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Strange bedfellows: The improbable romance of accounting and nursing, part II

May 5, 2008
by Jill Smoller and Anthony L. Morrone
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What is the magic number for nurses and nursing assistants on any given nursing unit? With the help of a knowledgeable accountant, a simple formula based on the actual needs of residents and nursing care is just a meeting or two away.

Strange bedfellows: The improbable romance of accounting and nursing, part I





Staffing
Finding the ideal admission mix, however, is not the only strategy for financially savvy nursing facilities. Facilities should scrutinize their personnel practices as well. There are staffing issues everywhere. In almost every nursing home, if you ask most workers, they will tell you that they could use more help. So what is the magic number for nurses and nursing assistants on any given nursing unit? With the help of a knowledgeable accountant, a simple formula based on the actual needs of residents (for direct care) and nursing care (professional) is just a meeting or two away. Residents who wander or who have behavioral problems take additional time for nursing assistants but probably require no additional assistance from nurses. Therefore, units designated for residents with behavioral issues may need additional CNA assistance but might do fine with less licensed staff. Residents who are medically complex may require additional nursing time but perhaps not as much CNA help. Rather than staffing all 40 bed units with the same canned staffing pattern, a wise accountant can discuss the combinations and permutations of staffing alternatives that result in better care for the residents and a more cost-efficient arrangement for the facility.

Another important aspect of daily operations that is frequently overlooked or inadequately addressed by administration is the use of overtime. In the nursing home industry, 75% of cost is labor intensive. The percentage of overtime in any given facility, if kept unchecked, is enormous. Using an accounting firm’s expertise and familiarity with census and staffing, the director of nursing and the scheduling coordinator can learn to relate occupancy to the staffing pattern. For instance, when a unit is functioning at full capacity, an agreed-upon staffing quota would apply. But when a 40-bed unit, which usually functions with five nursing assistants is now only 50% occupied, there would be a conscious shift of staff from that unit. It is true that any facility should be committed to providing full-time employment for full-time employees, as per union contracts. But the work time for part-time employees can be adjusted depending on demand. A very basic part of reducing costs during decreased occupancy would be not to replace sick calls. If these basic concepts are not a part of routine staffing decisions, the facility loses opportunities to reduce its costs and loses opportunities to increase the bottom line.

What is most difficult for an accountant, an administrator, or a director of nursing, is trying to alter a staffing pattern that has existed for years. Just because a 40-bed nursing unit has functioned adequately with two nurses and five or six CNAs for years doesn’t necessarily mean that this is the ideal arrangement. An analysis of the acuity of the patient population can determine more realistically what the unit may need. If staff reduction is a consideration, the staff members should be participants in that conversation. With an accountant at the helm, the CNAs can discuss whether their services may be of better use elsewhere in the building. The inclusion of staff in decisions that directly affect them is an enormously powerful tool for reaching mutually agreeable decisions. An accountant’s explanation and ongoing dialogue with healthcare workers is an ideal way to effect positive change within a facility. Workers and residents alike will reap the benefits of a more sensible staffing system and the profits that come with it.

Optimizing Reimbursement
Yet another powerful role that knowledgeable accounting firms can play is to strategically embrace the entire concept of RUGs III with the rehabilitation director and MDS coordinator. Facilities that have not been guided regarding optimizing reimbursement or have not had the chance to become savvy with the MDS tool invariably give away thousands of dollars because of dates entered a day late or a day too soon. With a nursing department that is aware of increased reimbursement for IV therapy (and other such things) prior to admission, and a rehab department that is aware that placing residents on therapy at the time of admission (and not a day or two later), the resident places into a higher category—which translates into significant revenue for a facility. Administrators should not assume that their rehab department or their nursing departments are aware of all the intricacies of the ominous MDS. A roundtable discussion, replete with informed accountants, pertinent facility staff, and donuts, should take place at least quarterly. The purpose of the meeting would be to familiarize and reacquaint key personnel with tactics and strategies that can be used to legitimately bolster the revenue via RUGs-III methodology. This is not a matter of gaming or manipulating the system, but rather it is about being smart enough to capture, document, and be correctly reimbursed for care that is actually provided.

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