SNF Survival Depends on Understanding the New Hospital Landscape, Among Other Factors

Posted by CC Andrews

Feb 15, 2018 12:00:00 AM

A recent report from CliftonLarsonAllen paints a stark picture for the future of skilled nursing facilities (SNFs), highlighting what stakeholders likely know, which is that operating margins are tighter than ever and there are fundamental shifts in how the flow of referrals reach facility doors.Hospital_photo

The good news is that providers can overcome these challenges to a large degree by—as you may have guessed—harnessing big data. “By embracing big data, SNFs can demonstrate their value to referral sources in a meaningful way,” the report says. “And by continuously improving outcomes, SNFs can position themselves to provide clinical services in a sustainable, profitable manner.”

The report, which is the 32nd of its kind published by CLA, is divided into two sections: one includes analyses of SNF financial and operating conditions by region and the other provides cost analyses tables displaying a variety of SNF cost data.

Hospitals Impacting SNF Admissions

According to CLA, hospital behavior is having an impact on SNFs in a negative way. Outpatient is the name of the game now (versus inpatient), resulting in fewer hospitalizations and thus fewer SNF admissions. This is mainly because, in a broad sense, the world of managed care, Medicare Advantage, and value-based care favors a process that gets people in and out of institutional care as quickly as possible, with the home care option seen as optimal.

Within this construct, CLA says this scenario is not necessarily dire for SNFs, if, and only if, long-term and post-acute care operators understand what they are up against. This makes it even more vital, they say, for SNFs to have their clinical, marketing, and data tools in top shape in order to make themselves attractive to an acute-care world where cost management is paramount. As this trend continues for fewer hospitalizations, the result will be that more SNFs face insolvency while at the same time others thrive.

This gap in how SNFs perform will be a feature of the industry for years to come and amounts to a Darwinian outlook where the difference between those facilities doing well and those doing not so well is wider and wider, CLA says.

Occupancy on the Decline

Diving a little deeper into the data points, CLA notes that in addition to the slowing of admissions from referrals there are shorter lengths of stay when people arrive. Case in point: there was a 120 basis point reduction in occupancy rates for SNFs between 2015 and 2016, according to the report. “Reduced occupancy is impacting all regions of the United States, and the overall occupancy median is now at 85 percent,” the report states.

This pressure can only continue with post-acute networks narrowing and solidifying, causing the thrive-or-die variances for SNFs. For instance, CLA says their numbers show the 25th percentile of SNFs experienced a 170 basis point reduction in occupancy, while the 75th percentile only saw a 50 basis point decline in occupancy levels. The Darwin movement is in action, CLA says, with those providers already in the mix of the new referral world seeing less of a hit, while those on the outside experiencing a larger loss of business.

Outcomes, Quality, and Efficiency

Options for providers are few, but the status quo is decidedly not one of those options. There must be a managed effort to gather information showing clinical success, which starts, of course, with positive outcomes for residents and patients.

There is a future for SNFs, CLA stresses, but there is a thin line, or margin if you will, between making it work and failing to keep up with a hyper-competitive marketplace that values results more than ever. Not to overstate the obvious, but “SNFs must demonstrate outcomes, quality metrics, and cost efficiency,” in order rise above in this environment, says the report says.

If you want a focused approach to staying on top of industry data and trends that is facilitated by experts in the senior living field, contact Quantum Age today.

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Topics: long term care, quality, data, skilled nursing

Wide-Reaching CMS Rule Opens the Door for Innovation

Posted by CC Andrews

Feb 15, 2017 12:24:00 PM

The final rule on the requirements for nursing homes to participate in Medicare and Medicaid is a bit of a behemoth, but it’s an important one since it touches nearly every aspect of a facility’s operations. In particular, there are many implications—as well as opportunities—within the longevity ecpexels-photo-52910.jpegonomy, especially for vendors in the long-term and post-acute care space.

Thanks to the agency’s willingness to meet with providers and educate the public about the rule, we have an idea of what to expect from it, current politics notwithstanding. Karen Tritz, head of the Centers for Medicare & Medicaid Services’ (CMS’) Division of Nursing Homes, offered an inside scoop on the rule at the Jan. 31 meeting of the Advancing Excellence in Long Term Care Collaborative (AELTCC).

Other than the fact that the requirements have not been updated since 1991, Tritz reported that CMS overhauled the rule to further advance its efforts in person-centered care and resident quality of care and quality of life. “Think of rule as raising the bar on quality,” she said.

The first thing to know about the rule is that it will be rolled out in three phases. The deadline for implementation of Phase III is slated for November 2019 (Phase I, which ended Nov. 28, is allegedly complete).

A look at some of these requirements should tell you that some of them may not be easy for providers to track or even implement. Vendors should seize this opportunity to develop solutions and innovations that can make providers’ and operators’ work easier:

The following items are scheduled for release or completion by the end of Phase II (Nov. 28, 2017):
  • New interpretive guidance, as contained in the State Operations Manual (SOM). An advance copy of the SOM will be available to the public early this summer. It will also include an overhaul of the F-tag numbers.
  • Development and testing of a new survey process will begin.
  • Implementation of the Quality Assurance and Performance Improvement (QAPI) program.
  • Update of infection prevention and control programs, which requires an infection-prevention and control officer and an antibiotic stewardship program that uses antibiotic-use protocols and a system to monitor antibiotic use.
  • Care planning improvements for discharge planning for all residents, with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity; giving residents information they need for follow-up after discharge; and ensuring that instructions are transmitted to any receiving facilities or services.
Following are the Phase III items:
  • Finalization of the QAPI implementation and discharge planning and infection control requirements.
  • Implementation of the requirement that call lights must be present at the bedside of all residents.
  • Implementation of new compliance and ethics programs to bring current programs into compliance. Programs must include written policies and procedures to reduce criminal, civil, and administrative violations and must be reviewed and revised annually. For organizations with five or more facilities, programs must include annual training, a compliance officer, and a designated liaison located at each facility.

There are obviously a number of provisions where long-term and post-acute care vendors, such as software solution providers, consultants,  and more can offer solutions and opportunities to make navigating the process easier.

It’s also worth noting that as the rule is rolled out, CMS will implement a new, common survey for all providers by the end of Phase III. The new survey will include elements from both the traditional and the newer Quality Improvement Survey process that has been implemented in more than two-dozen states since 2007. Also part of the new survey will be “new and innovative approaches” and a “balance between structure and surveyor autonomy,” Tritz noted.

I will post more updates as implementation of the rule moves forward. In the meantime, you can read the entire rule here.

If you want a focused approach to creating innovative solutions for elder care, facilitated by experts in the field and candid feedback, contact Quantum Age today. 

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Topics: long-term and post-acute care, quality, longevity economy

Five-Star Calculations Demystified

Posted by Meg LaPorte

Aug 16, 2016 10:02:26 AM

The Five-Star Quality Rating System is getting lots of attention these days. Not only did CMS announce that the six new quality measures have been officially added to the rating system, but the program has also drawn criticism from a U.S. senator. According to an Aug. 10, McKnight’s news story, Sen. Robert Casey (D-Pa.) Stars_blog_image.jpgbelieves that while “the updated measures give prospective nursing home residents and their families more information when choosing a facility, they do little to ‘impact the accuracy and reliability of the measures reported.'"

No matter what one thinks about Five-Star, it’s certainly not expected to go away anytime soon. And according to American Health Care Association Senior Vice President for Quality and Regulatory Affairs David Gifford, MD, MPH, the new quality measures will have a modest impact on overall five-star ratings for nursing homes.

However, Gifford, who presented at the eHDS/Ability user group conference in Chicago earlier this summer, explained that the impact on individual quality measures for nursing homes will be more pronounced.

In light of this news, I feel obligated to share Gifford’s compelling presentation about how the staffing measures—as well as the overall stars—will be calculated. Here’s a synopsis:

  1. Staffing Measures: Using a matrix on the staffing measures (see graphic below), Gifford explained that the measure is calculated by combining registered nurse (RN) and direct care staff hours.
    • Each row of the matrix contains the RN hours for each patient day, and each column includes the total direct care staff hours per patient day.
    • Nursing homes with scores that appear in upper-left red box will lose a star, while those that fall within the lower red box area will gain a star.


Gifford explained that CMS has established threshold rates for each measure to determine the points for that measure. “They don’t change those rates,” he said. “They’ve stayed fixed since February 2015.”

With regard to staffing scores that fall within the one-star ranges, Gifford believes that one major reason why a nursing home gets there is its location. If it’s in Texas, for example, the Medicaid reimbursement is “really bad” there and staffing numbers will be low as a result, he said.

The other reason for low staffing scores is related to Form 671–Long Term Care Facility Application for Medicare and Medicaid. “When surveyors coming in and yell at you for obstruction of justice for not filling out Form 671, your staff will, of course, fill it out and hand to the administrator, who will sign it,” he explained. “The problem with this is that no one is likely to check the staffing numbers on it. If that’s the case, unfortunately, there is no way to change it,” and it becomes part of the nursing home’s record. “There is no changing it,” Gifford said. “I’ve never seen it changed in 10 years.”

Finally, don’t forget that starting in 2018, CMS will use data submitted from your time and attendance systems into CMS Mandatory Payroll-Based Journal (PBJ) to report staffing levels and turnover and retention.

  1. Overall Star Ratings: Calculate your overall five-star rating as follows:
    • Assign 20, 40, 60, 80, or 100 points for each quality measure based on the quality measure rate against a set of threshold cut-points.
    • Add up the points for all 11 quality measures.
    • Compare your aggregate score of the 11 quality measures against the threshold cut-points to determine your stars (see graphic below).


All the points will be added together to come up with the final five-star rating, and since there are 11 measures currently, 1,100 is maximum number of points you can get, Gifford reported, while 225 is the minimum number (see graphic 2). “When adding the five measures to the eleven they do roughly the same thing,” he notes. “So there will 16 measures, so your score will be between zero and 1,600.”

If you calculate 760 points out of 1,100, you will get five stars. “So the magic number is 760,” said Gifford. “If you’re less than 544 you’ll get one star, and you will lose a star. Everywhere else, there will be no impact.”

Gifford emphasized that the biggest impact of the new measures is “the fact that the measures will be used by hospitals and ACOs for network selection.”

Half of nursing homes will see their individual quality measures star ratings change at some level, and half of those will go up, while the other half will likely go down, Gifford noted. “The impact on overall star rating will be a lot less, with about 15 to 20 percent seeing changes in their overall star ratings.”

In conclusion, Gifford said that CMS will likely make changes to Five-Star again in a few years. For example, in 2018 staff turnover will be added. In addition, CMS will, at some point, add SNF Quality Reporting Program (QRP) measures, resident review measures, and measures on functional improvement.

Gifford noted as well that customer satisfaction measures will likely be added in about four years.

Keeping those stars aligned will help you stay on track with the news measures 

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Topics: long-term and post-acute care, CMS, quality, five-star, Medicare