Dr. Kenneth Scott is CEO and founder of SilverSage Management Servicesproviding doctors and advice to the long-term care sector.
In his State of the Union address last year, President Biden sought to improve the quality of care administered in nursing homes across the country. He doubled down on that plan more recently in October, announcing a series of new actions designed to increase accountability by stepping up enforcement for the worst-performing facilities.
Ensuring that money goes to nursing homes that provide high-quality care — while cutting the worst-performing facilities at the same time — is the main thrust of the president’s plan. Biden and the Centers for Medicare and Medicaid Services (CMS) plan to improve the nursing home experience by addressing substandard facilities, highlighting new areas of focus and reducing readmission rates.
While most nursing homes have some deficiencies, facilities that exhibit excessive problems or deficiencies – as determined by government agency oversight in a points-based methodology – will be assigned to the Special Focus Facility (SFF) program watchlist. This also applies to nursing homes that show a pattern of problems that has persisted for a period of time without correction.
Fortunately, there are now things nursing homes can do to make improvements and increase accountability. Let’s dive in.
Start by changing your mindset on leadership and reactivity.
Whether your facility has had a relatively good survey or you are already on the Special Focus Facility list, there are several simple steps you can take to improve your ranking.
The first thing I would suggest is to change your mindset, starting with the attitude set by the leadership of each facility. I’ve found that one of the biggest problems healthcare facilities face today is the mindset of being reactive rather than proactive. Thinking proactively can be challenging at first, not only because habits are hard to break, but also because the rules change so quickly that it’s hard to stick to long-term plans. What your nursing home team decides today based on the rules may be obsolete in a month.
However, the core of your business should be focused on good care for patients and support for your staff. Those are principles that will not change. Losing sight of those principles can cost a lot more than trying to overcorrect with every change in government oversight.
Restructure core meetings for improved productivity.
Two core meetings that need to be re-evaluated and revamped for better productivity are Quality assurance Performance improvement (QAPI) and Interdisciplinary team (IDT) meetings. The goal of QAPI is to evaluate your facility’s overall performance and trajectory, including comparing your results to national and state averages, while looking for ways to improve. IDT involves reviewing individual patients’ care plans and verifying that the team is coordinated to provide the best possible care for each person.
I recommend that both meetings be adjusted based on each facility’s latest state/federal survey. Those results should be reviewed at each QAPI and IDT meeting. While the format of both the state and federal survey process is punitive in nature, your goal should be to turn that experience into a learning experience for your team.
QAPI meetings should look monthly at the shortcomings mentioned. Measurable statistics around the received tag should be evaluated and discussed on a monthly basis. Falling back into bad habits can be recognized and remedied. New issues can also be found, with the end result being that the same tag is quoted again, except for different reasons. It’s better to proactively figure this out on your own and avoid getting the tag again.
In the IDT process of reviewing individual care plans, mention the deficiencies identified in the last survey and ask if any are still applicable. Possible ways to improve your processes can be found, and when the state reviews that chart for the next year, the documentation should reflect the team’s understanding of the key requirements that the state and federal governments are looking for. Immediately show the surveyors that your team understands the quality measure and applies it to specific situations.
Prioritize readmission rates.
Biden’s plan for strengthening skilled nursing facilities (SNFs) continues to strengthen the Value-Based Purchasing (VBP) program. In particular, the VBP recognizes the quality of care, partly on the basis of readmissions from nursing homes to hospitals.
One way to reduce hospital readmissions would be to employ a full-time physician at each SNF. (Disclosure: My company helps with this, as do others.) Nursing homes have long realized that they are no longer the retirement homes of 50 years ago. Rather, they often function more like a stand-alone medical/surgical unit, similar to a hospital – only they don’t have the assistance of their own pharmacy, laboratory, X-ray, ER or sub-specialist. Many of them don’t even have a doctor who comes by every day.
Readmission rates can also be reduced by quickly recognizing changes in a patient’s condition. I’ve found that early recognition by an attentive nurse—and quick team communication during a busy shift to think critically about what that change means—can often divert a hospital readmission.
Finally, readmissions can be reduced by realizing that not all patients who begin to decline need immediate rehospitalization. This requires meaningful conversations about quality of life and helping families define long-term expectations well before the downturn begins.
Trust and dignity are essential elements for success.
Patients and their families, despite all the emotions involved, usually understand the need to be admitted to nursing homes. What most patients want is to understand their current situation and have a clear vision of the goals of care delivered in a thoughtful manner – one that allows them to trust the information and maintain their dignity. A well-oiled team willing to empathize with the patient early on can usually achieve positive outcomes and pave the way for the right decisions to be made, whether that be medication adjustments, appropriate readmission or transition to comfort measures of being the hospice.
The information provided here is not intended as medical advice, diagnosis or treatment. You should consult a qualified health care professional for advice on your specific situation.