Tuesday, May 14, 2013


Get Ready Post-Acute to join in the fun of Readmission Penalties

The Affordable Care Act’s mandate for payment reductions for hospitals with high rates of readmissions is heading toward the post-acute industry. 

The U.S. Department of Health and Human Services (HHS) 2014 budget proposal includes a Medicare legislative proposal that could save $371 billion over ten years and smack in the middle of that proposal is a recommendation that would impose payment reductions to skilled nursing facilities for preventable hospital readmissions.

Told you so!

HHS references research by the Medicare Payment Advisory Commission that notes that nearly 14 percent of Medicare patients that are discharged from a hospital to a post-acute setting – primarily a skilled nursing facility -- are readmitted to the hospital for what they consider avoidable care issues.  The budget proposal is recommending that beginning in 2017, payments made to post-acute/skilled nursing facilities be reduced by 3% for facilities that have high rates of preventable hospital readmissions.

But it’s not your fault! Right? 

Unfortunately that argument is not going to resonate.  Right now, hospitals are tracking patients they discharge, noting where they are being discharged to and whether they are being readmitted back to the hospital.  They are literally tracking utilization figures of nursing facilities because they have to report their rehospitalization rates to Medicare.

It is just a matter of time until the hospital is going to report to Medicare the names of the skilled nursing facilities that contribute to high rehospitalization rates, and that is when it’s going to affect you, the nursing facility.  Medicare will note your rehospitalization rate and penalize you.  Thus the 3% reduction begins. 

As a skilled nursing facility you may logically try to explain that the rehospitalizations came as a result of physician’s orders, non-compliant patients, and so on and so forth.  It’s not your fault.  But the finger pointing will only get you so far.  The hospital will start to select facilities that they know can provide quality in-house care to higher acuity patients, therefore preventing rehospitalizations. 

Is your staff trained to reduce rehospitalization?  Can your staff ensure that the hospital has provided the necessary information regarding the patient’s plan of care prior to admission? Are they trained to care for the diseases and conditions most associated with rehospitalizations? And finally, do they have the skills required to provide the quality care needed to prevent rehospitalization? If you can’t answer yes to these questions, you may be looking at a 3% reduction in your bottom line in addition to a lower census since your hospital partners might just stop referring patients to you.

Check out our Reducing Rehospitalization Series of courses and our Rapid Review Series which will provide your staff the knowledge needed to prevent rehospitalizations so you can say YES to your hospital referral network!

Cheryl Swann RN-BC, BSN, WCC, LNHA
VP of Clinical Services

Thursday, April 25, 2013

Medication Reconciliation: Where to Start in Reducing Rehospitalizations


In the many years I walked the halls of the skilled nursing facilities where I worked as regional manager, I saw residents go through a revolving door from facility to hospital and truly experienced the “reducing rehospitalization” issue first hand. While I don’t have all the answers, there is one area of the transition of care from hospital to post-acute that I believe truly impacts the rehospitalization rates we and our soon-to-be acute care partners need to figure out fast … and that is medication reconciliation.

Transitions of care occur throughout the entire long-term care continuum, which includes skilled nursing facilities, assisted living facilities, home health care, and hospice, among others. Getting it right is critical. Poor transitions of care are the leading cause of medical errors. They result in adverse events, avoidable complications, increased hospital readmissions, duplication of services, and wasted resources.

According to recent studies, 49% of hospitalized patients who are discharged experience at least one medication error within 60 days of leaving the hospital—frequently while in the common 30-day post-acute period. Do you see the potential for finger pointing at your facility? Further, approximately 60% of medication errors occur during a transition. Many of these are related to changes to the medication regimen that occurred in the previous care setting. There are several different reasons why changes in medication occur; one distinct cause is formulary restrictions.

Each care setting has a unique formulary of medications that are preferred for use. Many times when an individual transfers from one care setting to another, the medication must be changed to correspond with the new care setting’s formulary. Without a proper transition of care, this can result in duplication of medications.

Medications change frequently when a resident moves from one care setting to the next.  And it’s confusing not only for the residents and their loved ones, but also for the post-acute care giver.  Communication about medication at the moment of transition of care is one of the top lines of defense to reducing hospitalization caused by errors in med reconciliation. Even more serious is that not only will that med reconciliation error send your resident back to the hospital, but it could have a critically negative impact on the resident’s health and thus become a huge liability risk for you, the provider. 

As acute and post-acute care providers move to a value-based health care system as dictated by the Affordable Care Act, we’re all going to be looking very closely at our partners. Wouldn’t it be nice to be able to have a system in place to demonstrate your ability to ensure accurate med reconciliation? Just follow these steps as a resident is being transferred to your facility:
  1. Ensure that you receive a list of current medications.
  2. Obtain a list of all prescribed medications.
  3. Compare both lists and ask questions to reconcile the two.
  4. Make a decision regarding which meds to continue based on medical  judgment, patient condition, and patient history.
  5. Communicate the med list to all caregivers, family members and the resident.

We are providing care for more acute residents in our facilities. There are many factors we as providers need to consider in order to prevent rehospitalization, and one of the most important is proper med reconciliation. Look at the systems you have in place and provide training to your staff. Using good med reconciliation techniques avoids medication errors such as omissions, duplications, dosing errors, and/or drug interactions. This should be done with any transition of care—whether it is between locations, between providers, or between different levels of care. For more information read our new whitepaper: Out of the Penalty Box: Avoiding Unnecessary Rehospitalizations in the Post-acute Setting.

Cheryl Swann RN-BC, BSN, WCC, LNHA
VP of Clinical Services

Tuesday, April 9, 2013

Reducing Hospitalization…One Infection at a Time

I recently had the opportunity to participate in a webinar for the Indiana Health Care Association in which an overview of Infection Control was presented.  I wanted to share some key take-aways that everyone in our industry should keep in mind.

It’s estimated that infections cost our industry $673M to $2B annually to treat, and account for up to ½ of all hospitalizations.  It’s no wonder F441 is one of the most commonly cited tags in the US.  We need a cure for the F441 infection!

Post-acute care organizations just need to develop infection prevention and control programs! Easy. Right?  Well here are a few key strategies that can help.

1) Establish a surveillance program that investigates incidents of healthcare associated infections to identify trends and/or outbreaks.  The McGeer criteria are an established set of guidelines specifically designed for surveillance use in LTC facilities. 

2) Perform a Root Cause Analysis of any trends or outbreaks (see previous blogs and white paper Developing an Effective Quality Assurance Program)

3) Prevent the spread of infection:
·         Through the use of transmission-based precautions, ensuring employees are free from communicable diseases, proper hand hygiene (see our course Hand Hygiene USS-7100), proper med pass protocols and by following the do’s and don’ts of glove use.
·         Review protocols for proper point of care device cleaning as well as linen handling and service. 

Even if infection control isn’t an issue your organization struggles with, be proactive and make it a part of the Performance Improvement initiative of your QAPI program.    

I told you it was easy.  With the right preventative measures, you’ll fight the F441 tags, reduce hospitalizations related to infections, and have a healthier resident population!

Jennifer Moore, RN
Clinical Content Developer

Tuesday, March 26, 2013

Antipsychotics & Beyond: What You Need to Know

The Centers for Medicare and Medicaid Services (CMS) launched an initiative in early 2012 to improve dementia care in skilled nursing facilities and assisted living facilities nationwide through a combination of better reporting and technical assistance; increased public awareness; regulatory oversight; and enhanced education and outreach.

Building upon the CMS initiative, the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) challenged members to safely reduce the off-label use of antipsychotic drugs by 15% by December 2012. When you consider that 80% of antipsychotic medications prescribed in skilled nursing and assisted living facilities are prescribed for off-label use such as behavioral conditions, reducing the use became a daunting task.

I recently hosted a webinar on the topic to explore the critical importance of proper documentation and monitoring as well as implementing a quality staff training solution. Consider that 25.2% of nursing facility residents receives antipsychotic medications, according to CMS. In order to meet reduction levels, providers need to convey to staff that antipsychotic medications should be used only as a last resort.

Tag F329 mandates that a resident’s drug regimen must be free from unnecessary drugs. Further, it specifically it states that antipsychotics cannot be given unless it’s necessary to treat a diagnosed condition, and that gradual dose reductions and behavior interventions are proposed.

Get Ready for the Surveyor!

The off-label use of antipsychotic medications can lead to significant penalties at survey time. Now more than ever, surveyors will be scrutinizing antipsychotic drug use and will look for and ask your staff about the following:
  • The effect on the resident involved: Changes in behavior, side effects, risk factors, etc. 
  • Non-pharmacological approaches: Were any attempted? Were they successful?
  • Efforts to minimize the need for, reduce the dosage of, and/or reduce the duration of the medication
  • When surveyors look at unnecessary medications and off-label antipsychotics, a properly trained and educated staff may be the difference between a good or bad survey. Surveyors will want to ensure your staff is properly assessing the need for these medications and that they took steps to address behaviors prior to initiation of antipsychotics. The only way your staff can do that is if they are trained on how to identify the meaning behind a resident’s behavior. Your staff needs to understand their role in your facility’s initiative to reduce the use of antipsychotic medications.

    Your staff will ultimately need to change the way they perceive a resident’s behavior and try to find alternative ways to address the behavior without defaulting to antipsychotic medications.

    Check out our courses:
    Understanding the Meaning behind Behaviors: Actions & Reactions
    Psychotropic Medications: Antipsychotics and Beyond



    Cheryl Swann RN-BC, BSN, WCC, LNHA
    VP of Clinical Services

    Tuesday, March 5, 2013

    Get Ready to Compare Yourself


    The Affordable Care Act (also referred to as Obamacare) has a lot of “hidden gems” for us folks in post-acute care. Besides the higher-profile mandates such as QAPI or Mandatory Corporate Compliance, one little-known treat is the requirement that mandates CMS to make a number of changes to the Nursing Home Compare website. For those of you not familiar with the site – the time has come! Check it out: www.medicare.gov/NHCompare.


    CMS created the Nursing Home Compare website in 1998. This website is intended to give consumers information about nursing homes in their area and compare the different facilities to help them make an educated choice. While this website is constantly updated, including the unveiling of the Five-Star Quality Rating System in 2008, thanks to the ACA you can expect to see even more additions.

    Transparency = The ACA would like to see greater transparency regarding who owns and manages facilities. That means that anyone having ownership interest or responsible for management of a facility will be identified on the site. The intention is that this information should be easily accessible to the consumer. While this posting is not a direct requirement of the ACA, CMS is developing scenarios in which this information would be posted.

    Posting of Nursing Home Staffing Data = Beginning in June 2012, CMS implemented a pilot project to directly collect payroll data from the provider’s payroll system to calculate staff turnover and retention. Currently staffing information is based on information facilities provide CMS, but you can expect this information ultimately coming directly from payroll systems. Hmmm… not loving the government having direct access to my payroll system.

    Creation of Standardized Complaint Form = There is a concern that it is not easy or consistent for the consumer to report complaints. So, no fear there will be a nice standardized and public place for the consumers to lodge their complaints and for any prospective families or residents to see!

    Currently, the website is full of very valuable information that is critical for every provider to be familiar with. All your survey results, including your life safety survey, staffing ratios, Five-Star results and special focus status are found on the website. In addition, there is educational information for families and consumers.  Bottom line -- your “dirty laundry” is there for the world to see.  Strong surveys and a better educated staff are more important than ever! Take advantage of the Care2Learn extensive library to educate your staff on the issues that are unique to your facility.

    Remember, this is Nursing Home Compare, so you certainly want to use the opportunity to see how the competition is doing. Your prospective clients sure will!

    Tamar Abell, MA, CCC-SLP, LNHA, is the president of Care2Learn / Upstairs Solutions

    Tuesday, February 19, 2013

    What’s New in 2013 – Regulatory Updates

    CMS was busy in 2012 preparing new treats in 2013.  What’s on the horizon for providers in regards to the survey process?

     New Survey Protocols

    The Appendix P to the State Operations Manual has been revised. There have been some revisions of forms to reflect the MDS 3.0 new QM reports. 

    Providers can expect to see an additional focus on monitoring of antipsychotics, staff education and training for dementia including behavioral and psychological symptoms, individualized care plans for dementia and a focus on special units for heavy clinical needs, dementia and specialized rehab. 

    In addition, if the facility utilizes paid feeding assistants, there will be additional scrutiny into how and where feeding assistants receive their training.  Use your Care2Learn Learning & Performance Engine (LMS) to track live trainings and have a record of it ready and accessible for the surveyor to review. 

    Take advantage of the extensive Care2Learn library to stay ahead of those potential deficiencies!

    Changes in Guidance to Surveyors

    There have been updates in the guidance to surveyors for F309-Quality of Life/ End of Life Care, F-155- Advanced Directives and F322-Feeding Tubes.  The overall intent of these changes: facilities have a clear, formal process in place for dealing with end-of-life issues. 

    F155-Advanced Directives:
    The facility must be sure residents are educated and informed about the facility policy and procedures so they can exercise their rights.  The facility must ensure that the residents’ choices are incorporated in their treatment, care plan and services.  The facility wants to be especially careful during transition of care that information is carefully communicated between care settings.  And remember the LTC mantra: if it’s not documented, it’s not done.

    F309-End of Life Care:
    This change helps the facility address death as a process.  “Providing appropriate care related to the dying involves ongoing recognition, assessment and response to the resident’s needs and goals.” There is renewed focus on palliative care and pain management. 

    Take a close look at your relationship with your hospice provider- because the surveyors will.  Are you taking a collaborative approach to care planning and resident care?  Be sure to include patient families in the process.

    F322-Feeding tubes:
    The use of feeding tubes has become very commonplace and has a major impact on a resident’s quality of life.  The major intent of this guidance is that the facility has determined there are no other viable alternatives to maintain nutrition.  The feeding tube should be viewed as a short-term solution whenever possible and there should be documentation that the least invasive interventions have been attempted. 

    Finally, be certain your staff is well-trained on the care of a feeding tube as well as the nutritional aspects of feeding tubes.

    We can expect to see some additional updates throughout 2013 including updates to F441, Infection Control.  Stay tuned!

    Tamar Abell, MA, CCC-SLP, LNHA, is the president of Care2Learn/Upstairs Solutions

    Wednesday, February 6, 2013

    Giving you a Hand with CMS “Hand in Hand” Training

    This Affordable Care Act is a lot to handle.  I’m sure many providers have heard the call…Section 6121 of the Patient Protection and Affordable Care Act requires facilities to ensure nurse aides receive regular training on abuse prevention as well as caring for persons with dementia. This training should be included as part of the mandated inservice education nurse aides must complete each year.  Ok, simple enough. Right? Sort of….

    The Centers for Medicare and Medicaid Services developed an instructor-led training series entitled “Hand in Hand: A Training Series for Nursing Homes”—a daunting and commendable effort by the CMS.  Now what do you, the provider, do with it?  Well, what hasn’t been thoroughly explained is that you might not have to do anything with it.  Other training options and resources are also available—including those provided by Care2Learn. In fact, according to the CMS memorandum on Hand in Hand training issued by CMS to State Survey Agency Directors and dated September 14, 2012 (Ref: S&C: 12-44-NH):

    “While annual training for nurse aides on dementia care and abuse prevention is required in current nursing home regulations, we do not require nursing homes to use Hand in Hand specifically as a training tool. Other tools and resources are also available.”

    As one of those “other tools,” Care2Learn compared its library of modules with the 6-hour CMS training series. Unlike the CMS training, which must be instructor led, Care2Learn offers a simpler, more convenient option to fulfill this training requirement with expert-developed courses that meet the training criteria and minimize the overall time investment. However, we commend CMS on its effort to support and provide the long-term care industry with tools and resources such as this solution. 

    The Care2Learn Difference
    Based on a thorough analysis of both the Hand in Hand tool and the current Care2Learn library, we have identified the following key differentiators:

    • CMS Objectives are Met: Care2Learn clinical experts have completed a thorough review of the learning objectives from the CMS course series and created a crosswalk to Care2Learn content.  
    • No Need for a Live Instructor: Unlike the CMS training, Care2Learn delivers the same easily accessible format (online 24/7) our clients have come to appreciate, and we do not require instructor involvement.
    • LMS Tracking: The Care2Learn Learning & Performance Engine (LMS) makes it easy to track and record training completion for all employees—making results easily accessible for survey purposes. If you choose to use the CMS Hand in Hand training, remember to use our LMS to track staff participation.
    • No Change to the Format You Love: Care2Learn makes the Affordable Care Act-required training on abuse prevention and dementia more accessible with a completely online option.



    Care2Learn Modules
    The following is a list of Care2Learn modules on abuse and dementia care that would mirror the objectives outlined in the CMS Hand in Hand training tools.

    Care2Learn Courses
    Providing High Quality Dementia Care
    Communication with Older Adults with Dementia
    Understanding The Meaning Behind Behaviors: Actions and Reactions
    Abuse and Neglect
    Abuse and Neglect Prevention Program
    What is Dementia?

    It’s just our way of giving you a hand with Hand in Hand training.

    Cheryl Swann RN-BC, BSN, WCC, LNHA
    Vice President of Clinical Services