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Providing Measurable Value In CaseMix

How many therapy companies tell you they’ll help you improve your case-mix? How many tell you they’ll help you with ADL training? (Section G isn’t going away if you live in a case-mix state.) How many claim their clients have better reimbursement because of more complete documentation?

The answer is nearly all of us make those claims.

How many rehab companies follow through? How many are will to talk about proof that they follow through?

Let’s look at the data

The following information came from the state of North Carolina.

Broad River Rehab Customers have higher average ADL scores.

Statewide our customers average higher ADL scores. Why? Better documentation: We train our customer CNAs to recognize the work they do and document it appropriately. Our acuity isn’t higher but our percentage of correct documentation is.

We use on-site as well as mobile training to continue to reinforce Section G. Training isn’t an event, it’s a way of life in skilled nursing.


Broad River Rehab Customers have higher than average case-mix.

Proper documentation results in more accuracy. More accuracy in case-mix usually brings higher case-mix. It isn’t complicated but it requires sustained effort and focus.


Broad River Rehab Customers have higher than average Medicaid PPD.

This one should be obvious, but here it is. Our customers average about $10 per patient per day more.


But, correlation does not equal causation!

Right you are. Let’s look at a facility we started serving in Kentucky recently. (I am picking this one for convenience. The North Carolina buildings look the same.)

Case-mix went up.


Pay followed.


In this building, Broad River Rehab was the only change. We’ve seen this happen again and again.

If you think your provider is under-performing or isn’t responsive to your needs, we can talk about strategies to help improve. We can create an action plan to help with case-mix, star ratings, or quality measures. We can also help get you ready for PDPM.

Contact us today!

Q4 2018 North Carolina Medicaid Data

Q4 2018 North Carolina Medicaid Data

The data used to set rates for skilled nursing facilities in North Carolina for the final quarter of 2018 is here. We mine this data every quarter for not only trends but to also identify opportunities for us and our clients. I’ll summarize the major points here.

Overall case-mix index continues to climb. No surprise here. In each state that implements case-mix, the index tends to rise over time. North Carolina is no exception. (In states under case-mix for a very long time I’ve seen rehab as high as 70% for Medicaid.) As you can see in the image to the right (click to enlarge), the latest increase of 0.0088 is not the highest we’ve seen but is significant.

ADL scores continue to fall. This one is more surprising given how important ADL scores are. I don’t know what exactly drives this trend but I do have a suspicion. (click to enlarge) Don’t let this happen to you. ADL scores are important. Contact us for help training!

click to enlarge

Rehab continues to dominate the Medicaid categories. This quarter continues a trend of rehab taking more patients from Reduced Physical Function and others. What makes this quarter more interesting than most is for the first time in a while we have a reduction in extensive services. The Rehab category picked up an unusually high 4%. This is what is driving the increase in overall case-mix, especially in light of the overall reduction in average ADL scores.

The number of people on Medicaid in skilled nursing facilities remains largely unchanged. It’s been higher. It’s been lower. It’s only about 70 people lower than the average for the past 6 quarters.


We have data for your facility as well if you’d like to see how you building looks compared to averages or your nearby peers. Contact me for more information!

4 reasons why you should have a robust Restorative Nursing Program in your facility

4 reasons why you should have a robust Restorative Nursing Program in your facility

Restorative Nursing Programs are essential for provision of care for residents in long term care.  Imagine yourself as a resident in a nursing home (for some that though alone causes anxiety) – would you want to maintain your physical ability to continue to be as independent as possible?  Would you want to have trained staff to provide individualized services for your needs (resoundingly the answer is yes!)  Beyond this fact, there are 4 distinctive reasons to build a robust Restorative system.

  1. OBRA 1987 – mandates we take care of our residents’ needs. The OBRA mandate specifically states that long term care facilities seeking Medicare or Medicaid funding are to provide services so that each resident can attain and maintain highest practicable physical, mental, and psycho-social well-being.  Further, each resident’s ability to walk, bathe, and perform other activities of daily living will be maintained or improved absent medical reasons.  This is clearly instructing all of us in long term care that we have a responsibility to each of our residents to provide care equitable to the mandate.  Per the RAI Manual, “Restorative nursing program refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psycho-social functioning.  These 2 descriptions are exceptionally similar, indicating that Restorative Care Nursing programs are instrumental in meeting the OBRA 1987 requirements.

  2. 5-star rating system, with emphasis on Quality Measure portion - There are multiple quality measures that can be positively affected with Restorative Nursing Programs. Long-Stay resident measures include:

    • Percentage of residents whose need for help with activities of daily living has increased

    • Percentage of residents whose ability to move independently worsened

    • Percentage of high-risk residents with pressure ulcers (sores)

    • Percentage of residents who self-report moderate to severe pain

    • Percentage of residents experiencing one or more falls with major injury. 

      With appropriate Restorative Nursing Programs in place, residents can be assisted with maintaining physical functionality and mobility which will also decrease risk of pressure ulcers and pain from inactivity.

  3. Jimmo V Sebilius which resulted in Medicare adding specific wording for skilled therapy services for “prevention of deterioration.”  Some of residents appropriate for this level of therapy can certainly benefit with the addition of Restorative Nursing Programs in conjunction with the skilled rehab services.  Maintenance therapy appropriate goals include:

    1. Preventing unnecessary, avoidable complications from a chronic condition, such as deconditioning, muscle weakness from lack of mobility, and muscle contractures

    2. Maintenance therapy goals also include reducing fatigue, promoting safety, and maintaining strength and flexibility.

      For a patient with a progressive neurologic condition, appropriate maintenance therapy goals include:

      • Maintaining joint flexibility

      • Preventing contractures

      • Reducing the risk for skin breakdown

      • Ensuring appropriate positioning. 

      Conjunctive skilled rehab services with Restorative Nursing Programs are key to adding into routine care services to assist with maintenance.

  4. Appropriate use of resources as related to reimbursement.  Regardless of RUG version and grouper utilized in each state, the addition of Restorative Nursing Services does not only provide required and appropriate care for residents but also includes a potential increase in reimbursement.  Restorative Nursing Programs can have a positive effect in numerous RUG categories including: Rehab, Behavioral Symptoms and Cognitive Performance and Reduced Physical Functioning.

Restorative often takes a back-seat to more pressing issues, like staff shortages, but as you can see, it’s deeply important to our communities and deserves our best effort.

Q&A with Joel VanEaton


Q&A with Joel VanEaton

Recently Broad River Rehab welcomed Joel VanEaton to the team. In this posting we’re going to ask Joel some burning questions we’ve been wondering about and get his perspective.

BRR: How will PDPM change the role of the MDS nurse?

JVE: Under PDPM the MDS nurse will only become more important for one primary reason: under PDPM, the MDS nurse will change from an assessment manager to a true resident condition assessor. PDPM will really require the MDS nurses to return to their nursing assessment roots. Under PDPM, the payment the facility receives will be determined not by service metrics, like therapy minutes, but will be the result of the resident characteristic picture painted by the MDS. Essentially, what that picture represents, in terms of what statistically it would cost to take care of that kind of patient, will be what determines the payment that the facility will receive. It will be up to a gate keeper, the MDS nurse, to ensure that that picture is complete and accurate and best represents what the facility should be paid for the care delivered to each Part A patient. One misstep could cost thousands of dollars. Instead of keeping track of assessment schedules, Under PDPM the MDS nurse must be able to keep track of the residents fluid characteristic profile.

BRR: We're approaching a time where MDS nurses will need to simultaneously use PDPM, the 66 grouper for managed A and whatever Medicaid system their state uses. If you owned a SNF, how do you handle training?

JVE: Training under the current RUG groupers that will continue to apply should continue to be provided so that payment for managed A type patients and state Medicaid payments don’t lag. Moving throughout the next year, there should be strategic training modules provided related to the specifics of PDPM, not only from an informational but also an operational perspective. Training to understand PDPM as a whole and then breaking it down into its component parts will be essential. PDPM is such a new and complex concept with so many moving parts that providers will need to have a working knowledge of before October or 2019.  Training must be informative and practical. Getting a handle on your facility data related to the kinds of patients you currently serve will go a long way to understanding how you will need to operate under PDPM. Training through PDPM would focus on real world scenarios that utilize facility specific examples.

BRR: You interact with a lot of MDS nurses, what are the biggest opportunities for improvement you see?

JVE: First, from my perspective, ICD-10 proficiency is number one. Currently ICD-10 is really a background item on the MDS at least in terms of payment. As long as the codes are to the required specificity on the UB-04, there is usually no problem. Most MDS nurses have had no formal training when it comes to ICD-10. Most are not certified coders and most nursing facilities do not employ certified coders. That may change over time as PDPM gets under way. However, for the time being, most providers will continue to rely on their MDS folks to get the ICD-10 job done. That said, under PDPM there needs to be a renewed focus on having people in your facility who are proficient with ICD-10.

Second, I think a focus on understanding and increasing aptitude with the CAA process is paramount. I say this for two reasons. One, from my experience, this is one of the least liked portions of the RAI. Many MDS coordinator find this sections difficult and time consuming. However, It is one of the most important sections to the RAI process as it brings together the entire picture of the resident for care planning purposes. Two, Under PDPM, becoming proficient at this process will set the good MDS nurses apart from the great MDS nurses. Understanding the resident condition and characteristics completely and monitoring this for changes throughout the Part A stay will be the key to successfully receiving appropriate payment under PDPM.

BRR: You have a passion for teaching, where did that come from?

JVE: My original college degree is in theater arts. Even though that has only recently surfaced as something I am doing in community theater on a regular basis, something about sharing stories and information with people has, in some way, always appealed to me. Early on in my nursing Career, a wonderful lady who would go on to be a mentor to me in many ways, Dr. Mary Marshall, came to the facility where I was working as a MDS coordinator and taught us Medicare Part A. This opened up a whole new world to us and the way she explained it was invigorating to our understanding and operations. Dr. Marshall and I formed a special friendship over the years since that early meeting and she helped me open up and develop my teaching capacities. It was through her encouragement and mentoring that she connected me to the Georgia Healthcare Association in 2009. Through the GHCA, I was able teach MDS 3.0 at multiple sites throughout GA and grow in my teaching abilities and confidence level. Since then I have had many teaching opportunities and have grown in my passion for it. I love to be able to present difficult material, like Medicare Regulation, and watch the light bulb go on and the connections be made. I love seeing people become passionate for what they do by making it a little easier to understand what they do.

BRR: We didn't get outcomes with PDPM. Is section GG the future of outcome reporting? How do we reconcile outcome reporting, value based purchasing and Jimmo v Sebelius? When will we get outcome-driven reimbursement?

JVE: These are good questions and I wish I had a crystal ball. I do believe that section GG is the future of outcomes reporting primarily because it is a site neutral set of questions. The IMPACT Act requires both PAC site neutral quality reporting and payment. Notice that the QRP quality measures that originate with section GG that will be initiated this fall related to outcomes all begin with, “An Application of IRF Functional Outcome Measure”. In other words this is a version of a QM was already being reported in the IRF setting and is now being applied to the SNF setting. So the outcomes measures as well as the other QRP measures are or will be applicable to all PAC settings as mandated by the IMPACT Act.

I don’t believe that Jimmo v Sebelius will pose a challenge to reconciling outcomes reporting and or value based payment. Notice again the new section GG based QRP measures that we will begin reporting this fall; “Estimates the risk-adjusted mean change in self-care score between admission and discharge for SNF Part A residents discharged from a SNF”. And, “Estimates the percentage of SNF residents who meet or exceed an expected discharge mobility score. Unless you have a inordinately high number of medically necessary maintenance case on Part A, I don’t believe either of these measurements preclude maintenance programs even if payment, via incentives/penalties or direct adjustments, ever occurs.

I do believe that we will begin to see benchmark related payment adjustments due to outcomes in the very near future. We are already seeing them this fall related to re-hospitalizations via the VBP incentive. In Tennessee, the Medicaid program will begin to attach quality related payment adjustments based on outcomes beginning as early as July 2020. While no specific program has been proposed, it does not seem to me that it will be long until CMS attaches some type of payment adjustment to the annual Medicare rates based on outcome benchmarks rather than simple reporting thresholds.

BRR: Section GG is a subjective measure. How can we possibly expect to be able to compare performance between different facilities?

JVE: While it is true that section GG is subjective it is based on objective guidelines that everyone should be following out of the RAI Manual and data set. The best we can hope for is that a majority of providers will accurately code resident function based objectively on those guidelines. All  of the other QM data is the same: self-reported. Even the VBP incentive that will be applied this fall is subjective in some way as it is based on what the hospital reports.

BRR: Do you think state Medicaid plans will eventually migrate towards a PDPM model?

JVE: In the FY 2019 final rule, CMS seems to indicate that this is their ultimate desire. However, they also indicate that they understand the challenges that this would pose. Even though PDPM is designed a s a short term payment system, in time, I am sure that some version of PDPM will find its way to the state level. With that in mind, I do not foresee any impending change to PDPM at the state level any time soon.

BRR: What would you say to a nurse that wants to learn the MDS?

JVE: I believe that this is the best time since the advent of the MDS Nurse role to pursue a career as an MDS professional. Never in the history of MDS and PPS has there been a time where the MDS nurse can truly be a nurse and do the things they were trained to do. The PDPM will require that the MDS nurse be accomplished and capable resident condition assessors. It is a challenging yet rewarding time to be a MDS professional and it is my opinion that accomplished and capable MDS professionals will be one of the most sought after individuals in LTC.

BRR: With all the focus on PDPM, how do we make sure we don't minimize the importance of long-term residents?

JVE: We are, after all, LTC communities. The bulk of who most facilities care for are long term. One way to ensure that we do not lose focus is to not assume that because there will be fewer PPS assessments that we need fewer MDS nurses. See my answer above for why that is true. Assessing LTC residents is just as important as it is for the short term resident. Facilities can’t lose that focus. Systems that are in place for doing this won’t go away. Learning PDPM will be a curve that we will navigate and become successful at. Caring for LTC residents, as well as capturing that care for appropriate reimbursement, is something we are already good at and will continue to be despite PDPM.