Guest Columns

The pressure is on, Part 1

Tara Roberts
Tara Roberts

The Centers for Medicare & Medicaid Services recently released its annual series of Medicare payment-related proposed rules for long-term care post-acute settings, which includes skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals last month.

In addition to updating Medicare payment rates for FY2016, each of these proposed rules include measures to satisfy the cross-setting requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). One such measure being considered for, not only cross-setting benchmarking and measurement, but also for an “update” is the Short Stay New or Worsened Pressure Ulcer quality measure.  It is the “update” that has providers feeling pressure.  The proposed update reads like this:

“As part of our ongoing measure development efforts, we are considering a future update to the numerator of the quality measure NQF #0678, Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay). This update would require PAC providers to report the development of unstageable pressure ulcers and suspected deep tissue injuries (sDTIs). Under this potential change we are considering, the numerator of the quality measure would be updated to include unstageable pressure ulcers, including sDTIs that are new/developed in the facility, as well as Stage 1 or 2 pressure ulcers that become unstageable due to slough or eschar (indicating progression to a stage 3 or 4 pressure ulcer) after admission.”

As a clinician and wound care manager, I agree that this measure, to truly reflect care and pressure ulcer development, needs to include unstageable PrUs in the numerator. This certainly brings on challenges and the likely significant change in a facility's score.

There also are several problems though with the suggested update. Thankfully, CMS allows for a comment period to provide the kind of feedback needed to make this type of implementation and update meaningful and accurate.

One big problem is the lack of sufficient risk adjustment. If we don't have the benefit of risk adjustment, nor any consideration for the complexity of a resident, or the potential for unavoidable pressure ulcers, than facilities put themselves at “quality risk” by accepting these types of residents. Even the best facilities that specialize in skin and wound care would be hard pressed to continue to take on such complicated care when faced with this measurement.

Another problem is the proposal to include sDTI or suspected deep tissue injuries in the numerator since they are considered unstageable pressure ulcers for coding purposes. This is a clinical consensus problem and thus would be a math problem for measurement. There simply is not enough research and competing literature exists on just how long it takes (some say 48 to 72 hours, others say up to 7 days) for sDTIs to develop and thus reveal themselves to the clinician.

What is needed is a consensus by the NPUAP. There isn't possibly enough consistency across LTC providers much less across all of LTPAC to consistently assess sDTIs and accurately determine “admitted with” vs. “facility acquired.” These are just a few examples of considerations that are needed to be taken and explored prior to implementing this suggested update.

No doubt, with or without the update, the increased focus on Short Stay New or Worsened Pressure Ulcers as a cross-setting standard means the pressure is on. It is time to get serious about your skin and wound care program and its ability to prevent pressure ulcers.  Where do you start? How do you start? I'll address these in a follow-up blog.

Tara Roberts, PT, is the Vice President of Rehabilitation and Wound Care Services at Nexion Health.

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