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Introducing ... Provider Rating Report Scanner!

As you are probably aware, Broad River Rehab created Staffing Navigator to make it easier for facilities to understand the interaction between staffing levels and star ratings. (If you haven’t heard of Staffing Navigator, check your app store. It’s free and we’ll train you.)

We learned a lot of things creating that app. The original plan was to create a “Quality Measures Navigator” app after Staffing Navigator. We wanted to create something to give people a starting point when it comes to quality measures; a road-map to improving quality measures. There were a lot of disadvantages to doing that. Two of the biggest problems:

  • The data we used for Staffing Navigator comes from the 5 Star Data set. That data is useful for long-term changes like hiring and acuity, but less so for quality measures. Using the 5 star database for quality measures is akin to steering with the rear view mirror. The data is pretty old.

  • When it comes to Quality Measures, we believe that CMS is going to continue to make changes. The quality measures are a moving target. As a result of this, data.medicare.gov is not so great. The data is spread across at least three tables. Making things more difficult, some measures have different supporting data. In short, CMS doesn’t provide enough data on data.medicare.gov to accurately recreate the data.

So, we decided to take things in a different direction. We built a tool that will analyze the latest information from your CMS reports and help you find opportunities to improve your quality measures. It even has a simple drag and drop interface.

We’d Like YOUR Help

This tool is brand new and we’d like your help testing it. All you have to do is drop your report on the webpage (link below) and look at the results. We’ll even help you interpret your data!

How?

It’s pretty simple.

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  1. Download your “Provider Rating Report”. The date of the report doesn’t matter, but it must be the correct report. The first page should look like the image to the right. If the report doesn’t say “Provider Rating Report”, it isn’t the correct report and will not work.

  2. Head over to our CASPER Report Scanner and upload your report. (Yes, we need a better name. You can use the form below to suggest one!) You can either drag and drop the report onto the tool or click the link to browse to your file.

  3. After the upload completes, results are displayed automatically.

Interpreting Results

The rest of this posting will show you what the results mean.

The summary is the place to start. In this case we can see this is a 2 star quality measure facility. We can also see that this facility is 120 points away from three stars and 76 points away from 1 star. The metric CPP is a measurement that tells you where you are positioned between the cutpoints. A CPP of 0.5 means you are exactly between cutpoints. This facility has an overall CPP of 0.39 meaning it is on the low side of 2 stars.

Taking a look at the long-stay, The CPP of 0.91 means we are very close to the next level of 3 stars. This building is only 9 points away. That means there may be opportunities to pick up a quick 15 or 20 points and hit 3 stars for Long-Stay. The short stay section works the same way. (Keep in mind that the short-stay metric is scaled to match the long stay. If you don’t know what that means then don’t worry about it.)

Long-Stay QM

Moving on to Long-Stay QM. (Note that I’ve switched to a different report for illustrative purposes.)

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You can see that this facility is color-coded red, meaning this measure is on the low end of the scale with only 40 points. The rest of the measures are designed to help you understand where you’d need to be in the next quarter.

In this example, the 4.7% is the oldest quarter and will be rolling off. Take a look at the Target column. This represents the value you would need in the new quarter to achieve those points. In this particular case, this facility can do as poorly as 6.96% and still get 40 points. To get to 60 points, this facility would have to get down to 0.64%. This is a level that far lower than they’ve demonstrated recently. This means that while falls are obviously a great concern in this facility, it’s unlikely to net any additional points in the coming quarter. That’s not great news, but it’s better know what you’re up against, right?

Other Metrics:

  • CPP tells us we are on the low end of the cutpoints, but not terribly close to moving to 20 points.

  • Departure from 3Q tells us we could be 2.43% worse than our 3 quarter average and still maintain 40 points.

  • The Up and Down targets are simple differences between your 4 quarter average and the cutpoints. (This is similar to CPP, but some people understand one of the other more easily.)

I’m including a couple more metrics between so you can get a sense of how this works. Try uploading your report to get a better idea. Short-Stay QMs work the same way.

Claims-based measures are displayed a slightly different way since CMS provides different information about those. Take a look at that section on your own.

If you have any questions or comments about this tool, I’d love to hear from you. Use the form below.

We are also looking for a name for this tool. Send me your suggestions!

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We’d like to hear from you!

Is this tool helpful? Would you like more? Staffing? Health Inspections? Some other report?

Please send us your feedback, good and bad!

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PDPM Navigator™ Updated with Final Rule

You might have noticed we’ve been absent on the blog for a while. That’s because we have a couple of big projects going on. While I can’t announce anything just yet, stay tuned…

I can say we’ve updated PDPM Navigator to reflect the changes in the Final Rule. Your phone will update automatically or you can visit your app store to force an update. The changes are relatively minor, but do impact rates.

We’ve also updated Staffing Navigator to include the data released in July.

How does case-mix drive staffing ratings?

Changes in patient acuity change the case-mix or “expected” hours used to determine staffing stars. That’s not news for anyone who reads this blog. The problem is the relationship is difficult to tease out. This is because CMS does not publish the exact criteria they use to select assessments that are included in calculating acuity and don’t give us any documentation showing the ones they used.

This leads to questions like “If my case-mix increased by X, how much pressure would that put on my staffing rating?” This is a common question for anyone who is considering implementing a program to improve documentation. ADL coding is a classic example of this. Improved ADL documentation nearly always increases case-mix, which increases the number of hours required to maintain or improve staffing ratings. (For the record, never let anything get in the way of improving your documentation. Better, more complete documentation should always be the goal, regardless of star ratings or quality metrics.)

Let’s see if we can create a surrogate measure.

Estimating Overall Case-Mix Hours

For this analysis we combined the detailed Medicaid assessment data from the state of North Carolina with the latest data extract from Nursing Home Compare. Once those were linked up we just use a simple linear regression analysis like so:

What that chart is telling you is that there appears to be a relationship Medicaid case-mix index and overall nursing case-mix (or required hours). This makes intuitive sense because at least some of the Medicaid assessments are used to calculate case-mix hours. (Or even all, who really knows?)

Specifically, we are explaining slightly less than 60% of the variation in the data using just Medicaid case-mix. This isn’t too bad if you consider in North Carolina we use a “point in time date”, often called a “picture date” in other states. CMS uses a much more complex criteria to select assessments to include.

The slope of our regression line is 1.307. This means that for every 1 point change in Medicaid case-mix, the overall nursing hours expected by CMS for staffing ratings increases by 1.3 hours per patient per day. If you happen to be close to the lower cut-point for staffing ratings and your acuity increases, you could drop a star. (As luck would have it, we have a great tool for checking how close you are to the next staffing cut point. Check out Staffing Navigator™. It’s free!)

How do I use this?

Using this estimate, we can figure out the break even point between case-mix “slope” and hourly nursing pay. Bear with me a moment:

First we can use the CMI “slope” to estimate the change in Medicaid pay like this: (I am using North Carolina data as well as the 34 grouper for this experiment. I am ignoring changes in Medicare Part A.)

Here is the equation to calculate daily change in revenue for Medicaid for a given change in case-mix:

CodeCogsEqn (7).gif

Here’s the equation for the change in nursing expense for a given change in case-mix index using our slope from the regression analysis:

CodeCogsEqn (8).gif

To find the break-even point we just set those two equations equal and solve. We end up with this beauty. Fee free to admire it’s elegant simplicity. I’ll wait. (This will set the mood as you take it in.)

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So if you believe your case-mix “slope” is $77 per point, divide that by 1.307 and you get $58.91. That means that as long as your fully loaded expense to hire and pay nursing staff (ALL nursing staff) is less than $58.91 per hour per nurse/assistant, an increase in case-mix index will cover the cost of increased nursing hours. (This is an oversimplification since nursing hours can’t typically be adjusted in fine increments, very large facilities excepted.)

If the average fully loaded pay of all nursing staff in your facility is greater than $58.91 per hour, you have my sympathy but with all due respect, check your math. Additionally, $77 is probably low. The take-away: Increased acuity (either real or due to improved documentation) may indeed increase the need for nursing staff to maintain a star rating, but increased pay from Medicaid should always cover it.

The sub-take-away: Always be closing improving documentation!

P.S. You can get an exact number for slope by examining your reimbursement report. It may be as high as 100. If you aren’t comfortable with that, let me know. I will help you.

Want to talk? Let’s.

Staffing Navigator™ - A Case Study

In today’s posting I am going to explain how to use Staffing Navigator™ to diagnose and troubleshoot a staffing issue that is causing problems in a 5 Star Rating. This post will also explain staffing cut points which can be confusing.

If you haven’t already, download Staffing Navigator™. It’s free in the app stores.

Hypothetical Problem Statement

Let’s say we work with a facility that bounces between 4 and 5 stars on Nursing Home Compare. It’s become a problem for one reason: This is a facility that markets itself on being 5 stars. They can’t have the rating occasionally slipping to 4 stars.

This is what most of us would consider to be a nice problem to have but it’s still a problem to solve. Let’s use Staffing Navigator™ to troubleshoot.

First, we select the facility from the list and check out the current situation. Right away we can see a few things:

Figure 1

Figure 1

  • The survey is quite good at 4 stars. Getting that survey to 5 stars would be one way to solve the problem.

  • Neither Quality nor Staffing are high enough to get an extra star, but staffing might be close. We’ll need to investigate further.

  • This building has average size and acuity, so changing the staffing rating should be reasonable to do. (I’m basing this on the SEI. See the app for details.)

(If you aren’t familiar with the rules, touch the word “Staffing” for documentation that includes the rules and a handy table showing how RN and overall ratings translate into staffing stars.)

For the sake of our example, let’s say the facility recently had a survey that is going to be with us for a while. So while improving the survey rating is the most important thing to do, it isn’t the most expedient.

Figure 2

Figure 2

Next, scroll down to the Adjusted Hours section. I find this part of the app is the most confusing for people so let’s spend a little time here.

The hours you report on your PBJ are not used directly to determine your staffing ratings. The hours are first adjusted based on the acuity of your residents and the national average number of nursing hours. After those adjustments are made, then the cut points are applied and you see a rating. That’s why your adjusted hours don’t match reported hours. Adjusted hours, not reported hours, drive ratings.

Second, we need to understand CPP. CPP is telling us our position between the cut points. If CPP is 99%, that means you are right on the cusp of the next higher staffing rating. Likewise, a CPP of 1% means you are on the edge of moving down a rating. A CPP means of 50% you are exactly between cut points.

This is important because even when your PBJ doesn’t change at all, the number or residents in your building and their acuity does. Remember we use adjusted hours not reported hours. If your CPP is either very low or very high you will find staffing ratings bouncing around from quarter to quarter.

Figure 3

Figure 3

Let’s take a look at our adjusted hours again. I’ve highlighted the RN CPP of 92.0%. This means we are very close to the next higher rating for RNs.

If we take a look at the star rating table, we can see that we’re currently at an RN staffing rating of 2. Given our CPP of 92%, we would occasionally expect to drift into an RN rating of 3, which would give us 4 overall staffing stars and trigger an additional overall star. (Again, see the rules below the table in Figure 4 in the app.) We’ve identified a possible cause of the problem.

Figure 4

Figure 4

Now that we understand what’s happening, we can start to make some recommendations. The first thing we want to do is select an RN target rating of 3. After we do that, we check the results.

Figure 5

Figure 5

You can see in figure 5 that the optimizer is trying to reduce LPN hours to get to the least expensive way to get an RN rating of 3 and a total rating of 5. Since we’re just trying to work on RN hours, this isn’t really what we want. We want the optimizer to leave the LPNs and CNAs alone and let us focus on the RNs.

To do this, touch the “Minimum Hours” button at the bottom of the app and then touch the “Use Current” button and then touch “Back to Detail”. This tells the optimizer “Don’t make any changes unless I change a target.”

Back at the detail, we can see that’s exactly what’s happened. (See Figure 6.) The optimizer is telling us we need to add 10% of a full time RN to all shifts to get to 3 RN stars. But we aren’t quite done.

Figure 6

Figure 6

Looking at the adjusted hours, notice that the CPP is 0.0%. If we’re trying to protect against fluctuations in acuity and caseload, this isn’t going to help. We need to push away from the cut points.

Figure 7

Figure 7

Fortunately, this is easy to do. We need to tell the optimizer we want more margin. Touch the “Minimum Hours” button and check the “CPP Target”. It’s set to 0% which means the optimizer will stop exactly when it hits the cut point. This isn’t what we want. In this case we want plenty of margin so we’ll choose 50%. That would place us exactly between the cut points.

Figure 8

Figure 8

Notice in Figure 8 that we now have an optimized CPP of 49.8%. That’s plenty of margin. (Also notice that the CPP target of 50% caused the overall hours to be increased as well. If we want 50% margin for RN, it doesn’t make sense to keep the CPP for total nursing hours at 7.6% so both are increased.)

Figure 9

Figure 9

Here are the final optimized hours. (Figure 9) We now safely have a 3 RN rating and a 5 total rating which gives us 4 staffing stars. (Is this the cheapest way to get a 4 star staffing rating? Let’s call that homework. Staffing Navigator™ can easily do that too.)

Figure 10

Figure 10

If you’d like additional help with Staffing Navigator™, or quality measures, or rehab obviously, then contact us!