&#58;5px;width&#58;350px;height&#58;350px;" /></span></span></h2><p>NALW also provided an opportunity to honor the memory of those loved and lost to COVID. A display of 2,428 pinwheels, set up in a Youngstown, Ohio, meadow, was created by staff members at Omni West Assisted Living in memory of assisted living and nursing home residents who have died from the coronavirus in Ohio. <span></span></p><p>“I wanted to honor their memory in a way that would be touching; each pinwheel represents someone’s life,” Omni West Activity Director Julie Scott says.<br></p><p>At Maple Pointe in Rockville Centre, N.Y., a special Rock Garden was created to honor community members lost to COVID. New York Assemblywoman Judy Griffin attended the unveiling of the garden and expressed her gratitude for the “compassionate, diligent, and dedicated staff who worked tirelessly during these challenging times to ensure the safety and well-being of residents,” noting that the new garden was a “beautiful way to honor each resident’s legacy and truly seemed to comfort the community in attendance.” <br></p><h2>Spirit Endures</h2><p>The week was recognized in many wonderful and deeply moving ways with the primary focus of honoring the commitment and dedication of caregiving staff and celebrating the lives of residents in their care.<br></p><p>Despite having opened its door five months into a pandemic, NALW activities at Evergreen Village in Fort Wayne, Ind., went full speed ahead. After a week of celebration,&#160; Administrator Amanda Palace noted that “…it takes a village to do just about anything these days, and the village being built here on a foundation of love, compassion, and dignity was solidified last week, and the happiness and positivity was palpable to all who helped us make it a success.” <br></p><p>To learn more or view the many ways that NALW was recognized this year, please visit #NALW, Facebook.com/#NALW, and <a href="http&#58;//nalw.org/" target="_blank">NALW.org</a>. <br><br><em>Lisa Hohenemser is marketing manager with the American Health Care Association/National Center for Assisted Living. She can be reached at <a href="mailto&#58;lhohenemser@ahca.org" target="_blank">lhohenemser@ahca.org.​</a></em></p>2020-11-01T04:00:00Z<img alt="" src="/Monthly-Issue/2020/November/PublishingImages/1120NALW_MooreElem.jpg" style="BORDER&#58;0px solid;" />Quality;CaregivingLisa HohenemserAcross the country, residents and staff honor each other and also have some good times.
Measuring Quality<p>There will need to be ongoing attention to developing quality measures that address quality of life, says Michael Wasserman, MD, CMD, and a geriatrician in California.<br></p><p>For instance, “If someone has end-stage Alzheimer’s disease and is in terrible pain and discomfort, is death a bad outcome? A good outcome is one that respects the dignity and wishes of our patients,” he says. <br></p><p>“This is the real determinant of whether we are delivering person-centered care. This is where quality measurement needs to go.”<br></p><p><img src="/Monthly-Issue/2020/August/PublishingImages/kumar.jpg" alt="Rajeev Kumar, MD" class="ms-rtePosition-1" style="margin&#58;5px;" />Facilities and their care teams take quality and quality measurement seriously, says Rajeev Kumar, MD, CMD, chief medical officer at Symbria.<br></p><p>“Health care quality is always about best practices that define a path to optimal outcomes. It is the guardrail that keeps us on track to success,” Kumar says.<br></p><p>However, he admits that the pandemic “has exposed gaps in our systems and processes as we seek to define quality in post-acute and long term care. Any quality measures that we use or create to track our success with a pandemic must include and account for external factors that impact our performance and, sometimes, are beyond our control.”​</p>2020-08-01T04:00:00ZQuality“Health care quality is always about best practices that define a path to optimal outcomes. It is the guardrail that keeps us on track to success,” Kumar says.