Reg's Blog

Senior and Post-Acute Healthcare News and Topics

National Commodity Report – August 2022

Attached is the most current commodity report for August.

August 4, 2022 Posted by | Uncategorized | | Leave a comment

Ohio Presentation Glitch – Fixed

I was informed that the presentation from LeadingAge Ohio did not download for some. Apologies to anyone inconvenienced by the glitch. The post now contains a PDF of the presentation which, is working and can be downloaded.

Sorry….

August 11, 2021 Posted by | Assisted Living, Policy and Politics - Federal, Senior Housing, Skilled Nursing | Leave a comment

LeadingAge Ohio Presentation

Last week I had the pleasure of speaking/presenting at the LeadingAge Ohio Annual Conference/Meeting in Columbus. It is always a treat to be with these folks and even more so this year – in-person!

Thanks to everyone at LeadingAge Ohio and the session attendees.

You may access/download the presentation at the link below.

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August 10, 2021 Posted by | Assisted Living, Policy and Politics - Federal, Senior Housing, Skilled Nursing | , , , , , , | Leave a comment

Updates

A bunch of folks continuously have asked – where’s your stuff? Well with COVID, engagement time and outlets switched quite a bit. I intend to return to more articles and have lots of stuff in the hopper including a book which, should launch this fall. Speaking engagements are starting to return though some will remain virtual/webcast at least for now. I am looking forward to in-person presentations again in August at LeadingAge Ohio and October for LeadingAge Annual Conference.

In the meantime, anyone wishing to catch-up on a few of the things I have been engaged-in can catch my recent podcasts at https://postacuteadvisor.blr.com/tag/reg-hislop/

I’ll try to drop in a recent presentation as well over the next few days and then a couple of articles I have been working on related to SNF and sector recovery/rebounds now that COVID is abating.

June 10, 2021 Posted by | Uncategorized | , , | 1 Comment

PDPM: First Blush Analysis

One quarter (three months and change) down and PDPM appears to be mostly positive for SNFs.  CMS is reporting a higher average per diem payment level than under RUGs.  Despite some added coding complexity, paperwork burdens are down for providers (two MDS’ during most stays now vs. many under RUGs).  Anecdotally, the industry is seeing added access for certain patient types that previously, were difficult SNF placements.  The NTA category is the driver of this additional access as payments help offset, higher clinical costs associated with certain patient needs and comorbidities.  Approximately 2/3rds of facilities have experienced rate increases (67%); 23% experiencing decreases.  Where rate erosion has occurred is in facilities that were heavily skewed under RUGs to RU and RH level therapy payments – 75% or more utilization.  Conversely and logically, the winners have been facilities with a much more balanced book of business; a normative or typical RUG distribution (historically) and a patient/referral base that included more clinical complexity.  Studies that initially showed a 90% plus increase in Medicare per diem rates in October erroneously ignored the initial conversion bounce (NTA pick-up) that came into play for residents in a facility under RUGs on 9/30 that carried-over into PDPM on 10/1.  Suffice to say, the playing field has leveled.

Originally, CMS estimated that PDPM would be budget-neutral with a modest or slight bias toward rates being flat or down just a touch at the facility level.  The projection from CMS using 2017 data was for a 1.37% decrease.  November’s data/results ran 5.7% above the CMS projection.  While CMS has provided no immediate reaction to the “better than expected” trend for providers, the reality is that an adjustment of some form is likely.  MedPac has called for no rate increases for SNFs in FY21.  It is possible that a flat-rate scenario will emerge for at least a few years IF, rate pullbacks aren’t part of the immediate solution.

While fee-for-service rates under PDPM offer encouragement for providers, the overall occupancy trend and payer-mix is a sobering element.  Since 2010, overall fee-for-service utilization is down by 17.7%.  Length of stay for the same period also declined by 7.4% (covered days).

Three factors are heavily influencing the fee-for-service utilization and length of stay trends.  First, Medicare Advantage is a growing payer type (covered lives).  MA plans simply account for shorter stays at reduced rates where SNF care is required.  Second, home health agencies have filled the bill for certain care needs, circumventing altogether, an SNF stay.  It is not uncommon for a routine knee-replacement patient with stable comorbidities to transition home with a home health agency vs. to an SNF or IRF (inpatient rehab facility).   Pneumonias, infections, wounds, etc. can be managed at home; preferable for the patient and often, for the payer.  Third, ACOs and Bundled Payment programs (and MA plans too) work to steer patients to home or outpatient settings either avoiding the SNF entirely or shortening the inpatient stay by a day or series of days.

While the PDPM rate bump may seem good news, and it is, the euphoric feeling is temporary.  Increased revenue is a function of not just rate but utilization.  If utilization continues to remain on a downward path, the dip won’t be offset by rate.  Similarly, utilization patterns are shifting and as of today, I see no progression or shift toward increased SNF utilization.  Frankly, there remains in most markets, too many SNF beds for the functional demand (certainly, for the demand with a good payer source).  Assisted Living models, those adapted to a higher-level chronic care model, continue to erode long-term SNF census.  This erosion causes a two-part dilemma for SNFs. First, fewer patients/residents to occupy beds and second, the remaining patients tend to have Medicaid as a payer source.  For SNFs that can’t play and survive to a large extent in the post-acute realm, alternative options are scarce for long-term resident occupancy (I-SNPs perhaps?).

One last caveat for providers at this juncture, is worth noting.  PDPM rates are up and CMS has yet to begin audits.  I suspect facilities will see some “shock and awe” once these audits begin.  Remember, audits are done by intermediaries and contractors – not by CMS directly.  I have seen some claim funk as facilities have strutted their way to some higher payments by additional speech utilization – utilization that wasn’t there under RUGs.  I’m watching facilities aggressively pursue cognition via Speech Therapy engagement; seeking to score residents at certain times of the day where cognition may be lower (later day, after a nap, etc.).  A note of warning here is warranted.  Coding opportunities are available under PDPM and IF, such an opportunity correlates to a higher payment, that’s great PROVIDED that, the care delivered and documented, supports the coding.  I am already seeing residents coded at one level of cognition, Speech being used for “cognitive training” and nursing documentation stating that the resident is, “alert and oriented x 3”.  Which is it as it can’t be both?  The proper approach is to evaluate the overall needs of the resident and develop a careplan with the whole team that reflects this holistic assessment.  The key then going forward, is for all disciplines to appropriately document the care provided, consistent with the careplan.

 

 

 

 

 

February 10, 2020 Posted by | Skilled Nursing | , , , , , , , , , , , | 2 Comments

BLR Media Forum in Phoenix

Last week I, I had the pleasure of speaking at the BLR Forum in Phoenix (Nov. 18 – 19).  My sessions were in the Post-Acute Forum. It was an honor to connect with the group and I truly enjoyed the various conversations, questions, etc.  My thanks to everyone that attended!

Attached is the Specializing Your SNF presentation.

Specializing your SNF

The second presentation regarding working with your staff and a series of associated tools for download can be found at this link: https://wp.me/ptUlY-ql

Happy Thanksgiving to everyone and I hope to see you all again at another BLR event!

November 26, 2019 Posted by | Uncategorized | , , , , , , , , , , , , , , , , , | Leave a comment

Revenue Integrity Symposium – Orlando

Last week Tuesday ( the 15th ) I was honored to speak at the Revenue Integrity Symposium in Orlando.  The presentations (slide decks) are attached as well as the referenced tools from the sessions.

It was my pleasure to be with the group at RIS and I look forward to (hopefully) connecting with you all again next year.  As always, questions on any of the materials on this post, please reach out to me via a comment here or the contact information provided on the Author page on this site.

RIS19_day1-9_trk4-2-Hislop

_prsRIS19_day1-18_trk4-4-Hislop_prs

ELOS (length of stay tool)

ELOS Orthopedic (length of stay tool)

QAPI Indicator Summary – blank  (QAPI dashboard)

 

 

October 22, 2019 Posted by | Uncategorized | Leave a comment

Wisconsin Directors of Nursing Fall Conference

Last Friday, I was honored to speak at the Wisconsin Directors of Nursing Fall Conference.  The crowd was great and I had a lot of fun talking with the hardest working professionals in health care.  As promised to them, I have attached the presentation to this post and a bunch of tools and references that everyone can use.  All links (except the books) are free!

Thanks again to everyone that attended.  Questions?  Feel free to reach out to me at hislop3@msn.com!  Looking forward to seeing you all again in the near future!

WI DON Council Presentation

QAPI Indicator Summary – blank

ELOS

PRE SURVEY OBSERVATIONS WALKING ROUNDS

QUALITY ASSURANCE- HOSPITALIZATIONS

Tuck in Program

CVA pathway

ANALYSIS OF UNPLANNED HOSPITAL TRANSFERS -blank

Admission Audit

5 day post discharge

30 Day Post Discharge Questionnaire

3-RoP-Checklist-overview-FINAL.101416

http://hcmarketplace.com/survey-success-for-long-term-care (book with great survey tools)

http://hcmarketplace.com/preventing-uti-in-ltc  (tools, etc. all pertaining to UTIs)

September 25, 2019 Posted by | Uncategorized | , , , , , , , , | Leave a comment

LeadingAge Ohio Annual Conference

Thanks to everyone that attended my session – Data Driven Organizational Improvement.  As promised, the presentation is available here (first link) as well as a bunch of tools that are free to download.  Any questions? Please feel free to drop me a comment on this site or email me at hislop3@msn.com.  Thanks again Ohio!  Hope to see you all again in San Diego!

Data Driven Org. Improvement

ELOS Orthopedic

ELOS

PRE SURVEY OBSERVATIONS WALKING ROUNDS

QUALITY ASSURANCE- HOSPITALIZATIONS

Tuck in Program

CVA pathway

CLINICAL REVIEW

ANALYSIS OF UNPLANNED HOSPITAL TRANSFERS -blank

Admission Audit

5 day post discharge

30 Day Post Discharge Questionnaire

QAPI Indicator Summary – blank

September 4, 2019 Posted by | Uncategorized | , , , , , , , | Leave a comment

SNFs: Five Issues and Trends to Watch…NOW!

The beautiful, fascinating thing about health policy in the U.S. is its cycle of evolution.  It evolves, sometimes slowly and other times quickly but always, in a progressive (not in the political sense) direction.  Providers today can be lulled to sleep (quickly) by the vacuum drone of big policy lectures, webinars, etc., easily thinking for example, PDPM is the two-ton gorilla in the room (we need to deal with).  Perhaps because reimbursement and survey/certification issues are so large that they shadow, seemingly eclipse, other trends and issues.  Yet, think of these other trends and issues like mosquitoes (the state “summer” bird in Wisconsin where I am from); omnipresent, annoying, nipping, but not large enough to cause much damage.  Still, mosquito bites can be a real nuisance and in rare cases, rather debilitating.

None of the following trends/issues weigh-out like PDPM but each has a potential impact for the post-acute sector, namely SNFs.

  1. QRP and VBP: Both can, with poor performance or lackadaisical compliance, reduce Medicare reimbursement.  Today, 73% of the SNFs are feeling some kind of Medicare reimbursement reduction due to VBP performance (lack thereof) in terms of readmissions.  Come October 1, the penalty for non-QRP reporting at a certain threshold kicks-in with a penalty/reduction equal to 2% of Medicare payments  Combine the two and the reduction can mount to 4% of Medicare payments (fee-for-service) to an SNF.
  2. Medicare Advantage and Readmissions: Tying one to the other for VBP is an interesting proposition.  Here’s how this works.  While VBP only positively or negatively impacts fee-for-service Medicare payments, the Medicare Advantage impact that the SNF market is seeing with respect to readmission rates, encompasses Medicare Advantage patients.  Convoluted, I know.  In short-hand: All Medicare patient days count toward the readmission (avoidable) calculation, fee-for-service and/or Advantage.  Based on a recent study published in the Annals of Internal Medicine, Medicare Advantage patients have a higher  readmission experience than their fee-for-service counterparts.  To be clear, the readmission contrast was for patient diagnostic categories of acute myocardial infarction, congestive heart failure and pneumonia. Still, the issue here is that facilities with a high percentage of Medicare Advantage patients need to be aggressive with these payers in terms of care coordination; particularly as the same intersects with length of stay.  Medicare Advantage plans often look to aggressively shorten lengths of stay, perhaps too aggressively.  Similarly, their networks may not coordinate post-inpatient care via home health agencies as well as one would expect.  They simply don’t have the best agencies in network or they don’t work to consistently integrate the post-acute providers in collaborative coordination efforts.
  3. More SNF VBP?: In a bill recently proposed in the House (bipartisan sponsors) known as the BETTER Act (Beneficiary Education Tools Tele-health Extender Reauthorization), Section 204 includes direction to the Secretary to adopt additional performance measures for reimbursement purposes beginning on or after, October 2021.  The language implies the categories (“additional measures determined appropriate”) to include functional status, patient safety, care coordination and/or patient experience.  As I have written before: Quality and revenue are directly connected today and more is coming.  SNFs better be “on” their Quality Measures and laser-focused on their outcomes or suffer the reimbursement (reduction) consequences.
  4. Quality Measures: Any SNF that hasn’t looked for a while at their Five Start report and specifically, their Quality Measures section is literally, asleep at the wheel.  The numbers now are broken down between long-stay and short-stay measures, with applicable detail.  It isn’t the aggregate rating any more that matters. The reality is the categorical ratings matter most and for SNFs hoping to play “big” in the post-acute arena, the short-stay ratings are KEY.  Today, referral networks are reshaping how and where patients go, post-hospitalization.  Not a day goes by that I don’t hear from hospital and health system folks about their current reviews of SNF QMs, and in particular, the short-stay measure performance.  In a recent discussion with a convener for a Bundled Payment project, she relayed how one SNF was beside itself when she said basically, “no inclusion in their preferred network”.  The SNF was unaware that their short-stay QM rating was only two stars.  The convener was only interested in SNFs with short-stay measures rating four and five stars.
  5. Phase 3 Conditions of Participation Requirements: Though not as impactful as Phase 2 requirements, there are a few here that could bite facilities surveyed post November 28 of this year.  The inspection star ratings are unfrozen now so survey performance  will impact star ratings again…no hiatus.  The biggies?  Infection control with a designated, trained preventionist is required.  Remember, infection control citations tend to be widespread in scope. A compliance and ethics program is required after November 28.  Staff need to be trained on the program and infection control.  The facility assessment is required to tie with the facility’s QAPI program. The facility must develop a person-centered, baseline care plan within 48 hours of admission. With respect to dietary/food service, the facility must designate a director of food service who will have training/certification as a certified dietary manager, certified food service manager, a dietitian, or some other equivalent certification and training in food service management or hospitality from an accredited institution.  A good resource that covers all Phase 3 requirements (as well as Phases 1 and 2) is available (download) here: 3-RoP-Checklist-overview-FINAL.101416

June 26, 2019 Posted by | Uncategorized | , , , , , , , , , | Leave a comment