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Enhancing Medicare PPS Service Quality and Reimbursement

October 1, 2004
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The rationale and recent successful experience with a new systematic approach by James J. Riemenschneider, LNHA, MBA, and L. Prentice Thompson
BY JAMES J. RIEMENSCHNEIDER, LNHA, MBA, AND L. PRENTICE THOMPSON

Now is an increasingly challenging time for post-acute care providers. The Institute of Medicine has called for new systems of care to address the expanding needs of the elderly. Today's skilled nursing facilities must adopt new systems that enable delivery and demonstration of high quality care and simultaneously achieve optimal financial performance. The challenge for long-term care providers is to meet the increased expectations of residents, families, referring physicians, hospitals, and payers within a climate of declining reimbursement and increased liability risk. Responding to that challenge requires a careful definition of the issues and use of a methodical system geared toward enhanced staff teamwork. Such a system is now being tested, with promising early results.

Defining the Issues
Nursing homes must learn to success- fully manage elderly residents presenting with complex chronic and acute diseases only minimally stabilized after a short hospital stay. During the past ten years, governed by prospective payment, hospital Medicare inpatient stays have decreased to approximately four days. In turn, this trend is stimulating earlier transfer of more medically unstable elderly patients from the hospital to the post-acute setting. The model of care delivery therefore shifts from an integrated team of highly skilled medical specialists using high-powered technology to an environment where the same level of care is expected with fewer resources and limited technology. While, in the hospital setting, the elderly patient is assessed and treated continuously by physicians and nurses, transfer to the skilled nursing facility places the elderly resident in a setting of intermittent assessment by nurses and limited involvement by physicians usually removed from the care setting.

Care in the subacute setting is further hampered by the absence at the bedside of the most experienced nurses, who are pulled away from direct care to complete regulatory and administrative tasks and are generally overwhelmed by paperwork. The resulting model of care delivery in many nursing homes is inconsistent, fragmented, and lacks a team approach. Furthermore, the model has been focused for years on functional rehabilitation (to maximize reimbursement) and often does not appropriately address management of complex diseases or other medical needs. Ironically, inadequate stabilization of complex medical conditions frequently ensures that the elderly resident will not achieve optimal functional rehabilitation.

Much of the nursing home industry has not yet learned to successfully manage the medically complex resident in an environment of limited resources and continues to operate based on blueprints of the past, when a nursing home's function was to provide a safe environment for elderly individuals with functional limitations to live out the remainder of their lives with appropriate support. Government reimbursement systems were designed to reward services delivered to maintain functional and daily activity needs, and nursing home care systems adapted accordingly. This approach has produced caregivers and operational systems that are unprepared to address the needs of residents with complex acute and/or chronic medical conditions.

Forging a New System
To address these difficult times, nursing homes must embrace a new system for delivering care that is disease-based and uses standardized processes that produce positive clinical and financial outcomes. The system must factor in all of the issues described above, as well as:
  • integrate care across disciplines

  • facilitate communication among providers, especially physicians at a distance

  • define and apply the increased resources needed

  • continually educate and improve the skill level of the post-acute nurse, the frontline professional caregiver in the nursing home

  • reintegrate the most experienced nurses (DONs and supervisors) into the process more effectively

  • provide a continuous data collection loop for ongoing analysis of outcomes

  • facilitate continued improvement of system processes
The system should also facilitate collaboration and information flow among disciplines and standardize and integrate the activities of the clinical team, tying together all the components of disease management.

The first component of the system should facilitate a comprehensive, holistic, interdisciplinary admission assessment of the resident. To appropriately care for the increased medical needs of elderly residents, the nursing home of today must determine true primary and secondary acute and chronic diseases, baseline medical data (including vitals, I&O, pain, behavior, skin, medications, labs, and IV treatments), bowel and bladder behavior, diet and nutrition behavior, functional capacity, resident and family educational needs, psychosocial needs, and care coordination (especially discharge potential and planning). To accurately and efficiently assess a resident in all these components takes real collaboration of all disciplines working as a team. Furthermore, to achieve efficiency, the team must eliminate duplicative steps in the admission process (e.g., asking the resident his/her name and age five different times).

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