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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!

Introducing: Staffing Navigator™!

Today we’re introducing a new software tool: Staffing Navigator™! This tool is intended to help operators understand how acuity, number of residents, nursing rates and mix (RN, LPN and CNA) work together to determine your staffing stars. Additionally you can use Staffing Navigator™ to:

  • Determine the ideal mix of RN, LPN and CNA to achieve any star level

  • See how close you currently are to the next highest (and lowest) star

  • Understand how the acuity and caseload of ANY facility compares to any other

  • See how many additional (or fewer) nursing hours it would take to hit any staffing level

  • Run complex nursing staffing scenarios

  • See acuity, number of residents and staffing levels for any facility in the US!

In the remainder of this posting I am going to explain in detail how to use this tool. But before I do that, let me just say: This is an advanced tool intended for users who understand staffing planning, star ratings, hourly and fully loaded nursing rates. It is a tool we use to help people understand what it would take to improve star ratings. You may need additional training to effectively use this tool. (Let me know if you’d like to do some private training using this new tool.)

If you’re still interested, great! Let’s get started. First things first, download Staffing Navigator™ from your app store. (Yes, it is free!, Spread the word!) Click one of the links to the right to install it.

Get it on Google Play

A tour of Staffing Navigator™

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Now that you’ve installed and before I explain how to use it, let’s take a tour of the interface.

Once you have selected a facility, you will see the screen to the right. Note the letters by each section.

Current Ratings (A Left)

The current ratings are taken directly from the Nursing Home Compare website. This information is for reference and does not change as you work on different scenarios.

SEI (A Right)

SEI is a metric developed by Broad River Rehab. It tells you how difficult it will be for this facility to change star ratings compared to all other facilities in the country. An SEI of 50.0 would mean that half the SNFs in the country are more costly to change staffing star ratings and half are less.

SEI takes into account both acuity and number of patients. The higher either of these, the more expensive it will be to increase your staffing star rating. You can touch the box for more information on SEI.

Targets (B)

We’ll cover the targets much more in depth later. For now, just understand that when you first select a facility, these will both be set to you current staffing ratings. Note that the small star(s) under the dropdowns tell you what your staffing star rating would be if your staffing ratings matched the dropdowns.

Labor Hours (C)

The labor hours section shows you the current actual labor hours per patient per day for the three nurse types. The next two columns show you the optimized hours and the difference between optimized and current hours. (Much more on optimization later.) The last column shows you the increase or decrease in staff to get to the optimized level of staffing.

Labor Expense (D)

Labor Expense (highlighted) shows your current labor expense based on actual hours reported and the rates you have configured. (More on rates later.) Like the labor hours section, this area shows you the difference between your actual hours and optimized hours.

Adjusted Hours (E)

The adjusted hours (not highlighted) show you current and optimized adjusted hours as well as how close you are to the cut points. If CPP equals 50%, that means you are exactly centered between the cut points for the current staffing level. Likewise, if CPP is 99%, you are very close to the next star rating.

Minimum Hours & Rates (F)

These will both make more sense to discuss as we talk about optimization, but the navigation buttons are at the bottom of the screen. For now we’ll just say that you can configure rates and minimum hours to do many different types of analysis.

Let’s move on to actually using Staffing Navigator™!

 

How to use Staffing Navigator™

Okay, let’s get to some usage examples. Select a facility on your app and follow along. I would only caution you that selecting a one-star overall facility can be misleading: if the survey score is one then the overall is going to be one regardless of other factors. Likewise, facilities with an RN rating of one can be confusing as well. Make sure you have a good understanding of the star rating rules before you study edge cases.

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I’m using this facility for my example. It’s got 2 overall stars with a two rating across the board for staffing. The SEI is 89.7 which means this building has high acuity, a relatively high number of residents and it’s going to be expensive to increase the star rating.

Initial1.PNG

Scrolling down, we can see the optimizer is suggesting changes to all three nursing types. Although we haven’t changed the RN and overall staffing targets, the hours can are still optimized for the current star rating, based on the minimum nursing hours and the rates, both of which can be configured to your needs.

The rates are straightforward and easy to understand. By default the rates are set to national average rates from the Bureau of Labor Statistics. More on these later.

The minimum nursing hours are a little more complicated. CMS publishes something called case-mix hours which are essentially the hours CMS expects to see given the reported acuity of the residents in the building. (These used to be called expected hours but have recently been changed to case-mix hours.)

By default, Staffing Navigator™ uses these case-mix hours as the minimum hours for each nursing type. You can see in my example facility both RN and CNA hours are less then than the case-mix hours so both were increased. LPN hours are higher than case-mix targets so LPN hours have been reduced. (I’m oversimplifying here. There are actually a few more things going on, but you get the idea.)

You can easily change the minimum hours to the actual hours, which will cause the optimization not to reduce any hours. Use this if you don’t want to reduce hours or staffing. Just keep in mind that you aren’t really optimizing at that point, but the tool will do whatever you ask. This technique is useful if you want to simply reach the next star level and you aren’t as concerned about the cost.

You can also reduce the minimum hours to zero, but beware: star ratings favor RNs, and CNA rates are typically lower than LPNs. If you set the minimums to zero you will not get any LPN hours. This isn’t a bug, it’s just the natural outcome of star rating rules and the economics of nursing.

Initial3.PNG

Based on this optimization, you could save $329.94 per day while maintaining a two star rating.

Back to the rates: the default rates are national averages and are not fully loaded. I highly recommend you update these rates for your market and use fully loaded rates if you plan on using the labor expenses for more than just differential comparison.

Below that, you can see that initially the RN hours were 5.6% away from the lower cut point for 2 stars. A small upward change in overall acuity or an increase in residents will cause RN hours to fall below that cut point and result in an RN staffing rating of one which would drop this facility to one staffing star. This is a serious concern.

After optimization, you can see we have much greater room for fluctuations in acuity and occupancy. You will find this isn’t always the case when doing optimizations however, as we’ll see next.

Simulating an Increase in Staffing Star Rating

So for my example facility you can see we have two overall stars. For a lot of markets, having less than 3 overall stars will have a negative effect on Part A admissions so getting one extra overall star could be very important. We can get a bonus star by getting our staffing stars up to four and we want to know how much that would cost. This would help answer the question: “Should we focus on increasing staffing or improving quality measures?” (Note that for this building, an additional quality star would result in a bonus star as well.)

targetChart.PNG

Our first hint should be the SEI of 89.7. That tells us right away that this is going to be expensive. The next thing to consider is what actions do we want to take. If you touch the blue circle or the section title “Adjusted Hours” you’ll see the cut point table. I’ve highlighted both where we are currently as well as three potential place we could go to get 4 staffing stars.

All we have to do now is change the dropdowns and compare the results. This type of analysis is called differential analysis: we don’t care about the exact dollar amounts, just which on is lowest. If we decide we’re actually going through with this, we would need fully loaded rates and we’d want to check facility acuity and caseload over time to see if this data accurately represents normal running conditions or is this quarter an outlier. In other words, this tool is pointing you in a direction only. Due diligence is important.

Scenario RN Total Change in Expense
1 ★★★ ★★★★★ $2,362.05
2 ★★★★ ★★★ $1,330.37
3 ★★★★★ ★★ $2,729.77
Optmized4Star.PNG

You can see that scenario 2 is the least expensive. Let’s take a closer look at the results.

We chose an RN rating of 4 and an overall rating of 3. You can see the optimized staffing changes to the right. We’d need to hire about 60% of a full time CNA for all shifts and a challenging 2.4 full time RNs for every shift. (You don’t need to spread those RN hours over all shifts, you just need the hours at some point during the day.)

You can see the optimization reduced the LPN headcount by nearly 1.5, which offsets the cost somewhat.

Speaking of cost, this is by no means inexpensive. Using national average rates, (again, not fully loaded) we’re looking at an increase of $485K annually.

Remember that SEI of 89.7?

Lastly, look at the adjusted hours. Notice that the optimizer hit the nursing target with minimal expense, which means you are very close to the lower cut point. If you were planning to implement this change, be aware that these are the minimum required hours to get the star rating. There is no margin for error built in.

Other Analysis

With a little practice and thought, there are hundreds of different scenarios you can do with this tool. You can also request private training sessions or custom analysis of your facilities.

PDPM Navigator Lite™ - Free in the App Store!

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We’ve decided to offer a lite version of our PDPM Navigator™ to everyone FOR FREE! PDPM Navigator Lite™ does everything that our website PDPM Calculator does (and more) but it does it all on your phone. You can use it wherever, whenever, however. No internet is required after the install.

How do you get it?

Simple. Click the links below and download it.

 
Get it on Google Play
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PDPM Navigator™ - Lite versus Pro

Feature Lite Pro
All Default Clinical Categories Yes Yes
All 50 Non-Therapy Ancillaries Yes Yes
Section GG Yes Yes
Speech Comorbidities Yes Yes
Nursing Categories with Requirements Yes Yes
HIPPS Codes Yes Yes
Length of Stay Yes Yes
Wage Indexing (Urban & Rural) Yes Yes
Detailed Summary Yes Yes
Complete ICD-10 Mapping to Default Clinical with FULL Search NO Yes
ICD-10 Mapping to I8000 Speech Comorbidities NO Yes
ICD-10 Mapping to I8000 Non-Therapy Ancillaries NO Yes
Email Reports NO Yes
RAI Manual Explanations & and Reference Pages NO Yes
Increased Compliance at Your Fingertips! NO Yes

When you’re ready to go PRO, contact us to find out how!

PDPM Calculator - Thank You!

Since we launched the PDPM Calculator in May of 2018, we’ve received an incredible amount of positive feedback. We’re truly flattered by the response. What started as a tool to help us understand PDPM has turned into something the entire community is using to get ready for this change.

We’d like to say a HUGE THANK YOU to everyone for their kind words, encouragement and suggestions for improvement!

  • The calculator is currently in use in the 48 contiguous states. (Where are you Alaska and Hawaii? Especially you Hawaii. We see you reading the blog!) I think I’ve spoken to people in nearly every state about it. Keep it coming!

  • A lot of our competitors use our calculator and at least one uses it to train their staff! Let us know if you’d like on-site training!

  • We even have users who may or may not work for CMS. (Don’t worry, we won’t tell.)

  • There are consultants from coast to coast using our calculators to train their customers! We’ve also trained a few of them. (If you are a consultant and we haven’t spoken, please contact me. I’d love to learn more about your business!)

  • The PDPM Calculator is the most popular PDPM tool that isn’t published by CMS according to Big G.

All of this is very humbling. That’s why we’re really excited to be releasing PDPM Navigator! Read more about it. Navigator is basically like the calculator, but with ICD-10 codes, RAI rules and you can use it anywhere on your phone or tablet.

We are looking for industry experts and influencers to try out Navigator and tell us what they think. (Corporate MDS, consultants, journalists, etc)

If you would like to help us shape the future of Navigator sign up right now! (Put ‘Navigator’ in the Subject line.)

PDPM Navigator™

You might have noticed that we’ve been pretty quiet on the blog recently. The reason is that we’ve been very busy building a tool for the future.

Our PDPM Calculator is incredibly popular but it doesn’t work well on a phone. We decided we needed a mobile version. THEN we decided to make it better, WAY better.

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We’re proud to be launching

PDPM Navigator™!

PDPM Navigator ™ does so everything the calculator does AND:

  • It works on your phone, obviously. But not only that, it works even when you don’t have internet access! Want to study PDPM while you’re on a long flight? PDPM Navigator™ can do it.

  • ICD Coding and PDPM Mapping! ICD-10 coding drives everything in PDPM. Imagine having all those codes in the palm of your hand. You can search them and see which PDPM categories they map to, color coded for ease of use!

  • NTA ICD-10 mapping is included! 27 of the NTAs are driven by ICD-10 coding. (Did I mention ICD-10 coding is important?) With one click you can see all the ICD-10s that are valid for each of the 27 non-therapy ancillaries that are ICD-10 driven.

  • Email Reports! With two taps you can email yourself a report that summarizes your PDPM Navigator™ session. You can even email a report to a client or co-worker.

  • Nursing “RUG” Requirements are included. Need to know which conditions and GG functional scores are required to be a CDE2?

    PDPM Navigator™ has it in one touch.

We designed PDPM Navigator™ to be an easy resource to help people who work on the front lines of delivering care. PDPM Navigator ™ will make it easy to get the data you need quickly and efficiently so you can spend more time working with your team to deliver great care and less time digging through manuals and searching Google for codes.