Overcoming Chaos in Your Nursing Home

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We are talking about chaos this week. Unfortunately, there is chaos on every level in most skilled nursing organizations.

Can you talk a little bit about the chaos in nursing homes today?

1. The primary issue we are dealing with now is changes in the regulation. They have caused infrastructure, policy and procedural changes in the facility. My opinion, which is shared by many of my peers, there comes a time when the quantity of regulations begins to take precious time away from the direct care to patients and/or residents. Paperwork, while necessary, pulls people into offices rather than being on the floor. The volume of change that came with the Requirements of Participation was difficult to process for most providers while still maintaining high levels of quality care.
2. In addition to the changes in regulation, the acuity level of the patients has gone up significantly. There seems to be a separation in that increase in acuity and funding. I don’t like to talk about funding as part of the clinical side, but it’s just a reality.
We are seeing penalties and take backs attached to our rates. In October of this year, 2% will be taken from SNF rates. It can potentially be earned back with high performance in lowering re-hospitalization rates. However, most facilities will never see the full 2% rate. It is, in essence, a cut to the SNF rate for most providers. With acuity higher than ever before, those dollars are valuable for staff training and equipment. It appears that the Quality Reporting Program is set to do the same things. Right now, penalties are based on completeness of the MDS, but it is taking the familiar framework of a penalty-based system.

In addition to the changes in regulation, the acuity level of the patients has gone up significantly. There seems to be a separation in that increase in acuity and funding.

3. Despite these concerns, the largest point of chaos facing SNFs is the labor force. It is becoming harder and harder to find qualified staff. The market is incredibly competitive for caregivers. We are all continually thankful for compassionate and nurturing people that are committed to caring for people no matter what the market looks like.
4. CMS is getting ready to potentially change the SNF payment structure to be based on patient characteristics. This will be a departure from our current therapy based system. The Resident Classification System 1, which is the new nomenclature for the system, will require more training and the adjustment of software systems to administrate.

5. Then, there is the mental health side of this. Hospitals and outpatient clinics are continually reaching out to SNFs to be able to manage mental health patients. There is a significant gap in treatment options and SNFs are trying desperately to do their part in the community. This requires more education of staff and tighter relationships with hospitals and community based resources as well as psychiatric clinicians.

6. We cannot forget the new survey system. It is a hybrid between the older traditional system and the most recent Quality Indicator Survey. It is giving more freedom to surveyors to interact with both residents and the important people in their sphere of care. Survey is necessary and everyone understands that. However, it is deeply tied to the Five-Star Quality Rating System and can significantly impact a facility’s score. The Five-Star Quality Rating System mandates that only 10% of the facilities in the state are permitted to have a 5-star rating in the health component. At the same time, 20% are mandated to receive a 1-star rating. Providers have a hard time believing in a system that does not provide every facility with the capability to succeed. Simply stated, it feels punitive. If you have one questionable survey cycle out of 3 and end up with a 1 or 2 star, it can be extremely detrimental. The community understands the need for a 5-star rating system, but I would say most do not grasp that only 10% are allowed to have a 5-star rating.

“The community understands a 5-star rating system, but I would say most do not grasp that only 10% are allowed to have a 5-star rating.”

7. Part B Caps – This issue is unfortunately attached to budget items at the Federal level. The Part B therapy cap exception review sun-setted on December 31, 2017. This was a very necessary process to provide therapy support to those that need resources to improve their quality of life. Currently, therapy services are capped at a very low level. If they are exceeded the financial responsibility will fall upon secondary payers. In many cases, this is the resident.

SNFs are in the classic scenario of trying to do more with less. There seems to be a disconnect between funding and expectations. I believe the people involved in shaping the health care systems in this country genuinely try to do so with a heart full of good intentions. However, the list of unintended consequences resulting from those good intentions is becoming difficult to manage.

When asked if chaos is the result, it seems reasonable in the current environment that chaos has become the status quo.

What are the top 3 actionable items that skilled nursing organizations can do to reduce their chaos in 2018?

1. Survey preparedness
2. Building strong relationships with hospitals and primary referral sources
3. Staff development

In my view, these three items are the keys to rising above the chaos.

-Shane Craycraft
Shane Craycraft has worked in the skilled Nursing profession for more than 20 years. His career began in 1995 as a Registered Nurse. While he maintains that license, Shane transitioned to the Administration side in 2002 and became a Licensed Nursing Home Administrator. He currently is the Director of Clinical Operations for the Health Care Management Group, a multi-facility organization based in Cincinnati, OH.

Shane has been active with the Ohio Health Care Association for many years. He has served in many capacities and is currently on the Board of Directors. He has also been active with the American Health Care Association and is currently on the AHCA Quality Improvement Committee.

To read more about the Health Care Management Group, click here.