This article is sponsored by Real Time Medical Systems. In this Voices interview, Skilled Nursing News sits down with Jim Shearon (RN, BSN, MHSA), Real Time’s Vice President Clinical Solutions, to learn what SNFs can do to navigate the changing payment landscape in skilled nursing, with a focus on approaching the new PDPM parity adjustment. Jim also talks about how providers are recouping losses from the 30-day incentive dismissal.
Skilled Nursing News: What career experiences do you most draw from, in your role today?
Jim Shearon: I draw from my career experiences with everything I’ve done as a nurse starting in the mid-’90s. When I came out of nursing school, I didn’t really have a direction and thankfully there wasn’t a nursing shortage then. I was drawn to post-acute care and began working in skilled nursing homes to fulfill my need for a job. This gave me an opportunity to build upon, “What can we do to improve the quality of care we’re delivering?”
This was back when we had paper charts and as the industry progressed and adopted electronic health records, I had an opportunity to become an MDS coordinator as that was the only way to work a daytime shift at the time. I progressed through the MDS process and grew to understand it beyond the reimbursement side. However, the original intent was to identify the care needs of each patient.
From there, I became a regional and corporate MDS consultant. After leaving that role, I transitioned into the QIO (Quality Improvement Organization) world and began working with nursing homes to improve the quality of care, with real-time data, not solely based on MDS data. Eventually that led me to Real Time Medical Systems, which is driven to improve clinical documentation by harnessing the live clinical records to drive the care, the quality and the dollars for those facilities.
CMS recently released the final rule for SNF payment for 2023. What does this new rule mean for SNFs and what are the three key takeaways that skilled care providers need to start paying attention to now regarding this new rule?
Shearon: The overall sentiment of this new rule is somewhat unfavorable, though I will point out that there is a 2.7% net increase. There is some positivity to this — even though it’s not keeping up with the inflation rate, it isn’t taking a lot of money away from nursing facilities either.
With the PDPM parity cut, it helped to keep that number higher because the 4.6% that CMS initially introduced is now spread over two years with a 2.3% annual reduction. Additionally, a lot of facilities were not happy about the SNF 30-day readmit measure changes that they worked so hard towards in reducing readmissions. Moving forward, it is going to be a flat 1.2% rate and everyone’s going to get it, which is great.
But where is the incentive? When I stand back and think about it, the incentive comes down to providing quality care and what nursing facilities can do to treat patients in place. Anything we can do to treat in place is the best thing for the patient.
Overall, when facilities can reduce readmissions, that’s going to have a huge financial impact on staff as well. I remember being a nurse on the floor and sending a patient back to the hospital for something I should have known, then readmitting them in that same shift. I spent three hours of my day with just one patient. People shouldn’t be looking at the 30-day as, “Wow. Where’s the incentive?” The incentive is about improving the care outcomes for the patient and for the staff.
What must SNFs do to prepare for the new rules, specifically in relation to staffing shortages?
Shearon: The first thing SNFs will need to do in preparation for this new rule is to evaluate current documentation processes. Are they using manual processes that can be automated? The health care industry is known for adding more work to clinicians’ plates, or duplicating data entry into multiple areas just because the need for data is so imperative. However, facilities need to find ways to automate processes in alignment with their current workflows.
The second thing is investing in solutions that will ensure accurate reimbursement for all the care and services that facilities are providing. There are a lot of different systems out there using two datapoints — MDS and claims data — to compile this information and state that they’re accurate or live. However, unless you can crack into the live medical records and harness live clinical documentation to meet those needs, you won’t have the accuracy you need.
Because of the new rule, what area within the PDPM parity adjustment should SNFs be paying attention to?
Shearon: First, SNFs must ensure that the MDS is as accurate as possible. This is key. We’re talking about 188 items that can affect the PDPM reimbursement, and there are over 1,500 ICD-10 codes that affect non-therapy ancillary add-ons, the NTA points. Ensuring that the first assessment is accurate is one of the most important things. Looking at claims or using the MDS and making assumptions prior to submission isn’t going to get an accurate MDS.
Second, as Real Time works with over 1,200 facilities across the United States today, we have seen so many missed opportunities with interim payment assessments. The interim payment assessment gives SNFs an opportunity to change the payment as the patient’s care complexity changes, but it can often be a very manual process.
This goes back to my previous statement, that facilities need to evaluate ways to automate manual processes and identify solutions that can ensure accurate reimbursements are met. Through automation and live analysis of EHR data, facilities can immediately alert the MDS coordinator and interdisciplinary team when a patient is meeting that interim payment assessment criteria and quickly take action to adjust care plans. They are thus getting accurately reimbursed for all the care that is being given.
How can Real Time’s PDPM solution help SNFs better address the new PDPM parity adjustment?
Shearon: Real Time can ensure that the first assessment is accurate. I learned on day one of my nursing career that if it’s not in the medical record, it didn’t happen. Real Time has the ability to read both structured and unstructured data — nursing notes — in the EHR and identify key areas in relationship to the PDPM reimbursement. We create a cheat sheet to an accurate MDS and we’re going to show you exactly what’s in your medical record before you encode it and send it into the database.
Additionally, our solution has the capability to assess every one of those patients, every single day, to determine whether they meet the interim payment assessment criteria. This is where the second piece of automation comes in with access to the live data. We can do comparisons of those patients throughout the day to see if their care needs have changed.
If they have changed, we’re going to notify the MDS coordinator’s interdisciplinary team immediately to inform them that an interim payment assessment should be considered. With Real Time, we are able to reduce the time it takes to identify, filter and code that information.
With the 30-day readmission measure being suspended under this new rule, how can Real Time help facilities find new ways to recoup this incentive loss?
Shearon: In looking at ways to recoup this incentive loss, I always go back to awareness. When I first started as a nurse, I focused on the primary reason for readmission. I rarely knew why patients were discharged. Eighty percent of the patients who came into our facility were readmitted for something that’s not directly related to the primary reason for their admission. Facilities are taking very sick patients without access to real-time data, and it puts their teams in a firefighting mode.
Clinicians are always running up for morning meetings, going up to units and putting out fires to keep that patient from going back to the hospital. If nursing facilities continue to do this, they’re never going to get ahead of the game. Real Time provides an automated process that provides a hard readmission risk score, assessing every single patient, regardless of payer, every single day. The risk score highlights which patients need attention when staff return to their units.
Morning meetings are great — they’re like a game of telephone. This shift tells the next shift, and the next shift tells the next shift. Now all of a sudden it gets back to you, and it loses its luster. Real Time doesn’t lose its luster. It’s grabbing that live data and identifying those high-risk patients based upon what’s been inputted into the EHR.
If you read any scholarly article on reducing readmissions, they will say that you have to know what’s clinically going on with your patients at any given time. You have to know how long they’ve been in your facility. Have they been readmitted before? What are their comorbidities? Those four things together are what Real Time automates to help identify high-risk populations, not just for the nurses, but also for the physician extenders, the nurse practitioners and PAs that can help focus on the right patient at the right time.
Even though the SNF 30-day readmit measure is now a flat rate, this measure is still significantly important to the facility’s acute care partners who are still accountable for readmission reductions. If a facility can continue to reduce readmissions for their patients, they are more likely to receive increased referrals from their acute care partners — thus improving census.
The key to reducing readmissions, in my opinion, is pointing the nurse to the right patient at the right time. When you’re able to do that, you cultivate that relationship with your hospital ACOs and other health care partners. Regardless of how CMS is going to improve nursing facility reimbursement based upon their rates, keeping census at a more productive level is critical to the facilities success.
Finish this sentence: “The top strategy skilled nursing providers should employ in 2022 to best prepare for 2023 is…”?
Shearon: Moving away from more of a data transformation to a data optimization model in order to optimize the data we put into our EHRs and make it useful and actionable.
You may view this article on the Skilled Nursing News website, here.