Pastoral Care and Risk Management
In 2001, the Association for Professional Chaplains honored me with their Distinguished Service Award for my work in expanding the impact of professional chaplaincy and programs of pastoral care/ ministry in specialized healthcare settings. This was (and remains for me) a huge honor. Yet, since that time, a little over twenty years ago, programs of pastoral care, Clinical Pastoral Education, and chaplaincy are struggling for a concrete place in healthcare. Sadly, instead of watching these programs expand, I’ve seen contraction. Even more sad, I’ve watched geometric increases in management positions in risk management, etc., often while chaplaincy positions were eliminated.
Entering the “way back machine”, the core of my work which was recognized by the Association of Professional Chaplains, was that chaplaincy and programs of pastoral care make good business sense. The clear revenue picture isn’t present – I get it. The payback however, expressed as ROI via reduced risk, reduced litigation, improved employee retention, and patient satisfaction is enormous. One needs to however, understand and live, the work of chaplains in a healthcare setting to understand how the benefits are manifested.
I have literally sat in exceptionally contentious family meetings, dealing with issues of death and dying, where years of anger, hostility, sometimes abuse, come forward. The patient gets lost. Staff get frustrated and no common ground appears visible. In this midst, a professionally trained chaplain enters and when introduced, the dialogue begins to change. The issues remain but in short order, a sense of calm and a sense of order begins to emanate. The anger drops as the chaplain listens differently, redirects conversations, asks probative questions, and turns the focus to core beliefs and values. Ultimately, almost all important, life altering decisions have as their basis, a person’s core beliefs and values. Even for folk not identifiably religious or denominationally, spiritual tradition faithful, a series of beliefs and values can be found and from there, a decision framework can be built.
What we know about litigation risks, patient and staff, is that the desire to litigate is often born in a search for an answer. Something less desirable happened or questions posed, were not answered or the answers were obtuse. Healthcare of course, is not an exact science and bad things happen for no particular reason, even with adequate protections in place. For example, and I know this one well as my firm via my wife’s practice, handles complex litigation matters for defense counsel; old people fall. Save physical restraints, prohibited by law, old people will fall and sustain injury, sometimes that same leading to death or being associated with death. Falls beget lots of litigation in post-acute care yet, when the organization is heavily invested in pastoral care and the approach of the care team is “transdisciplinary” and the care coordinated, litigation risk can be minimized. I know, I’ve seen it in action.
Healthcare phraseology loves the words, multi-disciplinary or interdisciplinary. Pastoral care and care coordination done right (see yesterday’s post on care coordination here: https://wp.me/ptUlY-xO) is transdisciplinary. Transdisciplinary process and teams occur when roles are shared beyond traditional boundaries (removing the silo effect) and people collaborate among themselves beyond their specific discipline and restrictions. The patient becomes the center and his/her values and beliefs are the focal point for decisions and plans. Incorporating the patient’s key stakeholders into this process is where pastoral care has power and risks are reduced. Bad outcomes, if they occur, are no longer viewed as something to litigate as all along, the patient had clear value, the team was collaborating in the patient’s best interest, familial stakeholders were present, and the need to find flaw and extract some sort of retribution, diminished. Is it a perfect process? Of course not. Is it a process that better handles the ambiguities and the imperfections of healthcare outcomes, especially among the oldest with comorbidities and fragility? I believe it is and again, I’ve seen it work.
Among the defined dimensions of human care, spiritual care is a specific dimension. Providers need to address the physical, the emotional, the psychological, the social, and the spiritual dimension of human existence if care is to be complete. Staff have the same needs in many regards. As direct witness to suffering, grief and loss, the meaning of their work is often only reconciled spiritually. Their own feelings manifest in the milieu with the patient, the family and each other and they too, require care. An excellent White Paper, funded by Bristol-Myers Squibb covers the role of Chaplaincy in healthcare. Its link is here: https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=6a559606ee9814ea4e9b6a39f677ad9114dd7386
The role pastoral care plays in risk management is evident in literature as well but, the words risk management specifically, are not always present. Managing risk is about reducing negative outcomes or for patients and staff, dissatisfaction with what has occurred or is occurring. For example, in the journal Supportive Care in Cancer, an article titled, “Unmet spiritual needs impact emotional and spiritual well-being in advanced cancer patients”, the authors noted: When spiritual needs are not met, patients are at risk of depression and reduced sense of spiritual meaning and peace. Spiritual care should be matched to cancer patients’ needs. The risk management that is evident is the reduction of depression and an increase in a sense of peace. Reductions in frustration, sense of loss, anger, etc., all are reductions in risk and without question, lessened frustration begets better outcomes for patients and their loved ones and lower levels of litigation risk.
May 11 and PHE: Provider Alert
On May 11, the COVID Public Health Emergency (PHE) is set to end and along with it, a whole slew of requirements end or change, and regulatory waivers applicable to the Public Health Emergency, the same (ending). The end of the PHE will have positive and negative impacts on providers of all types though some things that were applicable during the PHE will continue via CMS rulemaking (tele-health provisions for example). One of the most negative impacts of regulatory waivers ending is the return of the three-overnight rule (3 day stay) for patients entering an SNF and potentially, receiving Medicare coverage for their qualifying stay. I wrote a post on this waiver change here: https://wp.me/ptUlY-w5
Among the most notable changes that will occur for providers with the end of the PHE are the requirements around masking, testing, and vaccination mandates for staff. Each of these conditions are effectively, eliminated with the expiration of the PHE. While other countries across the world have eliminated all or most of their pandemic restrictions/requirements over the past year, the U.S. and its health system have been slow to relax requirements with the Biden Administration extending the emergency up until May 11. Similarly, the emergency patchwork has followed through to states, some long ago abandoning masking requirements, vaccination mandates, testing, etc. What has been confounding is the myriad of rule interpretations and requirements that varied from municipalities to counties, to states, and ultimately, to the Federal government. For Medicare/Medicaid providers, Federal requirements superseded all other provisions in any other jurisdiction.
Within the Public Health Emergency period, even providers not participating in Medicare or Medicaid were impacted by the Federal policies. Many states chose to follow the Federal PHE provisions, layering the same over providers within the senior housing industry (aka Assisted Living and some CCRC/Independent Living under state law). Illinois is an example. In contrast, other states chose to ignore the Federal PHE provisions when not applicable to providers such as hospitals, nursing homes, home health, etc. Iowa, Florida, Texas are examples of states that early-on in the pandemic created rules or as in the case of Iowa, passed legislation prohibiting vaccine or mask mandates within state control.
Come May 11, confusion will no doubt remain prominent on COVID infection control/public health requirements. For example, the only updated CDC guidance on masking requirements dates back to September of 2022. In this guidance, the recommendation for masking requirements for visitors, patients, and staff is conditioned on a CDC tracking mechanism for the level of community concentration of COVID infection. Reporting from health departments, hospitals, SNFs, etc., fed this mechanism. Masking recommendations were tied to this level (high recommending masking vs. low, recommending optional masking). COVID testing requirements were also tied to this measure.
Effective with the end of the PHE, CDC has indicated that it would no longer report on the level of community infection/transmission. The PHE has deferred consistently to various agency recommendations for requirements and then subsequently, enforcement as needed. Clearly, we will see extensive confusion unless the CDC issues new guidance clearing up, the masking requirements tied to community COVID prevalence. I’ve watched many providers already move to a “no mask required” status, regardless of updated guidance. I’ve also watched many providers stuck and confused by virtue of state requirements vs. CDC requirements vs. where the community COVID prevalence really was in their area. The CDC guidance for long-term care (fundamentally the same for hospitals) is here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-home-long-term-care.html
I’ve seen some news coverage/reporting on the end of the Public Health Emergency, but it is very spotty. I also know by virtue of travel, etc., the awareness of COVID among providers and the community is varied. As I routinely traverse Illinois, Wisconsin, and Iowa, I see wide differences in COVID precautions, alerts, monitoring, requirements being applied, etc. Some of this due to region and state policy and some of it is due to provider behavior. Iowa as I mentioned, long ago took a stance against most PHE COVID related mandates and recommendations whereas Illinois, has followed the PHE Federal recommendations consistently. Iowa hospitals required to follow CMS COVID regulations, maintained vaccination and masking conditions though recently, I have seen most hospitals end masking requirements.
For providers, May 11 is very near. I suggest providers adopt the following strategies realizing, come May 11, regulatory confusion will likely remain.
- Update internal infection control policies regarding vaccination, testing, masking to conform to the changes that will occur with the end of the PHE.
- Communicate these changes to staff ASAP.
- Communicate these changes to patients and families, ASAP. Remember, the end of a mandate does not mean a change in behavior. It may be that staff will want to maintain their masks in some cases and patients/families the same. Allow for flexibility.
- State agencies that are required to survey and enforce compliance may also be slow to adopt. Trade associations are your best bet to help with regulatory transition. Recognize, state agency behavior will not adjust in some cases, as quickly as provider behavior.
- Conduct ongoing public communication via your website, via newsletters, etc. One and done won’t work.
- Definitely, DON’T, follow a path of resisting the end of the PHE and its requirements. I’ve watched provider sometimes, fail to adjust and in this failure, more problems occurred. I know the old “an ounce of prevention” thinking may still apply when it comes to vaccines or masking but be careful. If the regulation is not there, a forced or strongly urged condition, can lead to regulatory problems, labor law problems, community relations problems, and potentially, litigation.
Medicare Advantage/Part D Final Rule
Early in April, CMS released the 2024 Medicare Advantage/Part D Final Rule and within, there are a number of interesting policy shifts that could benefit providers. The rule addresses a common practice that has been frankly, often abused by Med Advantage plans – prior authorizations or more commonly known as, “prior auths”. The crux is authorization provisions created delays in care and sometimes, denials for services that the patient and/or his/her physician believes are medically necessary. The SNF industry has most often been on the denial side of prior authorization requirements, either for the whole stay (initial transfer) or for a requested longer stay. The fact sheet for the final rule is here: https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
With respect to prior authorizations, the rule seeks to make their use more connected to national coverage determinations (NCDs) and local coverage determinations (LCD), common to traditional Medicare. Back in April of 2022, the HHS Inspector General issued a report that included findings of Med Advantage plans use of authorization provisions to issue fairly widespread denials for various care and services. The denials either bar access to care for the patient or in some cases, deny payment to the provider for care and services rendered, subsequently determined by the Med Advantage plan to be “not medically necessary”.
The study noted that the Med Advantage plans were using medical criteria more restrictive than criteria under traditional Medicare (the national or local coverage determinations). Among cases reviewed, 13% of the Med Advantage denials were for care or services that would be covered under traditional Medicare. Other denials were technical in nature whereby the Med Advantage plan denied an authorization as insufficient in documentation yet, the patient medical record contained sufficient documentation of the medical need. In the cases of payment denials, while the payment requests were proper in terms of meeting Medicare criteria, the denials that did occur were due to processing or human claim review error. At a rate of 18%, this is a bit alarming as Medicare fee-for-service claims, properly billed, don’t have such an error rate. The OIG report is here: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp
Another target within the rule with respect to Medicare Advantage plans has to do with marketing practices. The plans have become popular such that today, 45 % of all Medicare beneficiaries are enrolled in Med Advantage plans. Medicare anticipates this number to rise to 50% by 2025. Apparently, those annoying generic television ads promoting various Medicare Advantage plan features, some featuring celebrities like JJ Walker and Joe Namath, have gotten notice in Washington. No longer will that style of ad be permitted instead, requiring a specific plan to be identified and each ad, to eliminate images and language that is confusing or misleading (not sure how that will be monitored).
Another change or improvement relates to behavioral health access and coverage criteria. CMS is finalizing a new set of rules requiring Medicare Advantage plans to: “(1) add Clinical Psychologists and Licensed Clinical Social Workers as specialty types for which we set network standards, and make these types eligible for the 10-percentage point telehealth credit; (2) amend general access to services standards to include explicitly behavioral health services; (3) codify standards for appointment wait times for primary care and behavioral health services; (4) clarify that emergency behavioral health services must not be subject to prior authorization; (5) require that MA organizations notify enrollees when the enrollee’s behavioral health or primary care provider(s) are dropped midyear from networks; and (6) require MA organizations to establish care coordination programs, including coordination of community, social, and behavioral health services to help move towards parity between behavioral health and physical health services and advance whole-person care.”
I’m encouraging providers to read the rule’s fact sheet. Medicare Advantage providers will not simply or quickly, make wholesale adjustments to their existing practices because of this rule. Additionally, providers should always be aware of National and Local Coverage Determinations and use the same, as a “road map” for dealing with Med Advantage coverage and authorization issues. Providers will need to push the plans to make proper adjustments accordingly and to protect and advocate, for their patients. It will take time for the Med Advantage industry to adjust but, movement will happen quicker if providers hold the plans accountable.
Top 5 Staff Retention Tips for a Tough Labor Market
Recently, I wrote a post on recruitment in a tough labor market. Suffice to say, I have not in my three decades plus career, seen a tougher labor market for clinical staff (all staff in many regards). COVID had a lot to do with the shifting supply of labor, but I’ll offer that health policies and economic policies during the prime pandemic period and since, had far more to do with where staff went – and clearly, stayed. Societal and government responses to COVID are in my opinion, primarily to blame for the largest impact on staff disengagement from direct care environments. Dissecting the policy side is a topic for another post on another day. The recruitment strategy post can be found here: https://wp.me/ptUlY-vj
The opposite of recruitment is retention. Arguably, the better an organization does at retaining its employees, the less it needs to invest in recruitment. Healthcare has notoriously been an industry prone to turnover, especially among para and non-professional staff. Back in the day (I sound like a codger), I knew some long-term CNAs, ten to even thirty years in one company (one I was running at the time) and similar for housekeepers, laundry staff and maintenance. I simply don’t see that kind of tenure any longer, save a few of the folk almost at retirement. Once the final generational shift occurs, primarily the folk in my age cohort (aka “Boomers”), new outlooks on longevity in one career and one employer become fully operable. Simply, length of service regardless of retention strategy will be shorter. Long-term may evolve to any service in one place between 5 to 10 years. Outliers will be those working in the same place for ten plus years, without a shift in position or level within the organization (e.g., move to management or some other promotion).
Combatting turnover is a function of understanding why people leave, voluntarily. Some of the primary conditions are symptoms of what is going on in the healthcare industry. For example, hours and workload are often cited as primary drivers yet, providers have (often) little choice but to mandate overtime or have folks work short, covering more patients (or cases) than ideal. There is a bit of a circular (dog chasing his/her tail) phenomenon about workload when overall, open positions exist. Staff get tired of working short or covering for call-offs, etc., and thus, turn over. Problem is perpetuated. A somewhat universal list of the top reasons staff leave is below.
- Supervision: Bad managers/supervisors create turnover.
- Recognition: This is different from reward. This is appreciation or acknowledgement of the work being done within the conditions/environment that it is being done in.
- Schedule/Workload: This involves everything from how much patients/cases are on the shift to when shifts change or rotate to length of shifts to weekends to on-call to overtime mandates, etc. Extra hours can sometimes be absorbed without too much difficulty but too often as of late, extra hours are the norm and staff burnout.
- Limited Promotion/Growth: Healthcare is very layered and often, the jobs stagnate. For example, lateral movement is difficult at a professional level. RNs in one area can’t always jump to another clinical area without additional training or without taking a back-step in schedules, etc. If the view is that the only promotion is to management, a couple of realities need to be considered. First, not all (or even most) clinical staff make good management/supervisory staff. The industry definitely does not need more weak managers. Second, taking good clinicians away from patient care is self-defeating to the organization and to the patient.
- Bureaucracy/Regulation: This I’ll call paper before patients. Healthcare as I often hear, is neither fun nor rewarding in the way it used to be. Too much regulation takes the clinicians who went into the industry away from patient relationships. Staff have tons of work to do and on top, supervisors crab constantly about keeping paperwork up to date (documentation). Meetings and in-services are constant and rarely, of any value (per staff). Don’t forget too, the industry lost untold numbers due to COVID mandates (vaccine, PPE, testing) that created massive burnout and frustration.
In a recent survey of post-acute and senior housing executives conducted by NIC (National Investment Center) only 30% of organizations noted retention of 80% of their new hires longer than a month. A year ago, this number was 46%. When looking out a year, only 7% of organizations retained more than 80% of their new hires for more than a year. I can only think of one word to describe this data – YIKES!
No magic bullets are available to remedy this issue. Turnover has lots of causes and organizations can only do so much. We have a supply problem in the industry and until the supply is increased, by societal value shifts and proper public policy, turnover will continue to be an issue. I do, however, know organizations that have made an impact and with the implementation of certain strategies, performed better in terms of turnover. These strategies comprise my top five tips/recommendations for improving staff retention.
- IMPROVE MANAGEMENT: This is not easy, but it does immediately and over the longer term, bear real results. Staff don’t work for companies; they work for leaders. Hire leaders that have proven track records in building teams and retaining staff. Don’t promote people without a prior, successful training program in management/supervision. Provide ongoing training in management and supervision.
- RELEASE AS MUCH CONTROL AS POSSIBLE OF THE SCHEDULE: Give staff say in what hours they work, when they work, etc. Of course, parameters are required but if any one major gripe can be alleviated, scheduling is a prime complaint. Staff need to be engaged directly and provided opportunity to address their own work /life balance. Team scheduling is awesome as are incentives around team performance in this regard. Likewise, stop thinking about shifts and how many staff per patient. Look at work blocks and patient needs and when duties really need to be done and by whom.
- RESTRUCTURE REWARD AND COMP: To the extent possible, flex everything and create for new staff, a very stepped process of achieving ongoing rewards/increases in pay and certain benefits like time-off, during that first year. Gainshare as much as possible as well. This is not about pay per se but about recognition and engagement. Everything needs to be on the table. Start with the total comp budget and note, “what’s the best way to spend it” – ROI v. wages and benefits. The more staff feel connected such that what they do correlates to a reward, a benefit or recognition to them (individual and team), the more they are likely to stay.
- ALGEBRA/SIMPLIFY: For decades, I have worked with and led organizations in healthcare that simply can’t stop themselves from doing dumb things. Often, the excuse is “regulation”. My answer: B.S. Rarely is all of the paperwork, forms, redundancy, etc., required or if it is, it can be simplified. Healthcare loves paper, regulations, rules, etc. Staff get trapped here and supervisors use bureaucracy like a hammer – a blunt instrument. My advice, deconstruct. Remove as much needless and redundant chores, paper, etc. from staff. Look acutely at who has to do what by when and then, look at how it is currently being done. Improvement is definitely possible. Pay very close attention to how much additional, non-nursing work nurses and nursing staff are doing.
- INJECT FUN INTO WORK: Healthcare is too serious and too bureaucratic. Give staff a chance to create an environment that encourages team, fun, fellowship. This is within the workplace and outside of work as well. The reality is that staff that feel part of something bigger, committed to each other, enjoy being part of a cause, etc., work harder and stay longer at their place of employment. This requires a culture shift for most healthcare organizations and a definite shift in management style.
SNFs: 3 Overnight Stay Requirement Returning
As the Public Health Emergency (COVID) ends, healthcare providers will revisit pre-pandemic policies as a slew of waivers expire. One waiver particularly impactful to hospitals and SNFs is the requirement of a 3 Overnight (3 Day Stay) for a patient to receive Part A Medicare benefits in a SNF. Recall, the rule pre-pandemic was that a person had to be admitted to an acute hospital with a stay of at least 3 overnights in the hospital prior to discharge to a SNF, in order to qualify for Medicare coverage applicable to the SNF stay. One little wrinkle, rarely experienced, is that the discharge could be to another location within a thirty-day window of the patient entering the SNF, and the patient still could qualify for Medicare benefits in the SNF. In other words, the patient could be sent home, and for whatever reason, subsequently enter the SNF within 30 days of the hospital discharge and still be eligible for Medicare SNF benefits.
While there has been support for the waiver of this requirement to remain via a continued policy change from CMS, it is now apparent that CMS will reinstitute the 3 overnight rule. The primary impetus for this? Of course, cost control. A study from the AMA, appearing in the JAMA Internal Medicine publication (released on Monday 4/24) basically provides CMS with its positional defense. The study is here for anyone interested: jamainternal_ulyte_2023_oi_230019_1681999138.05344
The study analyzed MDS data for patients admitted to a SNF between January 2018 and February 2020 (pre-pandemic) compared to admissions between March 2020 and September 2021 (pandemic period). During the pre- pandemic period, there were 130,400 care episodes per month, 59% of which were female. During the pandemic period, there were 108,575 episodes, again 59% were female. Per the study: “All waiver episodes increased from 6% to 32%, and waiver episodes without preceding acute care increased from 3% to 18% (from 4% to 49% among LTC residents). Skilled nursing facility episodes provided for LTC residents increased by 77% (from 15 538 to
27 537 monthly episodes), primarily due to waiver episodes provided for residents with
COVID-19 in 2020 and early 2021 (62% of waiver episodes without preceding acute care).”
What was interesting to me is where the predominant utilization of the waiver for non-prior hospitalized patients occurred. Per the study, the 80% v. 68% of the LTC waivers (non-prior hospitalized) were for-profit facilities. These facilities had lower overall star ratings on average with the for-profit average at 2.7 stars v. the non-profit average rating of 3.2 stars. The same kind of variance was found looking at the staffing star ratings – 2.5 v. 3.0. Skilled admission spending was $2.1 billion prior to the pandemic and $2.0 billion during but a big jump in LTC (Medicare covered) occurred from $301 million to $585 million. Hospital spending remained relatively unchanged, despite lower overall patient volumes (COVID incentive payments making up outlay differences).
Here is the key takeaway from the study:
Key Points
Question: Did skilled nursing facility (SNF) care volume and
characteristics change when the public health emergency (PHE)
waiver for 3-day qualifying hospitalization was introduced in March 2020?
Findings: In this cohort study of SNF care provided for 4 299 863
Medicare fee-for-service beneficiaries from January 2018 to
September 2021, waiver episodes without preceding acute care increased from 3% to 18% during the PHE in 2020 to 2021. Among long-term care residents, such waiver episodes increased from 4%
to 49%, with 62% of episodes provided for residents with COVID-19.
Meaning: This study found that the use of SNF care for long-term
care beneficiaries without a preceding qualifying hospitalization
increased markedly during the PHE, primarily for care for patients with COVID-19.
So SNFs will return to a pre-pandemic point where coverage for SNF skilled services under Medicare will require a 3 overnight hospital stay as the Public Health Emergency ends. The study cites cost as the main driver, but I also believe, that cost on an escalatory basis is more the concern. As the pandemic has ended and hospital volumes are normalizing, we’ve seen SNF referrals increase. I noted this trend in a post on Monday…link is here: https://wp.me/ptUlY-vL What this means is that a shift toward more expensive post-acute care is happening and may be more longer-term in trend than not. In other words, while a bias toward discharge to home health was prevailing pre-pandemic, the factors of reimbursement policy, staffing dynamics, and increasing patient acuity on discharge have moved the needle (so to speak) toward SNF discharge. Staffing is of course, the main driver.
What does this mean for hospitals, if anything? Maybe a bit of shift in consciousness about length of stay, inpatient admission, and discharge planning will occur. The growing use of observation stays vs. inpatient admits was always a sore spot for SNFs and patients and families. I saw lots of confusion a few years ago among SNFs and, then unfortunately families, when a patient arrived for admission and lo and behold, the majority of the stay was classified as observation vs. an inpatient admission, not meeting the 3-day inpatient admission requirement.
Medicare Advantage plans will also need to rethink some approaches in their care coordination. While the preference may be a discharge to home health, admission acceptance is still on the lower side (lots of rejections). it may just require a shift in focus from Med Advantage plans toward better coordinated SNF stays.
For SNFs, the loss will be felt among facilities that were able to “skill” typically, long-term care Medicaid patients. The missing revenue will be felt without a counterbalance pick-up readily available. For good performing SNFs that have focused on building strong value propositions and positioned themselves well for value-based care, options are plentiful, but they had been prior to the pandemic. Staffing remains the challenge. My advice for these folk? Get your care pathways together and your algorithms and be efficient in cost and length of stay. Use your data to drive partnership referral bases with hospitals and in particular, Med Advantage plans. Now is a good time to take advantage of the shifting policy dynamics.
Staffing and Turnover: Medicare Payment Implications?
This morning, I caught some reporting on the Biden Administration’s plan to issue an executive order, a rather large order, that will include several provisions related to jobs and long-term care. Recall in recent articles on staffing on this site, I’ve noted that the Biden Administration and CMS are working on promulgating rules under Medicare for required direct care staffing levels in SNFs and ultimately, tying these levels and turnover to Medicare payment in some regard. This is an off-shoot or addition to other non-staffing related VBP (Value Based Purchasing) elements already in-place or soon to be added. See my post here on the recently released SNF Proposed 2024 rule: https://wp.me/ptUlY-tj
The order is expected to include direction to DHHS (Dept. of Health) to adopt a series of rules that add to minimum/mandatory staffing levels for SNFs (these levels yet unknown) and to condition some elements of Medicare reimbursement to staff turnover at the SNF. The expectation remains that DHHS and CMS release the proposed staffing rule yet this year (some say spring, but I doubt that timing).
Also within the order is a directive to cabinet level agencies (e.g., Interior, Commerce, Energy, Education, etc.) to expand access to long-term care and childcare and, provide financial support to workers for these services. The objective is to improve access to care and support for people such that the same with financial support, will allow caregivers to thus, be employed rather than staying at-home to support childcare or adult care. The rule will also seek to have Medicaid dollars apply to fund an increase in home care workers to support additional seniors and the disabled accessing care under Medicaid.
The devil, as always, will be in the details. I’ll be watching for the final order once it is signed and released. Typically, these kinds of Executive Actions/Orders come with little detail as they are a series of directives to cabinet agencies to develop the rules and apply them going forward. What is clear is that the Biden Administration is heavily invested in creating some kind of staffing mandate for SNFs and tying the same to reimbursement. As I have written before, I’m not sure a mandate in an environment with a caregiver supply problem is going to do anything other than create additional economic hardship for providers that already, can’t obtain enough staff. Similarly, while I know turnover is a problem in the industry, many of the turnover drivers (regulations, aged facilities, inadequate numbers of staff, negative regulatory environment, etc.) are beyond control of the industry.
Friday Feature: Nursing and LTC
Each Friday (hopefully so), I will take a specific topic that has been in the news or been directly posed to me by a colleague or a reader and do a bit of a deep dive feature. This week it’s the future of nursing or more directly, nurses in senior housing and long-term care.
As I’ve discussed in other posts and in presentations I have done, the U.S. post the pandemic has a major nurse shortage – RNs and LPNs. The shortage is most noticeable at the bedside, hospitals and SNFs standing out. This is not to say that home health and hospice are immune from short numbers, but the most acute demand/supply contrast is found in inpatient settings. This shortage creates care problems and access problems. The typical admission/discharge cycles among providers are constantly interrupted such that patients are often stuck in one element or another of a care queue simply because not enough staff are available to provide care. I’ve seen all too many times over the past two years, SNFs not accept discharges, even of their own transfers, simply because staffing is inadequate in number to provide the care required.
To anyone watching prior to the pandemic, the shortage problem has been building. The pandemic exacerbated what was already a modest imbalance (more demand than supply). For various reasons from safety to mandates to burnout, COVID pushed retirement numbers for nurses and/or, created a disengagement from inpatient settings to other settings where nurses could work in a more even-keel environment, less taxing. Clinic settings, schools, software companies, lab companies, insurance companies, etc., all consume nurses, especially RNs. While the wage trade-off may be a few bucks or so per hour, the stability and scale of Monday-Friday, days only even some with full remote work, pulled nurses away from hospitals and SNFs.
The demographics in terms of age illustrate nursing to be an older profession. In other words, the nurses working are more seasoned in years than compared to other professions. Younger people are not entering the profession with the same pace of say, twenty or thirty years ago. Too many other alternative professions exist and the “care” calling just doesn’t appear to be as strong as it once was. I also know too many nurses of parent-age or slightly older that no longer advocate for their children or grandchildren to enter nursing. Being in a family of nurses (my mom, my aunt, my wife, my daughter, etc.), nursing was almost the family profession in some regards and thought highly of as a noble calling and a great career. Here’s a quick snapshot at the demographics, albeit a couple of years old: https://www.ncsbn.org/research/recent-research/workforce.page
A recent report from the National Council of the State Boards of Nursing highlights the negative trend of supply in nursing. The report illustrates a major forward problem in terms of the supply of nurses. According to this report, 100,000 nurses left the workforce during the pandemic. Of a total workforce of 4.5 million nurses, 900,000 are projected to leave the profession by 2027 – four years from now. What’s most concerning is the profession negativity among nurses with less than 10 years of experience. This lack of regard and dissatisfaction with the profession spills over into their cohorts/peer groups, painting nursing as a less than desirable career.
Image and positivity among professionals within any vocation is a key recruitment and retention factor. For a parallel, look at what has happened to police officers and law enforcement. The negativity and disdain for policing that has occurred over the past three years primarily, has driven large numbers of officers away from police work. Concurrently, recruiting new officer candidates has become a major challenge. Nursing is seeing a similar, though not as pronounced, trend. The report and data observation is here: https://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing-workforce-shortages-and-crisis
Digging a bit deeper, I looked specifically at senior living and long-term care. While most other health care sectors have recovered for the most part, hospital and senior living, direct care have continued to struggle. Long-term care bedside nursing has struggled to recover the most, not that it was super staff healthy prior to the pandemic. According to the American Health Care Association (AHCA), an industry trade association, long-term care is 400,000 workers short of demand and the rate is climbing. Per AHCA, 90% of SNFs report being understaffed, 50% severely understaffed, and 98% report hiring is problematic. The result of this staffing crisis is 60% of facilities are reducing census due to lack of staff. A study from the University of California, San Francisco projects that the long-term care/senior living industry will be short 2.5 million workers by 2030. NOTE: CMS and the Biden Administration are proceeding on developing required, mandatory staffing levels in SNFs, in spite of this information. The reference article is here: https://qz.com/no-one-wants-to-work-in-american-nursing-homes-after-co-1849446021
What we can glean from literature, nursing professional organizations, nursing unions, and providers is a rather bleak picture of an industry problem that seems to be getting worse, not better. Fixes will require a whole of industry, profession and government approach. Policy makers are definitely going to have to develop a different mindset regarding the work of nurses in nursing homes and how overbearing regulations and enforcement actions don’t improve patient care but do drive nurses from the industry. Listening and reading, what nurses say about why they won’t work in LTC or are leaving their LTC jobs is summarized below.
- Working conditions – short staffed, short supplies, outdated equipment and environments
- Pay and benefits not par with other nursing jobs
- Turnover, especially management
- Bad management
- Paperwork burden
- Negative surveyors and regulations – focus on paper compliance, not patient care
- Mandatory overtime
- Lack of support systems internally
- Lack of training
- Difficult patients and families – unrealistic about care demands
- Negativity of the industry.
Solutions? My vantage point encompassing thirty plus years in health care and senior living says we nationally, need a two-prong approach. First, we need to ramp supply. Make nursing a cool and rewarding profession and easy and inexpensive or free to become a nurse. Second, obliterate the foolish impediments to job satisfaction for nurses. Reimbursement in LTC is atrociously low and unable to seriously sustain needed environmental updates and improve comp opportunities for nurses. Pay is not the sole issue, but it is an issue. Likewise, regulations and heavy-handed enforcement is anathema to attracting and retaining good nurses and especially, good nursing leaders. I lost track of how many RN managers and Directors of Nursing I know that have left their jobs because of regulatory foolishness, inept surveyors, and illogical citations. Paper compliance and the amount of time devoted to the same versus patient care is a huge dissatisfier and an equally huge trigger to exit long-term care. A final reference: https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Data-Show-Nursing-Homes-Continue-to-Experience-Worst-Job-Loss-Of-Any-Health-Care-Sector.aspx
TGIF!
SNF Proposed Rule – 2024
‘Tis the season for CMS to release updated payment and program rules for providers under Medicare. In the past week or so, we’ve seen releases for Hospice and Inpatient Rehab Facilities. A couple of days ago, CMS released the proposed 2024 rules/updates for SNFs (skilled nursing). The fact sheet for the release is available here: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2024-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1779-p
Like all of these proposed rules, there are two categories of information within: what will happen and what CMS is signaling for the future. I find the forward commentary, the future stuff, far more interesting. It has in prior rules, given us insights into programmatic staples such as VBP (value-based purchasing), PDPM replacing RUGs, etc. In this rule, we see commentary on CMS studying a move toward minimum staffing requirements. CMS/Biden administration has targeted a move toward minimum staffing requirements (direct care) concurrent with COVID. I am leery of moves like this especially since a future mandate will likely come without additional major funding increases and within a labor market that simply won’t accommodate additional direct care staff. Facilities that I know are groveling, begging for more staff and simply, cannot find them. And yes, turnover in the industry is high but much of that is tied to structural problems within the industry and corollary staffing problems (staff turning over because there is not enough staff – a circular argument). In a post from earlier this week, I touched on the current staffing dynamics: https://wp.me/ptUlY-sp
What CMS is proposing which, is likely to happen in the final rule and move forward on October 1 of this year, is as follows.
- A 3.7% increase in rates. This number comes about via a rather convoluted process and formula. Essentially, the market basket (inflation costs) update is 6.1%. This amount is the aggregation of a 2.7% market basket increase plus a 3.6% market basket forecast error, plus a .2% productivity factor adjustment = 6.1% (rounded). To get to the 3.7%, CMS reduces the gross calculation by 2.3% which, is attributable to the parity adjustment under PDPM. Recall, CMS missed the spend mark with PDPM (high side) so the budget neutrality required when the payment systems changed, is being factored in via rate offsets going forward (2023 and 2024). I know, this makes little sense to anyone trying to rationalize these rate mechanics logically.
- Additional changes to the ICD 10 code mappings under PDPM. The goal here is to improve consistency between coding and diagnostic maps under PDPM.
- A bunch of proposed refinements and additions to the SNF QRP (quality reporting program) are within this proposed rule.
- Addition of a discharge function score which, assesses the number of residents that meet or exceed an expected score, using self-care and mobility items from the MDS. This score is proposed to replace the discharge assessment measure (Application of Functional Assessment/Care Plan).
- Adoption of the Short Stay Discharge Measure known as CORE Q, beginning in FY 2026 (October 1, 2025). This measure assesses the percentage of residents post-discharge within 100 days that are happy with their care and stay in the SNF.
- A COVID 19 measure for FY 2026 assessing what percentage of SNF residents are up to date with the recommended COVID 19 vaccination schedule.
- A COVID 19 measure for FY 2025 assessing what percentage of SNF staff are up to date with the recommended COVID 19 vaccination schedule.
- Remove for FY 2025, the Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Application of Functional Assessment/Care Plan) measure.
- Remove for FY 2025, theApplication of the IRF Functional Outcome Measures: Change in Self-Care Score for Medical Rehabilitation Patients (Change in Self-Care Score) measure; and the Change in Mobility Score for Medical Rehabilitation Patients (Change in Mobility Score) measure.
- By FY 2026, CMS will require SNFs to submit QRP data on 100% of collected QRP data on 90% of MDS assessments submitted. SNFs that fail to meet this standard will face a 2% reduction in the annual payment update for the fiscal year.
- Public reporting of the transfer of health information requirement to the patient and to the subsequent provider post-discharge, will be implemented in FY 2025. The information required is a reconciled medication list.
- Under the VBP for SNFs, CMS is proposing a number of instrumental changes, effectively reducing the weight of readmissions via complete elimination of the 30 day all cause readmission measure. The proposed program changes are,
- Add a nursing staff turnover measure where data is compiled in FY2024 and factored into performance in FY 2026.
- Addition of a discharge function score that assesses the number of residents via a functional score, that met or exceeded anticipated functional levels on discharge. Data will be gathered in FY 2025 with performance factored in for FY 2027.
- Addition of a long-stay hospital measure per 100 residents with data gathered in FY 2025 and performance factored in for FY 2027. The measure assesses the hospitalization frequency of long-stay residents.
- A measure addition for falls with major injury for long-stay residents. The data collection begins in FY 2025 and performance is factored in for FY 2027. the measure assesses the rate of falls with major injury among long-stay residents.
- Adding a new readmission measure to assess the potential for avoidable (hospital) readmission within the SNF stay for residents (SNF WS PPR) with data collected in FY 2025 and performance factored in for FY 2028.
- CMS is expecting to increase the bonus payment (payback)levels for high-performing facilities from 60% to 66% of the dollars withheld.
- Finally, CMS is proposing to make a technical change to the process for CMP reductions. Right now, if a facility waives its right to an appeal hearing, the CMP is reduced by 35%. As 90% plus of all facilities receiving a CMP take the reduction via the waiver, CMS will change the process to one where the waiver is imputed UNLESS the facility requests a hearing within the required timeframe.
My best wishes to all for a blessed Easter and Passover holiday season!
Hospice Proposed Rule – 2024
Just about a week ago, CMS released their proposed payment rule for hospices, effective for the Federal Fiscal Year of 2024, beginning October 1, 2023. As readers likely know, these proposed rules are more than just payment rates, incorporating certain regulatory requirements that pertain to the program and Medicare participation (for providers). The rules are subject to change and often, end-up somewhat modified. In most cases however, one can get a pretty good feel for the final “macro” events – rate and programmatic changes to getting a provider, reimbursed for the work it did.
As has been the trend with all Medicare programs, rate is noted as “gross” then subject to certain offsets. The offsets are typically, changes in the labor regions, market baskets (inflation), and the dreaded “multi-factor productivity adjustments”. Each of these elements singular or in combination can influence the final rate providers receive. Note: Initial payment rate updates are basically internally modeled CMS rates, times the market basket calculated inflation.
For Hospice, the market basket inflated rate projected for 2024 is 3.0% – increase. The net rate, after the productivity factor adjustment of .2% is applied is 2.8%. The aggregate cap (max payable to a hospice patient per year) inflates as well by 2.8%, from $32,486.92 to $33,396.55.
Now, the rub for 2024 in this proposed rule is the penalty hospices will receive for failing to meet quality reporting requirements. CMS is recommending that the penalty move from 2% to 4%. This would provide a deficient hospice (not meeting quality reporting requirements) with a rate reduction equal to -1.2% (2.8 – 4.0). CMS indicates that it will provide updates to the HQRP (quality reporting) data reporting periods along with updates on new quality measures and the HOPE patient assessment (Hospice Outcomes and Patient Evaluation) development.
Part of this proposed rule incorporates the end of the COVID -19 public health emergency, slated for May 11. As such, certain elements within the emergency are updated within the proposed rule. Telehealth is one such element impacted. In the rule, CMS is proposing to end the allowance of telehealth routine visits on May 12, 2023, but continuing the allowance of routing home care certifications via telehealth until 12/31/2024 (yes, through the end of 2024).
In an effort to address what is believed to be, on the part of CMS, increasing hospice fraud, CMS is proposing that physicians or permitted providers that can certify patients for hospice, be participating Medicare providers or have validly opted out of the program for the certification period of the patient.
The proposed rule incorporates a fair amount of statistical data on utilization and program growth. Without questions, CMS is concerned about program integrity and in particular, the growth of for-profit agencies. States that have raised suspicion with rapid growth are Texas, Arizona, California, and Nevada. California took action to restrict new agency growth, creating a moratorium. At issue? Hospices where the license location includes more than one hospice, management working at more than one agency simultaneously (a no-no) and concerns about legitimacy of certification of cases. To note however, this issue is not new within the hospice industry as even the large providers (e.g., VITAS) have come under scrutiny for inappropriate certifications, long-lengths of stay within institutional settings, etc.
The fact sheet for the proposed rule is here: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2024-hospice-payment-rate-update-proposed-rule-cms-1787-p
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.
- 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.
- 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.
- 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.
- 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.
- 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
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