Skilled nursing facilities

Skilled nursing facilities provide:
Medical and social services for people of all ages with complex co-morbidities
Most patients are admitted to a skilled nursing facility from:
An acute care hopital
Long term care is a continuum of care that includes:
Non skilled care and skilled care (often in Medicare certified unit in nursing home)
A skilled nursing facility is an institution which:
Is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care; or rehabilitation services.

A Medicare certified skilled nursing facility has an RN available 8 hours daily and an LPN available 24/7

Skilled nursing facilities must be certified by:
SNF are the most or least highly regulated health care setting?
Most highly
There are more or less than 1,750,000 skilled nursing beds in US for pts on Medicare or Medicaid?
More than
The average monthly charge per resident in a SNF is….
In 1987 federal nursing home reform act included this act_____, which was a catalyst for changes in long term care.
OBRA: omnibus budget reconciliation act

Included a requirement that each resident shall attain and maintain the highest practical physical, mental and psychosocial well-being in order for the facility to receive Medicare and Medicaid funding

Established national standards of care (individual care plans, right to choose physician and access medical records, right to participate in family council, right to be free of unnecessary restraints)

Established annual survey and certification process

From 1964 when Medicare begin until 1998, payment to SNFs were:

Provide services submit bills, get paid for costs

Outside vendors (PT/OT contract groups) billed Medicare directly without involving SNF

1997 the balanced budget act (BBA) goal was focused on:

SNFs no longer paid on a reasonable cost basis or through low volume prospectively determined rates, but rather on the basis of a prospective payment system (PPS)–are adjusted for case mix and geographic variation in wages.

The BBA mandated the implementation of:

Major elements of the system include:

Per diem prospective payment system covering all costs related to services furnished to beneficiaries under part A of Medicare.

Major elements of the system include:
-case mix adjustment
-geographic adjustment.

One payment is made to SNF based on the patients _____ category.

and SNF s responsible for paying outside vendors from this single payment.

So what services are provided by the SNF?
Depends on the RUGIII category generated by the MDS data.
What is RUG?
Resource utilization group.
RUG categories classify patients according to their resource needs in these areas:
Quantity of rehabilitation (highest reimbursement $$$)

Activities of daily living


Nursing rehabilitation needed

How many rehab categories of RUG are there and how many non rehab categories are there?
5 rehabilitation categories (based on the amount and type of services received)

6 non-rehabilitation categories.

What is MDS? What is it for?
Minimum data set.

MDS is a way for Medicare to compare SNFs

It allows common definitions/ ratings to get applied to the physical/psychological/cognitive performance of a patient.

MDS rates patients in the following categories:
Mobility (bed mobility, transfers)

ADL (eating toileting)

Functional status

Nursing needs

Therapy needs

The data from the MDS is the basis for determination of:
Each patients case-mix RUG group
MDS data indicating greater severity results in a higher or lower RUG score?
Of the 44 subcategories of RUG, the top 26 probably (not definitely) qualify for:
Skilled rates
How is MDS used?
Commonly used as a retrospective outcomes measure to answer questions such as: how does a RUG category of patient respond to services?

A recent change has occurred where it is being used prospectively in attempt to influence outcomes such as: already know pts in certain RUG category or who score below certain levels on some of the MDS items are more likely to fall. So should implement a falls prevention automatically when a new admission fits this criteria.

One challenge of the SNF Is that many have begun to switch from contractual groups (harder to control costs) to in-house employees. Why is this a problem?
Under PPS, SNF might higher fewer therapists or assign 1-2 therapists to multiple sites with care extenders in place.
What is the problem with therapists placing patients into rehab or high RUG categories than needed if it means they will be reimbursed more?
The patients may not need or tolerate therapy.
Since PPS, what are the two diagnosis were the most common admissions I to SNF?
Post-CVA and post-orthopedic surgery bc these fall neatly into DRG–due to short LOS in hospital, they enter SNF with lower levels of physical functioning.
So why not others dx or multi-system dx?
Because it is harder to identify which case-mix group they fit in to for reimbursement.

It has never been easy to find SNF placement for complex patients, but under PPS it is harder.

What is the impact of PPS on the patients?
A study showed that after PPS, patients tended to receive 5days/22 min per day less therapy than prior to PPS.

The problem is that it has impacted accessibility for patients with needs that exceeded their PPS payment.

Finding: since the MDS (PPS) began, the results suggest that rehab providers differentiate treatment on the basis of payer. Medicare residents have odds of receiving therapy that are substantially higher than even private pay. Medicaid residents, whose payment rates are the lowest, have significantly lower odds of receiving therapy and receive less total therapy time. What is a possible explanation for this and what is the impact?
Explanation: higher payment rates for those at top RUG Medicare categories. Also, Medicare baby boomer pts/ families educated to understand the benefits of receiving rehab.

Impact: subtle discrimination based on reimbursement.

Finding: SNF are reconsidering traditional staffing mix. What is a possible explanation and what is the impact?
Explanation: reimbursement constraints make it more financially attractive for facilities to use more aides instead of licensed therapists to deliver therapy with contract therapists as needed.

Impact: licensed therapists covering multiple sites may be pressed to violate protoceratops act supervision and delegation rules in SNFs.

What opportunities are offered at a SNF?
To work with the unique challenges of residents with chronic diseases, needs for sophisticated post-acute care and complex regulatory requirements.

To have greater autonomy for clinical decisions In the daily management of patients.

To work with interprofessional teams

To interact with and educate families

To advance to upper level management roles involving interprofessional teams within the organization

What management roles are offered in a SNF?
Integrate organizations mission/vision into the daily actions of the rehab team

Collaborate with nursing home administrator and director of nursing

Develop policies that include clarification of roles and responsibilities

Implement federal and state regulations

Network for strong relationships with referral sources

Develop employee retention strategies

Identify marketing strategies (niche markets, unique aspects a SNF facility, patient outcomes)

What are some management issues?
Patient care
Budget issues
Quality control
What is your role regarding professionalism?
Put the patients best interests first

Remember your values and ethics (accountability, compassion/caring, excellence, integrity, professional duty, social responsibility)