CLINICAL REIMBURSEMENT ESSENTIALS for LEADERS. David Rokes, RN C.E.O.

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1 CLINICAL REIMBURSEMENT ESSENTIALS for LEADERS David Rokes, RN C.E.O.

2 Understand effective strategies and systems implementation to ensure appropriate reimbursement and withstanding audit scrutiny Understand effective Medicare management Understand the Medicaid Case Mix process Managing Managed Care Gain knowledge on the most common areas where reimbursement opportunities are missed Understand the importance of the MDS & it s relationship to Quality Measures Be able to define techniques for Denials management and the medical record review process

3 Increase in Daily Medicare Rates Increase in CMI Increase in Length of Stay Cost Containment Ensuring Compliance with State and Federal Regulations Process Standardization Throughout Facilities Improved Quality Care Through QM Focus Denials Prevention Increase Profitability of Managed Care

4 Decreased Funding from State and Federal Government Implementation Of Pay for Performance-Value Based Purchasing Govt. Move Toward Bundled Services ACO s and PACE Type Programs Increase in Transparency for Public Reporting Provider Relationships Setting yourselves apart from the competition Ensuring Appropriate Reimbursement for Services Delivered to Your Residents The Recovery Audit Contractors (RAC) are increasing focus in the SNF s

5 RUG Score Distribution Therapy Categories Nursing Categories End Split Capture Length Of Stay Appropriate Skilled Services and Documentation Therapy Program Implementation and Oversight MDS and Medicare Compliance Case Mix Management Implementation of Metric Tracking Tools QM Tracking and Management

6 Skilled Nursing Facility Primary Payment Sources Medicare Part A Managed Care Commercial Insurance Managed Medicare Part C Medicaid Private Pay Long Term Care Insurance

7 Daily Medicare Management

8 Daily Focused meeting with PPS team Nursing, Rehab, Business Office, Social Services, etc. Meeting should take no longer than 1 minute per skilled resident Effective way to monitor reason for skilling on a daily basis and update any changes in condition and/or treatment Process leads to clean month end close and effective Medicare management

9 Should actually lay eyes on the patient and hospital record to prevent any surprises Outpatient Treatments Watch for non-hospital based treatments CT scan, MRI, Venous Studies, etc. Bone Scans, urology work-up Diagnosis related treatments Behaviors Infections (requiring private room, long term IV antibx) Medications (i.e, epogen for pre-esrd)

10 Check CWF to ensure days available Contact Hospital Business Office to ensure patient had three inpatient overnights Contact other facilities if resident had a prior stay at another SNF Get copy of Medicare Card Do not assume that hospital has correct information Assignment of Benefits Authorization to bill Medicare on the beneficiaries behalf

11 Estimate RUG score and cost of treatment Therapy cost Consolidating billing charges Pharmacy, lab, Radiology Expenses Ensure copay situation in place Back-up payer source Can be skilled today but not tomorrow

12 Establish reasons for skilling Rehab # of disciplines to be involved Estimated time frame to meet goals Nursing Any treatments requiring daily skilled monitoring Infections, Wound Treatment, Cardiac Issues, Behavior Monitoring and Medication Adjustment, etc. Teaching Needs Diabetic Teaching Colostomy Medication Regimen Wound Care, etc.

13 Discharge Plan Estimated Length of Stay This is just an estimation, may vary greatly from by time of actual discharge Final Discharge Destination Home, ALF, Another SNF etc. Discharge Barriers Level of Function needed to reach D/C destination Any Community Services Medication/02 management Home management (e.g., stairs, ability to care for self at home, meal preparations)

14 ICD-9 Codes Reason for admission to hospital and continued need for skilled care in the SNF Use V-codes when applicable For Ortho aftercare Use appropriate code to specify area to be treated Remember we do not treat the actual fracture we are treating the aftermath Medical Codes Therapy Codes

15 ICD-9 codes (cont.) Be sure to have the most current ICD-9 code book as these are frequently updated 2013 was the last year of updates to ICD-9; ICD-10 will be implemented in October of 2014 Codes should paint a picture of why the resident is skilled Use only codes that relate to why the resident is currently in a Part A stay i.e., if resident has HTN that is stable and not affecting current treatment do not include

16 ICD-9 Codes (cont.) Make sure the codes support the services billed on the UB-04 If in a rehab category there should be therapy charges (only exception may be period pending an OMRA) Readjust codes as needed New onset of disease while in a Part A stay Newly diagnosed pneumonia, code should be on correlating month s UB-04 If issues resolved they should be deleted from the next month s bill

17 ICD-9 Codes (cont.) Watch for benign codes I.e., IDDM without complications (250.00) vs IDDM with renal manifestations (250.4 and follow with 5 th digit when necessary) etc. Updated ICD-9 codes should be communicated to the Business Office when they occur instead of waiting until the end of the month This can be one of the biggest hold-ups at month end close At least weekly Track Diagnosis and ICD-9 codes on log UB-04 only records the number codes ICD-10 Coming October 2014 Announced August 2012 that they would delay Oct 2013 roll-out for 1 year

18 RUGS-IV Management Know your 66 RUGS (Resource Utilization Groups) Categories and reasons for residents to qualify into each Do not use RUG score to determine whether resident is skilled or not RUG score sets up a payment rate, it does not mean that a resident meets daily skilled requirements Example: A resident falls into HE2 because of IV fluids that ended 7 days ago, but is currently clinically stable, may not require daily skilled care vs. another resident who was started on an antipsychotic 2 days ago may fall into a PD1 but requires daily monitoring for behaviors, medications and side effects management, frequent psych reviews, etc., this resident does meet the daily requirements

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20 Extensive Service Qualifiers Must be while a resident Ventilator or Respirator Tracheostomy Care Isolation for Active Infectious Disease

21 FY 2012 Changes to Assessment Reference Date Windows to reduce duplication of minutes on subsequent assessments Assessment Type ARD Range with Grace Days 5 day Days 1-8 (no changes) 14 day Days (was 11-19) 30 day Days (was 21-34) 60 day Days (was 50-64) 90 day Days (was 80-94)

22 Use days in allowable time frame, do not get caught in trap of setting routine days for all assessments (i.e., day 13 for all 14-day assessments or day 27 for the 30- day assessment) Use the day that best captures the clinical picture of the resident Examples: If a resident is receiving therapy 5 days a week, but during an assessment time frame refuses a treatment you may need to change days to get the most accurate RUG score for treatment delivered If a resident frequently receives transfusions and the ARD is estimated for Day 27 but a transfusion is scheduled for day 29, readjust the ARD to day 29 to capture the transfusions as this paints a more accurate picture of the resident s clinical condition

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24 ARD Management (cont.) Be cautious to not ignore medical treatments just because they classify into a rehab RUG score Most pre-pay and post-pay reviews conducted by Fiscal Intermediaries/Medicare Administration Contractors are in Rehab categories, if the F.I./M.A.C. medical review department does not feel that the therapy treatment delivered was appropriate, then they will drop the score into the next qualifying category; it s better to have a more appropriate clinical category than the default rate or similar.

25 MDS Cycle Discuss where they are in the MDS cycle daily ARD Status of completion (daily meeting is a good format to remind disciplines of need to complete) Date of Transmission Must be transmitted within 14 days of completion require a shorter time frame) MDS must be transmitted and accepted into the State/CMS database prior to billing (some states Some FI/MAC s are now cross referencing the MDS repository when UB-04 s are submitted

26 MDS Cycle Discuss RUG score to ensure that the group is in agreement with the outcome (esp. therapy to ensure the appropriate days and minutes were transcribed on the MDS) Combine OBRA Assessments as needed with the Medicare Assessment These two cycles run separately and should be combined whenever possible Recommend: Combine Admission Assessments with the 5-day to allow more time for CAA s to be completed and to not disallow use of grace days on the 14 day because Grace Days cannot be used on a 14 day/admission assessment to comply with OBRA regulations.

27 MDS cycle Remember: If resident is a readmit to the facility s/p hospitalization, and is not a significant change in status, then you only need to start the Medicare assessment cycle and combine with OBRA as needed I.e., 5-day can be combined with a quarterly if that is where it falls in the cycle You do not need to start a new OBRA cycle just because the medical record is closed per facility policy If discharge return anticipated (A310F=11) is completed then just pull the MDS history forward to the new record and start the Medicare cycle; Only need to restart the OBRA cycle if a discharge return not anticipated (6) was completed.

28 MDS Cycle LOA s If resident is out for MLOA for <24 hours (and not admitted to the hospital) and not in the bed at midnight, that day cannot be billed for and the MDS cycle is readjusted by one day, you do not need to start a new MDS cycle If out greater than 24 hours or <24 hours but admitted to the hospital then a new Medicare cycle must be started An exception to this rule can be a social leave, a new cycle does not need to be started upon return, but the facility cannot bill for the days that the head is not in the bed at midnight (use caution in these situations as it may jeopardize Medicare coverage)

29 OMRA s (Other Medicare Required Assessment) Now there is an End of Therapy OMRA and a Start of Therapy OMRA End of Therapy OMRA Required only if the resident was in a Rehabilitation RUGS-IV Classification and will continue to need Part A SNF-level services If last RUG score was in a clinical category an OMRA is not required May be set day 1-3 after completion of all therapy. Payment changes on First Non-Therapy Day Start of Therapy OMRA When a resident returns to Therapy 5-7 days/week ARD is set 5-7 days after therapy starts

30 OMRA (cont.) Last day treatment was furnished is day zero Not the day the discharge order was written May vary due to refusals, MLOA s, late order transcription Billing changes on the start or end date of the Therapy (unless it is into grace days, then you need to go back to the original date of the payment change over)

31 End of Therapy Resumption (EOT-R) To replace End of Therapy OMRA and Start of Therapy OMRA s on residents that missed at least 3 consecutive days of therapy but resume services with in 5 days Require one MDS to be completed rather than two Resumption must classify into the same RUG level Will require new item set on the MDS O0450A and O0450B resumption of therapy dates

32 Change in Therapy (COT) OMRA Needed whenever there is a change in therapy level that would result in a change in RUG-IV level using RTM (Reimbursable Therapy Minutes) rather than just total minutes reported on the MDS. Must monitor residents on a rolling 7 day cycle beginning the day after the previous assessment reference date For example, if a 14 day MDS ARD is set on day 14, then the facility must monitor minutes delivered days 15 through 21. If a decrease in RTM s is noted then the COT would be performed. Payment would change on day 15 to the new RUG-IV level. Then reassess on day 28. ARD would be set on the 7 th day resulting in payment change

33 Recent clarifications: When a COT and regularly scheduled assessment are due at the same time the facility has the decision to decide whether to combine or not. For example, if the COT and 14 day assessment are due on day 14. The facility would be better off combining if the RUG category went up; and doing the 14 day as a standalone if the RUG category went down related to the 7 day retrospective payment that accompanies a Change of Therapy OMRA.

34 Reasons to Skill Know the Medicare Regulations Publication 12 is no longer an active manual INTERNET Based Manuals are the most current information source Ensure all disciplines are aware of why the resident is in a Part A stay Esp. the nurses on the unit so they understand what needs to be documented and monitored

35 IV medications, IV therapy, and IM injections SQ Injections are not deemed skilled NG tube, G tube, J tube feedings Feedings account for 51% of daily calories or 26% of daily calories and 501cc Nasopharyngeal and tracheotomy aspiration

36 Suprapubic catheters Insertion, irrigation, and replacement of urinary catheters has been deleted Application on dressing involving prescription medications and aseptic techniques Pressure or stasis ulcers 2 or more of any stage and treatment Any Stage III or IV pressure ulcer and treatment

37 Reasons to Skill Management and Evaluation of a Care Plan Are you establishing and/or monitoring the treatment regimen to meet the resident s physical and emotional needs? Do needs require licensed staff to manage them? Are the total sum of unskilled services requiring skilled management? Are you providing the nursing process of observation, assessment, planning, implementation and evaluation? Risk of complicating factors, high probability of relapse Is the resident s condition stabilized?

38 Reasons to Skill Observation and Assessment Is there the likelihood of a change in the resident s condition? Are skills of a licensed nurse required to monitor and evaluate the possible for a modification to treatment? Is there a need to initiate medical procedures (labs, radiology, blood gases, etc.)? Does the physician think there is a high likelihood of a change in condition?

39 Reasons to Skill Observation and Assessment (cont.) Is there a need to observe for therapeutic effects and/or adverse side effects of drug dosage adjustments or newly prescribed medications i.e. Coumadin, antibiotic therapy, new or adjusted steroid therapy, chemotherapy, pain medications, cardiac medications, psychotropic medications Is the resident dehydrated, electrolyte imbalance Are you performing daily assessment for: neurological, respiratory, cardiac, pain/sensation, gastro-intestinal, nutritional, circulatory, genito-urinary, musculoskeletal/mobility, skin

40 Reasons to Skill Teaching and Training Activities Self-Administration of: Injectable Medications Complex Range of Medications G-tube Feedings New Diabetic (Medications, dietary changes, foot care) Self Catheterization Skin/Wound Treatments Prosthesis Care, Care of Splints, braces, orthotics Maintenance of Central Lines, Suprapubic tubes New colostomy or ileostomy care

41 1. Must be directly and specifically related to an active written treatment designed by the M.D. after any needed consultation with a qualified therapist Signature must be obtained prior to billing Medicare 2. Must be of level of complexity that requires the judgment, knowledge and skills of a qualified therapist 3. Assessment based on patients restoration potential in a reasonable and generally predictable period of time 4. Services are necessary for establishment of a safe and effective maintenance program

42 Reasons to Skill Rehabilitation Needs At least 5 days per week Watch for Dialysis patients, rehab must be at least 5 separate days a week to meet skilled criteria Caution: Watch for residents falling into RM category who do not receive therapy 5 separate days a week The MDS cannot tell if it 5 different days when there is a combination of therapies, i.e. PT and OT 3 times on the same days Therapy must be delivered for at least 15 minutes a day to code on the MDS (this does not need to be all at once)

43 Reasons to Skill Rehabilitation Needs: Count only therapy delivered in the facility or with the facilities therapists (i.e. home eval/treatment) Count only actual treatment time-reimbursable Therapy Minutes Group therapy cannot exceed 25% of the time in the 7-day observation period Number of Disciplines Involved Monitor minutes delivered on a daily basis as a team when they are in the assessment date range Appropriate amount of disciplines and minutes for the assigned RUG score

44 Reasons to Skill Rehabilitation Needs Be sure the therapy department is aware of any planned LOA s (medical or social) to adjust treatment times accordingly Monitor refusals for any reason (medical, emotional, etc.) Monitor for change in RUG levels for COT Again, Monitor ARD s closely in this time frame Discuss any D/C planning needed for therapy (continued treatment at home, any medical equipment needed such as wheelchair walker) Status of Discharge Barriers

45 Rehab Low with therapy involvement Restorative Nursing Therapy 3 days a week for at least 15 minutes a visit and restorative 6 times a week in qualifying areas for at least 15 minutes in each (they do not need to be 15 consecutive minutes) This makes more sense for the LTC resident in that the actual transition plan will be over to nursing Know if your M.A.C. allows for restorative as a stand alone skill Probably no more than 2 weeks Must have 6x/week in 2 areas at least 15 minutes each, licensed progress notes (can be written by R.A. and countersigned by nurse), and care plan Must have goals for continued improvement Recommend an MD order is in place but not required

46 The key to success is appropriate/accurate documentation!

47 ADL Score One of the most inaccurate areas in the DAVe audits Facilities tend to under code this area Remember to include care delivered around the clock Many residents require increased levels of care at night Monitor ADL care given by all disciplines In therapy, activities, esp. with the Nursing Assistants on all shifts Code for actual care delivered not what you think the resident is capable of doing

48 ADL Score (0-16) Bed Mobility (0-4 Points) Eating (0-4 Points) Toilet Use (0-4 Points) Transfers (0-4 Points) One incorrect coding of an ADL category from limited to extensive assist or number of assist required can cost over $ 120/day

49 DME/Dressing Supplies/Oxygen Are we using the most cost effective appropriate treatment for the resident Know what cost entail on a daily basis Monitor Supplies/adaptive equipment ordered Be sure any special equipment for the resident is labeled Custom W/C s, W/C cushions, Dressing and O2 supplies, IV/Tube feeding supplies

50 Pharmacy Cost Know the medication regimen prior to admit Is there a less expensive equal alternative? Discuss any changes in medication treatment Especially IV therapy, Epogen, Neupogen type medications Monitor your pharmacy bills to ensure the charges are correct Correct medication for patients and price Watch for house stock medications being ordered as resident specific from the pharmacy Use your pharmacist s recommendations

51 Lab/X-Ray/Radiology Charges Review upcoming procedures Watch for unnecessary procedures and repeat procedures Know what was performed in the hospital and have available for Primary Physician Repeat stable tests (can frequency be decreased) Monitor invoices at the end of the month to ensure accurate prices and that test were actually performed on the stated resident s in a part A stay Are Medicare consolidating billing exclusions performed in an outpatient hospital rather than at the MD s office

52 Excluded services when performed in outpatient hospital setting: Cardiac Catheterization CT Scans MRI/MRA Radiation Therapy Angiography Venous Procedures Lymphatic Procedures Ambulatory Surgery involving the use of an Operating Room Certain Chemotherapy Drugs and Administration Services Dialysis and ambulance transport Physician Professional Services Certain Emergency Room Services ***Reviewing PET Scans for possible exclusion

53 Physician Outpatient Visits Watch for Outpatient Procedures and Visits Physicians can bill separately for the professional component Bill us directly for the technical component Example: Resident goes for MD appt and blood work is drawn, we pay for actual blood work, but the physician can bill for interpretation on the labs Do you and the physician have an authorization form in place to perform tests on a Part A resident Is the physician willing to perform certain tests in an outpatient hospital setting What tests can be done at the facility prior to the resident s visit to the physician s office (i.e. labs, portable x-ray)

54 Use the SNF Consolidated Billing Annual FI/MAC Update File (formerly the SNF Help File) on the CMS website to help find what the facility is liable for or whether the physician or service provider can bill separately Reimburse at the Medicare Allowable Rate with the correlating HCPCS code, also available on the CMS website, not the actual amount charged with mark-up (which can be over 1000%) CMS actually only pays 80% of this rate The provider should know ahead of time on your intention to pay at the Medicare Allowable Rate to avoid any confusion after the services have already been rendered (include with Provider Agreement or Continuity Form)

55 Transportation Monitor how your resident gets to outpatient destinations Is an ambulance necessary vs. chair Does the facility have a transport vehicle Know what is covered for ambulance transport ER Trips, Dialysis, Outpatient visits for consolidated billing exclusions: cardiac cath, MRI/MRA, CT scans, radiation therapy, etc.)

56 Keep the meetings brief and to the point Divert unnecessary non-team related conversations Expect team members to come prepared with the information they are expected to provide Wait until weekly meeting to elaborate if needed (i.e. ICD-9 code changes, future discharge plans) Have log updated and available for the month end close process

57 Continue to monitor residents in their 30 day window for any presence of returned skilled needs Number of days available after the part A stay Return to Part A without a hospital stay Monitor for 60 day break in skilled needs to see when the resident is eligible for a new benefit period/spell of illness

58 Monitor the status of non-coverage letters, SNF ABN forms Generic Notice (CMS Form 10123) Beneficiary has 48 hours to request an expedited appeal Detailed Notice (CMS Form 10124) Will be requested by QIO if appeal requested by beneficiary Keep MDS cycle going if QIO review or demand bill is requested or CMA review is anticipated SNF ABN form is available on CMS website (Form # CMS-10055) for Part A CMS is still working on final draft (will probably be different from current form available on the website) The intention is to replace all of the other forms (determination for continued stay, determination upon admission, etc.)

59 Reconciliation with Business Office, MDS Coordinator, and Therapy Department Verify: Certification/Recertification are updated (including therapy certs) SNF care must be certified upon admit, within the first 14 days and then every 30 days thereafter Have MDS been transmitted and accepted into the state data base MDS Info on UB-04: ARD s, RUGS-IV Classification, days in each category, correct HIPPS codes Therapy Charges (Do they support the RUG score?) Ancillary Charges (Are they appropriate?, Were they delivered?)

60 ANY QUESTIONS?

61 The Medicaid Case mix process David Rokes, RN C.E.O.

62 Participants will gain: Understanding of the Medicaid Case Mix Process Knowledge to implement an effective weekly meeting involving the interdisciplinary team Understanding of the importance of the relationship between the clinical team and the therapy department The skills to implement an effective Part B program The ability to withstand audit scrutiny Overview of the potential changes to the process

63 Most states have or are planning to move to the RUG-IV system Directly driven from MDS data 48 Group model seems to be what most states are implementing It uses all of the clinical/non-therapy categories Use one therapy category RA which is the equivalent of RM with 5 ADL index breakdowns A-E as is used in many of the clinical categories There are also many factors that vary state to state that tie into the rate. I.e. cost report information, capital cost components

64 Weekly IDT review Recommended team members Nursing leaders MDS Therapy Activities Social Services Daily review at clinical report for any potential significant changes in status and changes in treatment

65 Review of the long term care residents that are coming due for an MDS assessment in the next 30 days Review previous RUG score Monitor for the potential need for Part B therapy Recommend quarterly Therapy screens are conducted during this 30 day window RUG utilization review Review to see what clinical indicators are present and the time frames in which they are delivered

66 RUG Score Projections Clinical Indicators ADL Status Do you have a mechanism to review daily changes in ADL status? Most electronic systems have an ADL index report End Splits Restorative Program Behavioral Indicators Estimated Case Mix Index (CMI)

67 Ensure the team understands the elements of the RUG system Diagnosis capture For example, if a resident has a diagnosis of CVA is there the presence of hemiplegia Often find that this is documented in therapy notes but there is no supporting physician diagnosis ADL s Restorative nursing Respiratory Therapy Behavior monitoring and documentation

68 Restorative nursing program Must have 2 programs consisting of at least 15 minutes per day per program Must have measurable objectives and interventions documented in the care plan Must have periodic evaluation by a licensed nurse and be documented in the medical record Nursing assistants must be trained in techniques that that promote resident involvement Does not include groups with more than four members

69 Appropriate capture of Respiratory Therapy Must total 15 minutes per day and be captured 7 days Remember assessment time captured must be completed by an RN Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws.

70 Watch for increased frequency of MDS Missed significant changes in status assessments Inaccurate coding of MDS Lack of supporting documentation Lack of team coordination RUG confusion More likely when using RUG-III system for Medicaid as RUG-IV is used for Medicare PPS Watch for dips in CMI during the off-cycle

71 Currently NY case mix consists of multiple components Direct costs Indirect costs Non-comparable costs Capital expenditures

72 53 RUG III Levels (current system used) Rehabilitation Extensive Services Special Care Clinically Complex Impaired Cognition Behavior Only Physical Function Reduced There are currently 2 picture window dates-last Wednesday of January and July

73 I recommend to keep the CMI process going everyday all year as most states review every 3 months Only OBRA assessments Annual, Quarterlies, Significant Changes and Significant Corrections of Prior Assessments Additional assessments Significant Change in Status OBRA assessment after a change in payer source Hospice assessments when on or off of service Assessments must be completed within 92 days of previous assessment

74 Rigid ARD selection Pre-set, convenient date Mr. Long had his ARD set for day 90 & grouped into a custodial level. His blood pressure had been unstable with order changes & physician visits 2 weeks before the pre-set, standard ARD. Pre-set ARD did not capture his unstable medical condition CC1 = 1.05 PE1 = 0.85 Variance = 0.20

75 Reactive versus proactive approach Lack of resident review before assessment Mrs. Klein had her assessment completed & it was noted that she had declined with her ADL function. Therapy started treating her after her assessment was completed. If need for rehab was assessed earlier, this service could have been captured on the assessment RMC = 1.36 PD1 = 0.77 Variance = 0.59

76 ADL Management Coding errors Lack of ARD coordination Mrs. Smith has Multiple Sclerosis & her ADL Index score was 6. She needed weight bearing assistance with bed mobility, but it was not accurately coded. If it was accurately coded her ADL Index score would be a 7. Inaccurate coding of ADLs resulted in custodial level SSA = 1.11 PB1 = 0.62 Variance = 0.49

77 Run an effective meeting Screening process Having a strong and well run Part B therapy program Communication between nursing and rehabilitation Knowledge of definitions Maintaining compliance with MDS process Accurate MDS coding Back up systems in place- support for MDS department, Assistant Therapy Director

78 NY potentially looking at conversion from Involves Managed Care Organizations managing the process Pro s and Cons to the system Multiple different entities in the process A/R timing generally triples to quadruple Increased denials May help overall reimbursement as the rate is generally resident specific Can potentially save the overall Medicaid system money

79 QUESTIONS

80 SNF PPS RUG-IV By David Rokes, RN

81 Based on data from the STRIVE Project (Staff Time and Resource Intensity Verification) Used total of 205 Nursing Facilities from 15 states based on approximately 9,700 residents Hospital based, high concentration of ventilator dependent residents, HIV, and Medicare Part A stays 90% of SNF Part A received therapy

82 CMS requires therapist to track and report three different delivery modes of therapy (individual, concurrent, and group) Concurrent therapy (RUG-III method) The practice of one therapists treating multiple patients at the same time while performing different activities Two-Thirds of Part A SNF patients receiving concurrent therapy per Strive Study No MDS coding restrictions on number of patients being treated or limitation of total number of the minutes delivered via concurrent therapy Will allocate minutes per patient

83 Concurrent Therapy Changes Consists of no more than 2 patients (regardless of payer source), both of whom must be in line-of-sight of the treating therapist (or assistant) On MDS: Report the entire unallocated minutes of concurrent therapy Group therapy Consists of 4 patients who are performing similar activities, and are supervised by a therapist (or assistant) who is not supervising any other individuals On MDS: Report the entire unallocated minutes of concurrent therapy (as long as the patient limitation is not exceeded and the supervision requirement is maintained) Limited to 25% of minutes reported on the MDS All minutes will be divided by four

84 This method will reflect the resident s entire time receiving therapy. However, CMS will assign the RUG-IV category based on allocated concurrent therapy minutes and maintain the 25% cap on group therapy

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86 RUG IV ADL index ranges from 0-16 as opposed to RUG-III with 4-18 Based on Bed Mobility, Eating, Toilet Use and Transfers Eating Tube fed residents (K5a) no longer affects the ADL score Activity Did Not Occur will result in zero points

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90 Elimination of the preadmission look-back period on the MDS for Extensive Services STRIVE Study specifically focused on MDS 3.0 only focuses on services post admission to the SNF IV Medications Tracheostomy Care Suctioning Respirator/Ventilator Services Blood Transfusions

91 Tracked in Section O on the MDS columns: While NOT a resident CMS notes this is important information for care planning services While a resident To track adequate and appropriate payments; this will affect reimbursement for RUGS-IV

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93 Modifying the 8 subcategories 66 Categories Rehabilitation plus extensive services Rehabilitation 5 subcategories remain Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms and Cognitive Performance Reduced Physical Function

94 Extensive Services addresses three treatments as opposed to five: Tracheostomy Care Ventilator/Respirator Isolation for active infectious disease All while a resident and require an ADL score of 2 or more Presumption of Coverage remains for residents now classifying into the upper 52 categories on the 5 day MDS

95 Rehabilitation Rx 720 minutes/week minimum AND At least 1 rehabilitation discipline 5days/week AND A second rehabilitation discipline 3 days/week AND Tracheostomy care, ventilator/respirator, or isolation for active infection disease while a resident AND ADL Score of 2 or more RUX ADL Index: RUL ADL Index: 2-10

96 Rehabilitation Rx 500 minutes/week minimum AND At least 1 rehabilitation discipline 5days/week AND Tracheostomy care, ventilator/respirator, or isolation for active infection disease while a resident AND ADL Score of 2 or more RVX ADL Index: RVL ADL Index: 2-10

97 Rehabilitation Rx 325 minutes/week minimum AND At least 1 rehabilitation discipline 5days/week AND Tracheostomy care, ventilator/respirator, or isolation for active infection disease while a resident AND ADL Score of 2 or more RHX ADL Index: RHL ADL Index: 2-10

98 Rehabilitation Rx 150 minutes/week minimum AND 5 days any combination of 3 rehabilitation disciplines AND Tracheostomy care, ventilator/respirator, or isolation for active infection disease while a resident ADL Score of 2 or more AND RMX ADL Index: RML ADL Index: 2-10

99 Rehabilitation Rx 45 minutes/week minimum AND 3 days any combination rehabilitation disciplines AND Restorative Nursing 6 days/week, 2 services (see Reduced Physical Function Category for restorative nursing services) AND Tracheostomy care, ventilator/respirator, or isolation for active infection disease while a resident AND ADL Score of 2 or more RLX ADL Index: 2-16

100 Rehabilitation Rx 720 minutes/week minimum AND At least 1 rehabilitation discipline 5days/week AND A second rehabilitation discipline 3 days/week AND RUC ADL Index: RUB ADL Index: 6-10 RUA ADL Index: 0-5

101 Rehabilitation Rx 500 minutes/week minimum AND At least 1 rehabilitation discipline 5days/week RVC ADL Index: RVB ADL Index: 6-10 RVA ADL Index: 0-5

102 Rehabilitation Rx 325 minutes/week minimum AND At least 1 rehabilitation discipline 5days/week RHC ADL Index: RHB ADL Index: 6-10 RHA ADL Index: 0-5

103 Rehabilitation Rx 150 minutes/week minimum AND 5 days any combination of 3 rehabilitation disciplines RMC ADL Index: RMB ADL Index: 6-10 RMA ADL Index: 0-5

104 Rehabilitation Rx 45 minutes/week minimum AND 3 days any combination rehabilitation disciplines AND Restorative Nursing 6 days/week, 2 services (see Reduced Physical Function Category for restorative nursing services) RLB ADL Index: RLA ADL Index: 0-10

105 Tracheostomy care, ventilator/respirator, or isolation for active infection disease while a resident AND ADL Score of 2 or more ES3 ADL Index: 2-16 ES2 ADL Index: 2-16 ES1 ADL Index: 2-16

106 Comatose Septicemia Diabetes with daily injections and order changes on 2 or more days Quadriplegia with ADL score >=5 Chronic obstructive pulmonary disease and shortness of breath when lying flat

107 Fever with pneumonia, or vomiting, or weight loss, or feeding tube; Parental/IV feedings Respiratory therapy for 7 days And ADL score of 2 or more

108 RUG ADL Index End Splits HE Signs of Depression HE No Signs HD Signs of Depression HD No Signs HC Signs of Depression HC No Signs HB2 2-5 Signs of Depression HB1 2-5 No Signs

109 Cerebral Palsy, multiple sclerosis, or Parkinson s disease with ADL score >=5 Respiratory failure and oxygen while a resident Feeding tube (calories>=51% or calories=26-50% and fluid >=501cc) Ulcers (2 or more Stage II or 1 or more Stage III or IV pressure ulcers or 2 or more venous/arterial ulcers or 1 Stage II pressure ulcer and 1 venous/arterial with 2 or more skin care treatments

110 Foot infection, diabetic foot ulcer/open lesions of foot with treatment Radiation therapy while a resident Dialysis while a resident AND ADL score of 2 or more

111 RUG ADL Index End Splits LE Signs of Depression LE No Signs LD Signs of Depression LD No Signs LC Signs of Depression LC No Signs LB2 2-5 Signs of Depression LB1 2-5 No Signs *Depression end split requires PHQ-9 score of >=10

112 Extensive Services, Special Care High or Special Care Low qualifier and ADL score 0 or 1 OR Pneumonia Hemiplegia with ADL score >=5; Surgical wounds or lesions with treatment Burns

113 Chemotherapy while a resident Oxygen therapy while a resident IV medications while a resident Transfusions while a resident

114 RUG ADL Index End Splits CE Signs of Depression CE No Signs CD Signs of Depression CD No Signs CC Signs of Depression CC No Signs CB2 2-5 Signs of Depression CB1 2-5 No Signs CA2 0-1 Signs of Depression CA1 0-1 No Signs

115 Cognitive impairment BIMS score <=9 or CPS>=3 OR Hallucinations or delusions OR Physical or verbal symptoms toward others, other behavioral symptoms, rejection of care, or wandering AND ADL Score <=5 See Reduced Physical Function for restorative nursing services

116 RUG ADL Index End Splits BB or more restorative nursing on 6+days/wk BB1 2-5 Less restorative nursing BA or more restorative nursing on 6+days/wk BA1 0-1 Less restorative nursing

117 Restorative Nursing Services: Urinary and/or bowel training program Passive and/or active ROM Amputation/prosthesis care training Splint or brace assistance Dressing or grooming training Eating or swallowing training Transfer training Bed mobility and/or walking training Communication training **No clinical variables used

118 RUG ADL Index End Splits PE or more restorative nursing on 6+days/wk PE Less restorative nursing PD or more restorative nursing on 6+days/wk PD Less restorative nursing PC or more restorative nursing on 6+days/wk PC Less restorative nursing

119 RUG ADL Index End Splits PB or more restorative nursing on 6+days/wk PB1 2-5 Less restorative nursing PA or more restorative nursing on 6+days/wk PA1 0-1 Less restorative nursing DEFAULT CODE: AAA

120 ANY QUESTIONS?

121 The Managed Care Process By David Rokes, RN CEO Post Acute Consulting, LLC

122 Attendees will understand: Preadmission requirements Post Admission Process Contract Review Outliers and Delivery of Services Weekly Managed Care Billing Reconciliation

123 We have seen an increase in all managed care products over the last several years Expect to see increases particularly in Managed Medicare Products (A.K.A. Medicare Part C) Increase in DSO of Managed Care products

124 Preauthorization Needs to be completed prior to admission by facility designee Verify that a contract is in place with the provider and levels in contract Cost-Out medications and treatments Rate should be verified and initial authorization prior to residents arrival at facility Verification Of Benefits Copy of Common Working File when indicated

125 Upon Admission Screening form* should be completed in its entirety Form should be distributed to Business Office, MDS Office, Rehab Department, Social Services, etc. Soft File should be created by delegated Managed Care representative in facility. i.e. MDS, CRC, RNAC, Social Services, etc. Get a copy of the residents Managed Care Card Very important to ensure you have the correct billing office to expedite payment

126 Ensure that you have a copy of all contracts Review levels available Ensure residents authorization is appropriate for services to be delivered Verify rates via contract Therapy Allowances per contracted level Outliers Pharmacy DME Are there specific transportation benefits in the resident s policy? I recommend reviewing on an annual basis

127 Responsibility of facility designee Update Managed Care representative as requested and with any change in level of care Negotiate appropriate level to serve the resident s needs Get all authorizations in writing when appropriate All conversations and paperwork should be documented and maintained in the resident s soft file and saved after discharge

128 Daily review of resident status All residents should be reviewed on a daily basis Any changes should be communicated to the case managers Change in rehab level of care Medical changes Medication changes Progress towards discharge External Appointments

129 Weekly billing reconciliation Review with the team on weekly basis the level of services being delivered support the payment level Purpose of reviewing weekly is because billing does not wait until the end of the month as Medicare Part A does Get pharmacy bills To review outliers that can be billed separately I.e. Many insurances over up to a set $ amount per day and IV meds excluded

130 QUESTIONS

131 THE QUALITY MEASURES David Rokes, RN Chief Executive Officer

132 Participants will understand: The updated Quality Measures The impact of the MDS 3.0 items How the new QM s will effect 5 Star Reporting How they effect your internal Quality Improvement Program Ongoing CMS initiatives related to quality of care Value Based Purchasing Initiatives and ACO S

133 To give information about the quality of care at nursing homes to help you choose a nursing home for yourself or others To give you information about the care at nursing homes where you or family members already live To get you to talk to nursing home staff about the quality of care To give data to the nursing home to help them with their quality improvement efforts

134 Quality Measures show ways in which nursing homes are different from one another There are things nursing homes can do to improve their percentages The measures assess the resident s physical and clinical conditions and abilities, as well as preferences and life care wishes In June 2011 the National Quality Forum (NQF) endorsed 16 Nursing Home Quality Measures

135 QM portion of 5 Star had been dark from April 2011 through April 2012 CMS and The National Quality Forum have endorsed and finalized 18 new measures 5 Short Stay Measures Calculations are based on PPS, regulatory & discharge assessments. Unscheduled PPS assessments are not included. 13 Long Stay Measures Calculations are based on PPS, regulatory & discharge assessments. Unscheduled PPS assessments are not included.

136 Percent of residents who selfreport moderate to severe pain* Percent of residents with pressure ulcers that are new or worsened* Percent of residents assessed and given, appropriately the seasonal influenza vaccine Percent of residents assessed and given, appropriately, the pneumococcal vaccine Percent of residents who newly received an antipsychotic medication *used for calculation of 5 Star QM rating

137 Percent of residents experiencing one or more falls with major injury* Percent of residents who self-report moderate to severe pain* Percent of high-risk residents with pressure ulcers* Percent of long stay residents assessed and given, appropriately, the Influenza vaccine Percent of long stay residents assessed and given, appropriately, the Pneumococcal vaccine Percent of longstay residents with a urinary tract infection*

138 Percent of low-risk residents who lose control of their bowel or bladder Residents who have/had a catheter inserted and left in the bladder* Percent of residents who were physically restrained* Percent of residents whose need for help with daily activities has increased* Percent of residents who lose too much weight Percent of residents who have depressive symptoms Percent of residents who received an antipsychotic *used for calculation of 5 Star QM rating

139 Drives internal Quality Review Process Provides state/surveyors with survey process guidance Public image 5 Star Quality Reporting Pay for Performance/Value Based Purchasing May affect Accountable Care Organizations (ACO) and Bundled payment initiative participation

140 Pay for performance Demonstration in process in New York (79 homes), Wisconsin (62 homes) and Arizona (41 homes) 3 Year project started July 1 st, 2009 Based upon Quality Measures Staffing Appropriate hospitalizations Outcome measures for the MDS Inspection survey deficiencies Satisfaction surveys (pending)-cahps

141 Performance payments Intent is to reward homes that provide overall high quality care rather than those that excel in individual areas Nursing homes will be eligible for awards based on both attainment and improvement Homes that have an overall performance score that is 80 th percentile or higher will qualify for performance payment Homes in the 90 th percentile or higher would receive performance payments that are 1.2 times those in the th percentile. To ensure the qualifying homes contribute to reduced hospitalizations rates Hospitalization rate does not exceed 20% OR Home hospitalization rate does not exceed median rate in the State

142 Preliminary data released with mixed results 77 page Plan to Implement Medicare Skilled Nursing Facility Value Based Purchasing Program report issued to Congress. Link: dicare/medicare-fee- for-service- Payment/SNFPPS/Downl oads/snf-vbp-rtc.pdf

143 Medicare Shared Savings Program Currently 153organizations participating in shared savings initiatives A voluntary program consisting of health care providers coordinating high quality care to Medicare beneficiaries 33 Measures to assess quality Electronic Health Records are not required but weighted heavier than any other measure for quality-scoring purposes Paid for reporting first year, subsequent years paid for reporting and performance Health Care delivery is trending in this direction

144 Publically reported Overall Quality Health Inspection Derived from Nursing Home Statements of Deficiencies (CMS form 2567) 15 months worth of complaint surveys that resulted in deficiencies Quality Measures 9 measures used toward score Staffing Looks at RN, LPN/LVN and CNA staffing (based on form 671) In July 2012 Physical Therapy staffing was added but does not affect score; it does not include PT Assistants

145 QUESTIONS

146 Challenges and Strategies for Success

147 Inappropriate coding on the MDS cost many facilities ADL s Missing Diagnosis that qualify into certain RUG categories Lack of Understanding of Skilled Criteria for Nursing Observation and Assessment Lack of documentation on behaviors Poor communication amongst departments Poor ARD management Missed MDS s Greater financial implications instituted April 2012 resulting in increased default and provider liable situations

148 Do you have the appropriate staff in the appropriate position Managing the MDS process has become very specialized Lack of systems Poor meeting management Meetings are a necessary evil

149 Turn Over in Staff What is the cause? Are people crossed trained? Increased Time Constraints Compliance with MDS completion Are all staff doing their parts? Timeliness of assessments Integrity of coding Late transmissions-only 14 days to transmit

150 Additional Assessment Types Discharge assessments Start and End of Therapy Assessments Change of Therapy OMRA Educational Needs Does your staff fully understand the process Does everyone know their part in the process MDS drives the survey process Errors on the MDS can also equate to survey tags The shift to the QIS survey makes process less subjective

151 Detail oriented Able to multitask Flexible Team approach Educator Organized Knowledgeable Must take ownership of the process

152 ICC-Introductory Care Conference Daily Skilled Review Meeting Weekly Skilled Review Meeting Weekly Medicaid Case Mix Meeting Month End Close Reconciliation

153 Interdisciplinary Team to meet with resident and/or responsible party within 72 hours of admission What does the IDT need to know? Outline the course of treatment by each member of the team based on their assessment. Discuss the services to be provided. Discuss the goals to be achieved prior to discharge. Discuss any barriers to discharge. Discuss prior services in the community. Address any questions or concerns What are the resident s goals and expectations

154 Brief Daily Meeting to Review Medicare and Managed Care Residents with PPS team Nursing, Rehab, Business Office, Social Services, etc. Effective way to monitor reason for skilling on a daily basis and update any changes in condition and/or treatment Process leads to clean month end close and effective Medicare management Daily Tracking Log Implementation

155 Items for review Pending Admissions/Discharges Medicare Stay Day MDS status including 3.0 required assessments (BIMS, PHQ-9,etc.) Assessment Reference Date Review RUG Score Any changes in clinical or therapy treatment Scheduled appointments Tests, labs, transportation and services to be delivered (Consolidated Billing) High Cost Medications Any update to ICD-9 Codes/Diagnosis Codes

156 Commonly referred to UR (Utilization Review) Meeting Focused interdisciplinary review of short term skilled residents Ensure all compliance criteria are being met Physician Certification of Skilled Nursing Facility (SNF) Requirements Review Elements of Daily Meeting Review in More Depth i.e. detailed therapy status updates, progression towards discharge and required services Also includes Managed Care and Medicare Part B Residents in 30 Day Window of Part A benefit cessation Residents in the 60 Day Window to Review for Spell of Illness/Benefit Period Brief Review of Exhaust of Benefits for No-Pay Billing

157 Review of the long term care residents that are coming due for an MDS assessment in the next 30 days Review of any significant change in current resident care needs Potential need for Part B therapy RUG utilization review RUG Score Projections Clinical Indicators ADL Status End Splits Restorative Program Behavioral Indicators Estimated Case Mix Index (CMI)

158 Reconciliation with Business Office, MDS/PPS Coordinator, and Therapy Department Verify: Certification/Recertification are updated (including therapy certs) SNF care must be certified upon admit, within the first 14 days and then every 30 days thereafter Have MDS been transmitted and accepted into the state data base MDS Info on UB-04 (Universal Bill): ARD s, RUGS-IV Classification, days in each category, correct HIPPS codes Therapy Charges (Do they support the RUG score?) ICD-9 Codes to support services billed Ancillary Charges (Are they appropriate?, Were they delivered?)

159 Keep your MDS Coordinators and Therapy Directors educated Ensure MDS department is keeping the rest of the staff educated Sign up for the CMS SNF Open Door Forum Call happens every 6 th Thursday Information is provided on these calls that is not provided elsewhere Sign up for the CMS SNF List Serve Ensure there are back up For changes Time off Times of increased volume

160 Communicate Daily meetings with the PPS team Listen to what staff are saying Focus on assessments completion daily Redefine the role of the MDS Coordinators This has become a specialty Is the correct person in the job Are they doing duties that could or should be assigned elsewhere Therapy Department Daily monitoring of minutes, refusals, treatment tolerance, upcoming appointments

161 Respond with a Sense of Urgency Staff the therapy department to be able to dedicate resources as indicated for evaluation and treatment seven days per week. Employ a computerized software product to assist in the planning, scheduling, sustaining and optimal capture of RUG levels. Implement concise daily and more in depth weekly meetings to discuss category tracking, clinical updates, and ensure that potential barriers to the plan of care are quickly identified and action planned as an interdisciplinary team. Develop and implement a functional therapy patient schedule. Greater importance must be placed on assisting the flow of patients to and from the therapy department (as well as between departments in many cases). This may require: Dedicating transportation aides Having unit personnel review the schedule nightly for appointment conflicts Having clinical nursing review the schedule nightly for clinical service conflicts (ie: medication management, wound care, bowel and bladder programs, etc.)

162 Don t settle for being less efficient Implement a forecasting utilization/staffing tool based on optimal service utilization to ensure that the therapy department has adequate resources to meet the needs of Medicare Part A patients without having to limit services to other beneficiaries. Employ real-time management reports to help analyze: Therapy minute threshold over-delivery (greater than 5-7 percent) Therapy minute threshold critical under-delivery (within 5-7 percent of higher reimbursement category) Fiscal impact and minute differential of Change of Therapy (COT) OMRAs Reimbursable productivity by department, by discipline, and by therapist Cost per reimbursable minute Implement and educate therapists on point-of-service documentation strategies. Flex therapy department staffing hours to minimize scheduling conflicts and ensure maximal opportunity to provide services to residents who may be either out for appointment or are experiencing medical complications or setbacks.

163 Stay the course Develop and implement strategies to ensure optimal, outcome supported lengths of stay. Employ a computerized software product to assist in the tracking of average length of stay by diagnosis, discharge destination, and referral source (if possible). Implement an outcome measure instrument (preferably computerized) and determine performance benchmarks. Educate therapists and nurses with discharge consideration points to review prior to recommending service termination Ensure that adequate restorative nursing resources are available to assist the transition to Rehab Low as clinically indicated for residents transitioning from therapy services to either skilled nursing care or long-term care.

164 Don t let therapy remain an island Facility administration should routinely observe the therapy department to: Provide feedback and support Evaluate use or scarcity of department resources Obtain feedback from clinicians on what their perceived needs may be Encourage greater visibility throughout the facility: Dining room observation Activities observation and co-leading Walk-to-dine program sponsorship Dementia therapy programming Attend to results: Month end service reconciliation for accuracy and skilling criteria adherence Quarterly utilization of service report with dedicated goal-action plan Identify success stories Recognize positive gains and benchmark achievement

165 Look for inefficiencies within the MDS Department Are assessments being completed that don t need to be Frequently find admission assessments being completed upon readmission Do not perform PPS MDS to early in the ARD window Assess whether MDS Coordinators are in unnecessary meetings i.e., care plan meetings when unit managers are present Assess resident interview ability to deem whether Resident vs. Staff assessment is performed.

166 Skilled Nursing Services Ensure that staff are aware of non-therapy skilled services Chapter 8 of the Medicare Benefit Policy Manual RUG-IV Management Ensure staff understand and all elements of the RUG-IV system to ensure that you are getting paid for the services delivered ADL management Monitor ADL s closely for accuracy and daily ADL index Ensure all staff understand the elements of ADL documentation and the impact on quality and reimbursement Transition to electronic documentation if feasible

167 Team process All members need to understand their roles What and when needs to be completed Accountability All staff need to be held to the same standards Everyone needs to understand the importance of the process Meeting Success Must be focused and well run Encourage your staff A little Thanks goes a long a way

168 Value Based Purchasing A.K.A. Pay for Performance Affordable Care Act directs Value Based Purchasing plan to implemented for SNF s Report to Congress due October 1 st, 2012 Pilot completed for SNF s in July 2012 Payment Adjustment of Hospital Acquired Conditions Outcomes to be reported to Congress by January 2012 Looking to apply to other settings Questioning Recalibration of RUG levels every year based on prior year utilization Allow SNF s to be originating site for Telehealth

169 Starting October 2012 hospitals with high quality care with be rewarded In 2013 hospitals will receive payment reductions if they have excessive 30-day readmissions for patients with heart attacks, heart failure, and pneumonia In 2015, there will be additional reductions related to certain hospital acquired conditions

170 Clinical Care Measures Acute MI, Heart Failure, Pneumonia, Health-care Associated Infections, Surgical Care Improvement Some of the Hospital Acquired Conditions will include Foreign Object Retained After Surgery, Air Embolism, Stage III and IV Pressure Ulcers, Falls and Trauma, UTI, Poor Glycemic Control Patient Experience Care Measures based on Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) Communication with Nurses and Doctors, Responsiveness of Hospital Staff, Pain Management, Communication About Medicines, Cleanliness and Quietness of Hospital Environment, Discharge Information, and Overall Rating of Hospital

171 Staffing Levels Appropriate Hospitalizations MDS Outcomes Chronic Care Residents Percentage of residents whose need for help with ADL has increased Percentage of Residents whose ability to move in and around room got worse Percentage of high risk residents who have pressure ulcers Percentage of residents who have a catheter left in the bladder Percentage of residents who are physically restrained Survey Results

172 QUESTIONS

173 Thank you (888) X202

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