A series of struggles around assessment began in fall, with the most extensive updates in years to the Minimum Data Set, which captures patients’ clinical needs and also serves as the basis for much of a provider’s state and federal reimbursement.

“It’s not news to anybody that this rollout was not smooth,” said Alicia Cantinieri, senior vice president of Clinical Policy and Education for Zimmet Healthcare Services Group. “There were a lot of technical issues with coding, with skip patterns, with Section GG, with HIPPS code calculation being incorrect.”

Despite the Centers for Medicare & Medicaid Service issuing corrections and technical clarifications in the weeks after the Oct. 1 launch of the updated MDS, some providers still may face long-term consequences of coding errors or delays forced on them by incomplete early guidance from regulators. That was just one of the cautions shared by Cantinieri and two of her Zimmet colleagues during a webinar titled, “Fasten Your Seatbelts: It Might be a Bumpy Ride.”

Cantinieri said the lasting implications of some software and coding issues in the first week of the launch were going to especially affect providers in states that used the Patient Driven Payment Mode to determine a Medicaid case-mix before the changeover.

In the case of providers who needed to code patients receiving respiratory therapy, for example, many found the section blocked out and were unable to capture payment for related services. Some went back and modified submission; others waited to submit until they had clarification on how to correct the problem.

“Facilities have been left with questions about when to modify, when to resubmit,” she added. “And we haven’t heard any guidance from CMS that they would waive or forgive the submission timing requirement, so there’s the potential that facility could be cited.”

Chief Innovation Officer Steven Littlehale said that regardless of the complication or system error, it is critical that providers keep related records for a few years “so that ultimately you’re not left holding the bag for this sort of failed launch.”

Duplication of efforts

The removal of Section G to measure a patient’s functional status also continues to wreak havoc on payment, especially at the state level. Many states used G to determine payments, and without it, complications have continued to crop up, said Melanie Tribe-Scott, vice president of Quality and Regulatory Compliance.

For providers in many states not using the PDPM yet, the workload has increased significantly, with many requiring that MDS coordinators record information in the replacement Section GG and capture details for all patients on an optional state assessment, too.

The advent of MDS also has led to frozen pay in some states, while upcoming quality measure changes will lead to freezing quality measures as well, the speakers noted. That may discourage providers from being diligent in some areas, thinking they are temporarily less important.

But that couldn’t be farther from the truth for payment, Tribe-Scott added. She said some states would undoubtedly be using codes captured in the frozen period to see how provider behavior and patient needs would shape spending under a system more aligned with PDPM.

And those frozen metrics, which lock in April to give regulators more time to collect full data before publishing new calculations, also could come back to haunt if not given enough attention. Most are connected to new quality measures, which will be used later to inform quality measure ratings on the Care Compare website.

“Eventually, it will be thawed and you’ll see those new measures,” Littlehale said. “It’s important to not turn your back, for quality improvement reasons, on those very outcomes. You need to get a little old school with how you’ve tracking performance in those areas.”

Stay ahead of problems, and no blanking out

Another critical change is coming Jan. 1: Providers will need to submit a higher percentage of MDS data than in years past to remain eligible for a value-based purchasing payment bump. It’s critical they not leave boxes blank, especially new ones, simply because staff don’t understand how or when to complete them, Cantinieri said.

Providers can stay ahead of some of the challenges by taking a few steps as 2024 gets underway, the presenters said.

Cantinieri recommended auditing MDS forms to make sure information is being collected and submitted correctly; a standard size nursing home could make it a quality improvement goal to review 10 charts per month and include charts from a variety of patients involving a range of interdisciplinary staff. An external audit also could benefit providers who want to ensure they’re capturing everything possible in line with the Oct. 1 changes.

The team also suggested reaching out to any MDS-involved software vendors to ensure updates have been made and that any incorrect data caused by early adoption kinks has been retroactively corrected, if appropriate.

The state’s budget has added significant funding for skilled nursing facilities beginning in 2024, including incentives for providing quality care that are still unusual from state governments. 

Sustained lobbying pressure not just from associations but also from individual providers in the state was instrumental in convincing policymakers to adopt these measures, said Jill Wilson, president and CEO of Otterbein SeniorLife, a Green House partner organization.

“We did feel very strongly that it was not a problem that should be delegated to our associations to solve,” Wilson said.

Wilson shared her organization’s story as a case study in how to turn more than $9.5 million in projected yearly Medicaid patient losses into projected profits during a webinar hosted by the Center for Innovation Thursday.

She said she hopes the success realized in Ohio can be replicated in other states.

Addressing a funding crisis

With inflation and labor costs skyrocketing after the COVID-19 pandemic and Medicaid rates in Ohio not keeping pace, Wilson said the situation had become a crisis for Otterbein.

More than 90% of its beds are currently dedicated to private rooms — mostly at small Green House facilities that support 10 to 12 residents at a time. Ohio, where all but one Otterbein facility is located, had not previously compensated private rooms any differently than shared rooms.

With a Medicaid funding gap projected to reach nearly $10 million in 2023 and federal COVID relief funds no longer in the picture, Wilson began an aggressive campaign of contacting state lawmakers and department heads.

“The reality is that it is all of our jobs to work with those who make these decisions and help them understand how their decisions will impact their constituents in their districts,” Wilson asserted.

Wilson sent letters outlining the funding gaps facing her facilities — financial problems that she was quick to point out are shared by many skilled nursing providers across the country. 

“I didn’t try to spin it, I didn’t try to adjust it, I just tried to give them the facts. And that letter was followed up with a request for a meeting,” she explained.

She successfully met with nearly all of the policymakers she contacted, including Lt. Gov. Jon Husted (R). Those meetings proved fruitful, as Ohio’s biennial budget passed in 2023 included significant and unusual incentives for nursing homes that prioritize care quality and privacy for their residents. 

Once all of these incentives take effect, Otterbein’s Medicaid reimbursement per resident per day is projected to increase from around $250 to around $325, an increase of 31%, according to Wilson. 

Other states, including Arkansas and Kansas, also have incentivized care quality and private rooms through reimbursements, but such policies are not yet widespread in the US. Wilson encouraged her audience to follow Otterbein’s example and approach policymakers even if the task seems impossible. 

“I had to shift a mindset that I had,” Wilson said. “If we all have that mindset, we can collectively garner that power we need — the energy that we need — that is more than the problem.”

The Nov. 30 order declares a timing emergency, allowing the Ohio Department of Medicaid to bypass the typical wait period and immediately adopt final rules for providers looking to apply for reimbursement. 

Ohio long-term care providers will share up to $40 million in Medicaid reimbursements set aside for private rooms in 2024 and $160 million in 2025 and beyond. 

Higher pay for private rooms have been a bucket list item for care providers for years, but the Centers for Medicare & Medicaid Services has left the ball in the states’ court. The Ohio single-occupant room funding, which passed in the 2023 state budget, has been an exciting development for providers in the state.

“I believe there is extreme interest in this,” said Peter Van Runkle, executive director at the Ohio Health Care Association. “I get questions every day — multiple questions — about private rooms.” 

Qualifying nursing homes would receive $30 per day for private rooms that also have a private bathroom and $20 per day for private rooms with a shared bathroom. 

A majority of Ohio providers are likely to apply, Van Runkle told McKnight’s Long-Term Care News on Monday. 

“I think those numbers are very attractive to providers,” he said.

Replicable reimbursement benefits

Facilities would receive this funding on a first-come-first-served basis up to the maximum amount allotted for each year. Private rooms with private bathrooms will be prioritized first in this process.

The state estimates that it will be able to cover around 29,000 private rooms within their spending limit, according to Van Runkle. 

“It would be nice to see that available to people across the country,” Van Runkle added, “Medicaid beneficiaries forever have not gotten the same kind of treatment in terms of private rooms as Medicare or private pay people and now they’ll have that access and I think that’s a really good thing. I know if I had to have a stay in a skilled nursing facility, I would certainly want a private room.”

With occupancy numbers hovering near 80%, legislation like this would give nursing homes a much-needed infusion of funding, especially if those facilities are able to convert unused space into single-occupant rooms. 

Private rooms also protect residents’ privacy and dignity and make it easier for facilities to curb the spread of infectious diseases.

Final hurdles

DeWine’s executive order clarified the application process in Ohio, but obstacles still remain. Primarily, funding cannot be given to approved nursing homes until six months after CMS reviews and approves the Ohio reimbursement policy. 

Ohio officials have not yet submitted their application to CMS and haven’t released a date they plan to submit, so the first reimbursements are likely to be delayed until at least the second half of 2024, according to Van Runkle.

Despite this, excitement remains high and care associations and policymakers appear united behind the goals of the reimbursement policy.

“The final version of the budget that went through on skilled nursing reimbursement was not touched by the governor, which is kind of unheard of,” Van Runkle said.

Despite ongoing delays, Van Runkle advises nursing homes to have their applications ready and to submit them as soon as the window opens — especially now that the executive order will help provide clarity to the rules.

The group of leading New York nursing home associations urged the state to include a $510 million investment and a promise to reform Medicaid reimbursements in next year’s budget.

Those striking figures are aimed at addressing an even larger $810 million gap between state funding and nursing home expenses. 

“New York’s Medicaid program pays for the overwhelming majority of our nursing home days, but the state’s Medicaid rate for nursing homes covers only 75% of the daily cost of care for each resident, resulting in an $810 million annual state share gap between Medicaid rates and costs,” the group claimed.

The organizations — LeadingAge New York, the New York State Health Facilities Association, the New York Providers Alliance and others — delivered the requests in a Nov. 3 joint letter to Governor Kathy Hochul. 

It’s the latest in a string of requests that the state government address funding shortages and small Medicaid reimbursement adjustments in New York.

In early 2023, nursing home advocates requested a 20% Medicaid boost. The state ultimately settled on 7.5% — a number that leaders say was a good, but inadequate step.

“While our members appreciate the promised 7.5% increase approved in the 2023-24 budget, it will not cover even the 2023 cost increases,” the letter states.

The organizations say the bump up has been largely offset by the high inflation of 2022 and the rising cost of wages. 

Leaders also noted that even a 20% increase would not have totally addressed the funding shortfall for nursing homes.

“While we are grateful for the 7.5% Medicaid increase that was included in last year’s final budget, it is insufficient to cover the cost of care for Medicaid patients in nursing homes,” Stephen Hanse, president and CEO of NYSHFA told McKnight’s Long-Term Care News. “The prior administration had cut Medicaid spending for over 15 years straight for nursing homes. So when you ran the numbers based on 15 years of no cost-of-living increases for Medicaid, to cover the cost of Medicaid, it would have required a 43% Medicaid increase.”

Hanse was emphatic that New York needs to take action: “The data speaks for itself. The state needs to invest in nursing homes.”

Ripple effects

The joint letter warned that failing to address this long-running funding issue is impacting healthcare across the state, not just in nursing homes.

“The gap between Medicaid rates and costs has led to wide-ranging ripple effects throughout our health care delivery system impacting consumers statewide,” the letter asserts.

The organizations note 10 nursing homes closed in the last three years and that there are 5,600 fewer beds available in facilities across the state due to funding struggles. These shortages have led to resident wait-lists, bottlenecks at hospitals and facilities being forced to refuse admissions for new short-term residents. 

These cascading effects underscore the importance of the state addressing the funding shortage in the short term, according to industry leaders.

“We recognize that $810 million is a large number — and that number is large due to the state’s failure to invest in nursing homes,” Hanse said. 

The New York organizations, however, also recognize that the entire funding shortfall cannot be made up in a single budget. Hanse described both last year’s 20% proposal and the current $510 million request as “bridges” between what nursing homes need and what the state is able to provide. 

“The $510 million we’re asking for in that letter will be a good downpayment to get us where we need to be. And then in 2025 — [we would] work with the state in the context of establishing an equitable reimbursement system for nursing homes throughout New York,” Hanse said.

Hanse was “cautiously optimistic” — citing a good working relationship with the state — and hoped that the reimbursement issue could be meaningfully addressed in a two-year timeframe.

Patients at those specialized facilities had 7% lower death rates and 2% lower hospital readmission rates compared with patients receiving care at less specialized facilities.

Those positive outcomes came with tradeoffs, however.

Patients at those facilities had 10% longer stays, on average, or about three additional days of care per patient.

Longer stays also meant greater costs: Medicare bills averaged $1,200 more for patients at the more specialized facilities.

“Our results contribute to the current debate around reimagining the financing and delivery of long-term care in the wake of the COVID-19 pandemic,” noted the LDI study. “The role of specialization in healthcare has been widely discussed by economists and policymaker and is often proposed as a way to improve healthcare quality, decrease healthcare spending, and improve the value of care.”

But the study’s results only seem to complicate the discussion surrounding increasing post-acute care specialization at skilled nursing facilities. 

The authors — Zachary S. Templeton, associate fellow at LDI, and Rachel M. Werner, MD, PhD, executive director of LDI — noted the ambiguity their findings could cause for policymakers and for SNFs focused on both shorter, post-acute care and long-term care in a statement to McKnight’s Long-Term Care News.

“This raises questions about whether we should move more post-acute care to specialized nursing homes,” they said. “On one hand, patient outcomes would improve. On the other hand, it would cost Medicare more. In addition, because nursing homes rely on higher Medicare payment for post-acute care to subsidize Medicaid’s underpayment for long-term care, such a shift could harm nursing home finances and quality of long-term care.”

Relying on lower Medicaid payments for long-term care has made the future of some facilities — especially rural ones — increasingly uncertain.

Deep dive on post-acute care

Less uncertain is the correlation between increased specialization and the resulting increases in positive care outcomes, lengths of stay and Medicare costs.

A research update from LDI noted that as the study tracked SNFs increasing their post-acute specialization over time, patient outcomes, length of stay and costs increased simultaneously. This correlation supports the link between increasing specialization and getting the observed results. 

The in-depth study used Medicare data to track 12 million nursing home admissions between 2011 and 2018. 

Although the study noted the differences in outcomes between specialized and less-specialized care facilities, it couldn’t isolate the specific policies driving those differences.

“We are unable to determine the exact mechanisms by which more specialized nursing homes improve patient outcomes and increase utilization,” the study noted. “Using more granular data, future research could examine the adjustments facilities make as they become more specialized.”

The authors noted that further studies could focus on facilities’ building conditions, staffing levels, training programs and other internal processes to pinpoint specific causes.

At least one observed factor was linked to lowering the downsides to residents staying at specialized facilities.

“The increase in patient length of stay and spending among more specialized nursing homes is smaller among facilities that face less uncertainty in the demand for their PAC services,” the study said, “namely those owned by or located near hospitals.”

That greater access to pipelines of post-acute patients is just one of many, often-competing incentives for nursing homes, though.

“The overall welfare effects of nursing home specialization are ambiguous based on our results,” the study notes. “Specialization, therefore, is accompanied by a complex array of costs and benefits that policymakers must consider as they weigh alternatives to the current nursing home model.”

The Jamestown, NY, skilled nursing facility has been struggling with the same string of problems facing other rural facilities, including Medicaid reimbursement rates that don’t adequately meet the facility’s expenses and a new staffing rule established earlier this year in New York. 

“They’re suffering the same flight of funding shortfalls that most of the facilities in upstate New York are sharing,” Keith Chambery, executive director of New York Provider’s Alliance, told McKnight’s Long-Term Care News. “Along with regulatory staffing challenges, the shortfall in funding has caused facilities to stretch to the limit. This facility got there and saw the writing on the wall.”

New York’s new staffing rules require that facilities provide 3.5 hours of care per resident per day from nurses and nurse assistants. A majority of New York facilities, especially those in rural areas, have struggled to meet this regulatory benchmark, which took effect in April. 

The general shortage of available workers is also exacerbated by the need to increase wages.

“​​About 70% of facilities in New York can’t meet that [regulatory] standard,” Chambery told McKnight’s, “due to the fact that skilled nursing personnel are not available and that the wages for nursing assistants need to be raised to be competitive with other establishments, even outside of the healthcare field.”

Chambery also highlighted that funding challenges have only worsened in the wake of the pandemic. 

“During COVID, facilities were helped out with a lot of COVID funding both from the state and from the federal government, and that helped them continue to be competitive with their wages throughout the pandemic,” said Chambery. “Now that all funding has dried up.”

A historic facility closes

Lutheran Home has been open since 1886 and currently serves 49 residents with a staff of 106. 

The facility has a 148-bed capacity. In statements to local news, Lutheran confirmed that their occupancy rate was around 30% below what they needed to maintain profitability.

“Lutheran is currently working with the New York State Department of Health to ensure that this transition is as smooth as possible,” said Tom Holt, president and CEO of Lutheran. “Our top priority is to work with every resident, their families and our valued employees, to secure new housing options, care and job placement.”

The skilled nursing facility plans to continue operating until Jan. 2 as its residents find new homes. 

Nursing homes in surrounding communities have stepped in to assist Lutheran Home and its residents.

“What some of our members have been doing is to help [Lutheran Home] out in terms of placing their patients and helping them place their employees,” Chambery told McKnight’s.

“It’s probably as important to talk about the ripple effects for the patients and the families in the area,” he continued. “They’ll have to leave a place where they’ve been comfortable and well-cared-for to go to another place that might not be of their choosing.”

Problems for rural facilities

Lutheran Home is not the first upstate New York nursing home to shutter due to these challenges — 10 others have closed within the last three years, according to a press release from NYPA. 

“The unfortunate truth is that Medicaid reimbursement rates for upstate facilities are woefully inadequate to cover the true costs of care,” Chambery stated in the press release. 

NYPA cited a 2022 Medicare cost report that showed, on average, upstate facilities were losing $2.1 million per year.

“A perfect storm of reimbursement disparity, demographics, case mix and occupancy has caused facilities like the Lutheran Home facility to make difficult decisions that affect access to care, especially in small towns where choices are limited,” said Chambery.

He also stressed the need for increased funding to avoid the risk of more closures and the cascading effects they would have on rural communities. 

To match the needs of thinly stretched upstate facilities, Chambery said, “the first step is going to be to get meaningful reimbursement reform in the Medicaid system to facilities in upstate New York — there’s no way around it. Losing $2 million a year is not sustainable for any business.”

But it didn’t work out like that. Federal Medicaid rules allowed people with high private medical expenses to qualify for LTC assistance. Anyone with income below nursing home cost qualified. That meant nursing homes carried many residents on Medicaid at rates below the cost of care. Even mandatory patient private contributions came to facilities at the Medicaid rate.

On top of that, federal Medicaid mandated asset exemptions that enabled higher net worth people to qualify. The home equity exemption was unlimited until 2006 and it remains over $1 million in some states. California axed asset limits entirely effective January 1, 2024. A big Medicaid planning bar specializes in impoverishing affluent clients artificially.

For decades, federal Medicaid tried to control the cost of long-term care by imposing asset transfer restrictions, liens and estate recoveries. But state Medicaid programs didn’t implement the rules fully; federal Medicaid didn’t enforce them; and the media didn’t cover them. Consumers’ behavior remained unchanged, ignoring long-term care until they needed it.

So where does this leave the profession today? SNF private revenue is down to only 7%.  Any incentive people had to pay privately or own insurance is gone. Primary reliance on Medicaid at meager rates undercuts access and quality, causes the caregiver shortage, and has skilled facilities across the country, especially in rural areas, on the brink of collapse.

Private pay revenue migrated to assisted living and home care. But those venues are gradually following nursing homes down Medicaid’s primrose path. Many years of rebalancing from institutional to home and community-based care in the hope of saving money, has only caused combined Medicaid long-term care costs to increase relentlessly.

None of this mattered much for the past twenty years. Bulging budget deficits and artificially low interest rates enabled politicians to ignore surging Medicaid expenditures. Providers were helpless, caught between the rock of inadequate reimbursement and the hard place of mandatory quality. Forthcoming staffing mandates are only the final straw, adding insult to injury.

But all this is about to change. Profligate government spending finally unleashed inflation, making everything, including long-term care, cost more. Rising interest rates make servicing the national debt prohibitively expensive. Soon federal and state governments will no longer be able to defer these problems. Budget realities will compel change. LTC providers will suffer most.

Last October, I explained the relationship between Medicaid financing and the long-term care system’s many failings in a paper titled “Long-Term Care: The Problem” published by the Paragon Health Institute. On Oct. 3, 2023, Paragon published my proposed remedy “Long-Term Care: The Solution.”

In a nutshell, we will have to return Medicaid long-term care to its roots. Switch back. Eliminate the “loopholes” that allow affluent people to qualify for benefits while preserving wealth. Is this too draconian? It needn’t be. New research shows long-term care risk is not as huge as once thought and that Americans own enough wealth to cover long-term care if it were unleashed and mobilized.

How to unleash trillions of dollars in home equity, retirement savings and life insurance lying fallow now and mobilize them to supercharge LTC service delivery is the new paper’s topic. How to do that without unsettling young people and families who have more immediate goals and responsibilities they currently put ahead of LTC planning is the paper’s proposal.

I invite McKnight’s readers to review “Long-Term Care: The Problem” and “Long-Term Care: The Solution,” consider their analysis and recommendations, and share your comments and criticism with the author.

Stephen A. Moses is president of the Center for Long-Term Care Reform (www.centerltc.com). Reach him at smoses@centerltc.com or 425-891-3640.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Countless MDS training sessions, manuals, tip cards and software updates have filled our inboxes and daily industry news. However, if the arbiter of success isn’t making it past the Oct. 1 start date, then what is?

With this in mind, I turned to some of the best and brightest at Zimmet Healthcare: Alicia Cantinieri, Melanie Tribe-Scott and Amy Greer. In total, the three of them have completed dozens of public and private training sessions on the new MDS. But what I wanted to learn from them were any early warning signs that the transition wasn’t going well. Their response made me sound the alarm: “Fasten your seatbelts: It MIGHT be a bumpy ride.” However, they also offered several sage tips that should help you avoid unnecessary potholes.

Bumps related to Medicaid reimbursement 

States that are already using or converting to a Patient Driven Payment (PDPM) methodology for CMI are primarily using the Nursing component. Accurate documentation and coding of the resident’s “usual performance” in MDS Section GG is crucial, as well as the capture of diagnoses and other higher-acuity items. 

In states that are continuing to use the Optional State Assessment (OSA) or have rates frozen while the state adopts a PDPM system, MDS coding on OBRA assessment is also important as the OBRA assessments after Oct. 1 may be used in rate development or rate setting. 

As always, it’s crucial for the MDS and supporting documentation to be accurate. 

Therefore, three months out, do the following:

1. Self-audit or have a third party audit a random sample of OBRA assessments; the size of the sample depends on the number of assessments completed. Does the MDS coding have support in the medical record? Would another MDS assessor code the items the same way from the available documentation?

2. Review your facility’s process for collecting Section GG data. Is data gathered from all shifts? Is there evidence of multidisciplinary collaboration?

3. Review diagnoses coded on the MDS. Does the documentation support for diagnoses follow the RAI Manual guidelines? 

Bumps related to Medicare reimbursement

Double down on triple-check for Med A residents coding in Section K and Section O. Both of these sections added a new column that is required for PPS assessments at the start of the Medicare stay. The PDPM group will still pull from the “while a resident” column, as always. However, the extra column may cause some confusion. If the dietitian or MDS coordinator doesn’t fully understand the coding instructions, then reimbursement may be missed. For example, oxygen during the first three days of the Med A stay needs to be coded at both O0110C1a on admission and O0110C1b while a resident.

The same situation may occur in Section K. If the resident received tube feeding during the first three days of the Medicare stay, this must be coded at both K05201a and K05201b.

Regarding the PHQ-2 to 9, the facility should expect to see a decline in residents with a depression end-split, but not necessarily on the quality measure (QM). However, that decline in the end-split should not be extreme. A facility that was reporting a PDPM depression rate of 30% should not drop to 0%. If there IS an extreme decline, additional training may be required to ensure social services, or whoever is completing the assessment, understands the interview process for the PHQ-2 to 9. 

Therefore, three months out, do the following:

1. Monitor your PHQ-2 to 9 scores by pulling a report from your software.

2. Pay close attention to PDPM Section GG function scores.

3. Pay close attention to SLP and Nursing component scores dependent on Section K.

Bumps related to quality reporting

Although the Discharge Function Measure has a complicated formula and risk adjustment, if status on discharge indicates no improvement or minimal improvement from admission to discharge for many residents receiving rehab, it’s likely to be a red flag. This could indicate a lack of carryover from the rehab gym to performance back on the floor. With a focus on successful discharge to the community and rehospitalizations, ensuring the resident can translate performance in the gym to the unit and ultimately to their home as appropriate is key. 

Also remember that the data reporting threshold for QRP items will increase from 80% of the assessments to 90% for FY 2026. This affects MDS assessments beginning with CY 2024. A low data reporting percentage is related to “dashing” (—) the required data elements. Education or system changes may be needed to ensure the data reporting is at 90% or higher. With the additional assessment items on the new MDS, hitting 90% may be more of a challenge. Not only are there new QRP items, such as B1300 Health Literacy and transfer of health information, but we are also not well practiced in capturing these items. How have you operationalized their data capture?

Therefore, four months out, do the following:

1. Review the QRP Threshold Report in CASPER. If the facility is significantly below 90% after one complete quarter of data, it is critical to determine the reason why and make corrections if possible. 

2. Review the process for the UR meetings and discharge planning. Are the functional gains made by the resident in rehab translating to the rest of the day on the unit prior to discharge? 

3. Again, self-audit or have a third-party audit MDS assessments for accuracy. 

Bumps related to Five-Star 

The new MDS will affect Five-Star ratings, especially the QMs domain. With the elimination of Section G, four of the QMs will be affected (Increased ADLs, Pressure Ulcers, Improvement in Function, and Move Independently Worsened). These measures historically were calculated using data from Section G, but they will now use data from Section GG. In April 2024, these four measures will be “frozen” on Nursing Home Compare for three months to allow CMS to “catch up.” 

Once the QMs are unfrozen, they will be based upon MDS data from Q3 2023. You don’t want this to be the point where you realize your facility has been missing documentation opportunities from Oct. 1 and onward. After Oct. 1, carefully review all MDS assessments on a weekly basis for coding accuracy. Don’t do this review monthly; accumulated errors will be time-consuming to correct, and possibly lower QM scores can impact your QMs star rating and possibly even your overall star rating. 

Therefore, one month out, do the following:

1. Go “old school.” Frozen QM CASPER reports will not suffice your QAPI or auditing needs. “Back of the envelope” is often as good as a dense analytical report. Manually track, audit and analyze those negative outcomes 

2. Ensure your clinical staff are educated on the changes. Are your CNAs coding accurately? Is your MDS coordinator updated and supported? 

3. Begin a QAPI for any issues that might arise during the transition (e.g., complete, accurate CNA coding; nursing documentation in ADL decline).

Bumps related to care planning

We’ve discussed how a facility might see a decline in residents triggering depression. It’s essential to ensure you’re properly identifying residents with depression, regardless of payer type or QM definition. Once you’ve done so, creating an appropriate care plan and evaluating its effectiveness is key to success. 

An exact cross-over between Section G and Section GG cannot be made. However, the facility should not see a significant difference in coding. For example, a resident typically coded extensive to total for ADLs in Section G should not be coded as independent to set up functional abilities in Section GG. Review and monitor for such differences prior to submission, as they may impact the care plan and Medicaid reimbursement in some states. Significant differences may indicate a need for additional CNA training or an update to the documentation system.

The facility should update verbiage in care plan templates to reflect the functional abilities in Section GG as opposed to Section G. Be sure to include new items in care plans such as social isolation, health literacy and indications for medications.

Therefore, immediately do the following if you haven’t already:

1. Provide follow-up education to CNAs on GG coding now and then two to three weeks after implementation of the new coding.

2. Supply additional education on interview techniques for the BIMS and PHQ-2 to 9.

3. Review GG coding prior to MDS submission for the first three or four weeks on all payer sources to ensure accuracy. 

Bumps related to survey

Surveyors will likely focus on Section GG and the newer items. If your facility lacks supporting documentation or has no process to gather the data to make a functional assessment, there will be a problem. Facilities that choose not to have CNAs document Section GG items still need a system for daily documentation to indicate the resident’s status and care provided, provide support for rehab referrals due to a change in function, and track significant changes. Lacking these items can be detrimental to the accuracy of assessment and care planning. 

Regarding missing indications in Section N, if the assessors are checking off “no” to indications for high-risk meds, that might signal an issue with documentation. Clinical support is required from the prescriber and not simply a diagnosis with no further support or rationale in the clinical record. The SOM requires physician’s visits to include an evaluation of the resident’s condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident’s current medical regimen, which is in line with the indication for high-risk medications in MDS Section N. 

Therefore, three months out, do the following:

1. Self-audit or have a third-party audit documentation to support change in function in ADLs and rehab referrals. 

2. Conduct a monthly review of CNA ADL documentation and ensure their involvement in the care plan meetings. 

3. Self-audit or have a third-party audit high-risk medications and clinical rationale. Pharmacy partners would be great for this. 

One final potential bump 

Have you updated your facility assessment, policy and procedures to reflect the new MDS changes? Is your interdisciplinary team comfortable with these changes? Specifically, are your nurses educated on medication reconciliation at discharge? Do they understand indication vs. diagnosis? Who will be responsible for ensuring that this requirement is completed, accurate and documented? 

Therefore, one month out, do the following:

1. Have conversations with members of your clinical team to gauge their adjustment to the changes. Do they have any ideas that may help improve your documentation?

2. Review all policies, procedures, facility assessments and census and condition reports to ensure that they are updated and that they accurately and compliantly reflect changes to the MDS. Incorrect or outdated data can also have repercussions for your health inspection survey. 

3. Audit your medication reconciliation and discharge documentation monthly.

This “new MDS” doesn’t carry the title MDS 4.0 but maybe it should. The amount of change is significant. Do fasten your seatbelts because we will experience bumps. However, a seatbelt constructed of audits, education and QAPI will keep you safe. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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Martin Allen, senior vice president of reimbursement policy for the American Health Care Association, cautioned providers Tuesday to advocate for themselves as states tackle routine rate rebasing, convert from therapy-based payment systems to case-mix versions more in line with Medicare, and also look to adjust to new federal regulatory requirements.

“We have to be very careful about the dollars associated with the next rate cycle and case-mix indexes associated with that as well,” Allen told providers at an educational session at the AHCA/NCAL annual meeting Tuesday.

“The general theme is acuity levels are still high and people coming into our buildings are still sicker, even though we’re not dealing with [significant] COVID diganoses anymore,” he added. “From a Medicaid perspective, we want to make sure those themes get built into  any rebasing process.”

Nearly half of states rebase per-diem rates annually, and the recent MDS transition will throw an extra wrench into the process for many states in 2023 and 2024. Gone with the old MDS system is Section G, which many states used to calculate clinical reimbursement on the Medicaid side. As of 2019, 34 states were still using a RUGS-based system to capture acuity, according to MACPAC data cited by Allen. 

Some states that were unable to transition to their own Patient Driven Payment Model-like models in time for that have frozen case mix while they develop a new standard. Others are using an Optional State Assessment that can be used to convert to old RUGS-based scores, but they will still need to work toward a permanent replacement.

“We have to be engaged in the process of revision,” Allen said, noting that AHCA is offering states feedback in addition to audits typically being led by accounting firm Myers & Stauffer.

One key will be for states to add measures that accurately reflect the needs and conditions of Medicaid long-stay residents, since PDPM is geared toward short-stay patients.

“We want to have adequate time to make the changes both from a cost standpoint and a rate standpoint,” Allen added. “With a hard transition … your risk of winners and losers can be very great.”

A phase-in would instead allow state Medicaid systems to catch problematic factors. So far, in states working on transitions, providers are asking for “hold harmless” provisions. Those can limit deep cuts, but they also limit higher payments to providers who would pick up significant acuity-based payment increases, Allen explained.

It’s important that states recognize a technical conversion shouldn’t be used to clawback money from providers, especially if cost-reporting information might be used simultaneously to adjust rate methodology or rates.

He said that states tackling both efforts at the same time could “muddy the water” and threaten providers’ livelihoods, and in turn, force providers to reconsider their approach to Medicaid patients or close units or buildings. That could be worsened by cost data that is skewed by COVID-era government support that temporarily helped providers counter higher costs.

“This shouldn’t be an opportunity for the states to pull money out of the Medicaid program,” he added. “Budget neutral or better. We need to hold states accountable to make sure there are no changes.”

In a LinkedIn post Tuesday, reimbursement expert Marc Zimmet cautioned providers against that “better” standard.

“Operators anticipate significant rate increases per pre-transition modeling, but without additional funds, we  end up exactly where we were under the old system,” the Zimmet Healthcare Services Group president and CEO wrote. “Invariably, the same operators with high scores in one system have the highest scores in the new one because CMI is often as much about reimbursement management as it is patient acuity.”

“When all is said and done, the state wasted valuable resources, providers wasted valuable resources, all to rearrange the same deck furniture,” he noted. “I asked this question when CMS effectuated the PDPM recalibration: What was the point?“