The demand for high-value senior care
The recent political transitions are making for many unknowns and insecurities in healthcare’s future. With the fate of the Affordable Care Act (ACA) and other long-term care quality initiatives hanging in the balance, providers are left questioning whether all the requirements they’ve been working so diligently to fulfill are here to stay. Rest assured, no matter which way the ACA and other contentious healthcare policies fall, payers have seen providers improve quality and efficiencies, and they won’t settle for less anymore. The focus on high-value, cost-effective healthcare accompanied by alternative payment models is here to stay, and staying ahead of the curve will be vital for providers’ success.
Although the ACA drives quality-focused oversight programs, the law’s passage in 2010 was certainly not the first time quality initiatives were embraced. CMS implemented Nursing Home Compare in 1998, and in 2008 added the Five-Star Quality Rating System. Nursing Home Compare publicly shares each nursing home’s last three annual surveys, survey complaint investigation activities, 16 out of the 24 Quality Measures counted in Five-Star rating calculations and the facility’s Five-Star ratings. Five-Star rating calculations are based on health inspection findings, staffing levels and Quality Measures. These public reporting initiatives focus on quality of care to enable consumers, payers and referral sources to make assumptions about the value of care provided in a specific facility and about whether or not to choose the facility.
The Improving Medicare Post-Acute Care Transformation (IMPACT) Act, passed in 2014, requires the reporting of standardized patient-assessment data from post-acute care facilities to help improve communication among the various care providers, improving resident outcomes. Programs like IMPACT and the additional programs derived from them, like the SNF Quality Reporting Program (QRP), have driven the lion’s share of reporting requirements for facilities over the past two decades. Over the same period, payers have been progressively linking more and more payments to positive outcome measures, a trend that will continue into the future.
Nurse leaders can take proactive steps to help their organizations provide the highest quality of care on a day-to-day basis and stand out as a high-value care partner.
Review patient procedures with quality in mind.
Not only should patient procedures be kept up to date and relevant, but their impact on the quality of care and their cost effectiveness also should be evaluated. For example, facility leaders might choose to save money by using a lower-cost wound dressing such as gauze throughout the facility. Gauze initially costs less than foam dressings, but the gauze may require daily changes, whereas a foam dressing can be left in place for three or more days, requiring less staff time. Furthermore, the foam dressing keeps the wound at an optimum temperature to promote healing, requiring less nursing time and ultimately costing the facility less money and improving resident outcomes. Nurse leaders should keep the bigger picture in mind when considering how facility protocols can offer higher value and improve resident outcomes.
Train staff to prevent missing information and avoid frustration.
What happens when your facility receives an admission with no documentation about the new resident’s influenza or pneumococcal vaccine status? Your team asks the resident and the family, but the resident doesn’t remember and the family doesn’t know. If it’s really difficult to get documentation in a situation like this, staff may be more likely to give up quickly. Similarly, what happens if a resident arrives with a Stage 2 pressure ulcer that was previously a Stage 3 or 4 but without documentation indicating this? If the pressure ulcer returns to a Stage 4, but your team has already coded a Stage 2, your facility reports will show worsening of a pressure ulcer, negatively impacting Quality Measures. Staff should be trained on the vital importance of collecting all the proper information and supporting documentation (including from the hospital) to ensure that these data points are included in the resident record.
Identify and mitigate patient-centered risk as quickly as possible.
As of November 28, 2017, CMS will require the implementation of a baseline care plan within 48 hours, which should be used to identify an effective person-centered care upon admission, based on professional standards of quality care. Using this care plan to monitor immediately for potential risks specific to the resident will support early identification of problems and person-centered interventions that can reduce emergency room visits and re-hospitalizations. For example, while assessing for a pressure ulcer risk, if the resident shows a risk for nutrition but no other areas (i.e., activity, mobility, sensory perception, moisture, friction, or shearing), you will want to address the nutrition aspect by ensuring the resident has adequate caloric, fluid and protein intake.
Stay on top of vaccinations.
Showcase your prevention skills through influenza and pneumococcal vaccination Quality Measures. Make sure that you are on top of vaccination schedules and are administering immunizations appropriately in accordance with a policy that follows the Centers for Disease Control and Prevention guidelines, and ensure that vaccinations are accurately captured on MDS assessments.
Review current prevention programs.
Review prevention programs for pressure ulcers, falls and infections to ensure that the interventions are evidence-based and meet the current standards of practice. Beginning November 28, 2017, facility leaders also will be required to establish antibiotic stewardship programs to ensure that antibiotic usage protocols and a system for monitoring use are in place.
Pay special attention to medication reconciliation during transitions of care.
Establish a process for reconciling medications during transitions of care (movement of the patient from one setting to another). Medication reconciliation is the process of establishing the most accurate list of medications that the patient is taking and includes the name, dose, frequency and route. The list is created by comparing the medical record to an external list of medications obtained from the resident, the hospital or another provider. This helps identify unintentional changes in medications that can lead to adverse drug events.
Ensure strong staff communication.
The impact of strong communication across all shifts and care teams on the patient outcomes cannot be overstated. CMS has made communication a required training element for direct care staff beginning November 28, 2019, but providers shouldn’t wait until then. Be sure that effective communication strategies are in place, especially for resident changes. One of the biggest communication issues facing staff members arises when a resident has a change in status. For example, two first-shift nurses might notice the change and share it with a second-shift nurse, but it never gets relayed to the CNA providing care. The CNA can provide a wealth of information about subtle changes in the resident’s behavior that can be key to understanding the root cause of the change.
The changes in long-term care and long-term care payment that have taken place over the past two decades have led payers to proactively seek provider partners who offer high quality, high value care—now measured in more ways than one, as anyone in reimbursement knows. And, more than ever, families are carefully seeking providers that can meet their loved ones’ needs and exceed expectations of care. Creating an environment in your facility that embraces and sustains high quality care won’t happen overnight, but instead, one step at a time.
Amy Stewart, RN, DNS-MT, RAC-MT, QCP-MT, is Curriculum Development Specialist at the American Association of Directors of Nursing Services.
Topics: Articles , Clinical , Infection control , Leadership