Getting the Dollars You Deserve for the High-Quality Care You Deliver

The Alliance Training Center, Inc.

Leah Klusch, Executive Director
Nurse, Educator, Consultant

ABSTRACT

In the face of increasing costs, declining revenues, and new changes to the Medicare and Medicaid reimbursement system on the horizon, more and more acute care and skilled or long-term nursing facilities throughout the U.S. are focusing on improving the quality of care to increase financial performance.

Nursing home and long-term care (LTC) facilities, while they have the capacity to provide higher quality care at a lower cost, continue to struggle to implement effective strategies that enable them to directly increase revenues through higher reimbursements from the federally mandated payment system. In fact, the quality of the institutional documentation process to gather data that is congenial and supportive of the Minimum Data Set (MDS) can be directly related to the quality of payments received through the Centers of Medicare and Medicaid Services (CMS).

However, the vast majority of LTC facilities have not addressed quality of the assessment process to ensure they are receiving the right reimbursement for the care they are delivering. Why? Because the documentation process must begin with definitions of the MDS assessment process; and as part of this, the accuracy of the data with which a facility documents resident status through the MDS system is crucial, but currently lacking.

The solution to these challenges rest with LTC facilities adopting interdisciplinary assessment procedures and extremely accurate, 24x7 documentation of activities of daily living (ADL) through the assistance of technology that enables staff to accurately document care directly at or very near the point of care.

A study documented in Health Care Management Review examined the relationship between quality of care and financial performance of nursing facilities and found that the facilities that produce better outcomes and care processes were able to achieve lower costs, and better financial performance. Although the study pointed to a connection among better clinical outcomes, lower resident care cost and improved operating margins, it concluded that quality outcomes do not automatically result in increased revenue.

This suggests that: (1) beyond a certain threshold, nursing facilities are not able to directly increase revenues by improving care quality, such as that required to meet regulatory requirements, or (2) nursing facilities with higher quality care were unable to adequately compile and disseminate this information, and thereby unable to realize higher reimbursements.

A separate study documented in the Journal of Nursing Administrators, suggests that the likely gap between quality outcomes and the ability to directly impact revenue is due to the difficulties nursing facilities experience in producing accurate resident assessments and documentation. Since the assessment and documentation process, represented by the MDS system, not only directly affects reimbursement but also influences the quality of care for residents, it is clear that mastering resident assessment and documentation is crucial.

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