Providers urged to use claims data to help drive LTC business plans

Skilled nursing providers should examine healthcare claims data to find regional or state trends that may change their business plan, an expert said Tuesday.

“In a general sense, we're seeing tremendous changes that are happening in the way people are seeking their care,” said Robin Gelburd, JD, of FAIR Health, a nonprofit focused on healthcare claims and insurance transparency. Her presentation at the LTPAC conference, titled “Precursors to LTPAC: How Healthcare Claims Data Can Help Drive Strategic Decision Making” examined diagnosis and other demographics related to how people seek care.

For example, West Virginia has a much higher rate of obstructive chronic bronchitis, which is often treated in an emergency room, like in heavy coal mining states such as Kentucky, she noted. West Virginia also has a high rate of septicemia.

Kentucky, meanwhile, has a high rate of acute kidney failure, which also is true in Delaware. Western states tend to have high rates of open wounds.

Understanding which referral sources tend to have higher rates of individuals with certain conditions could be very helpful for skilled nursing operators. Home health, for example, tends to see higher open wound rates.

“The data tell a story about where to allocate resources,” Gelburd said. SNF providers, who are constantly busy, can get “X-ray goggles,” meaning they don't always show the larger picture. Examining the data can “allow you to identify areas of weakness” and find best practices, Gelburd said.

“You can start introducing remediation techniques,” she explained.

Examination of data and better care management was the thrust of a separate presentation on the impact of electronic technology in preadmission screening and resident review in California. The state requires Medicaid-certified skilled nursing facilities to submit Preadmission, Screening and Resident Review (PASRR) evaluations for residents to identify those who need services for mental illness. The first phase of paperwork, called Level 1, is necessary in order for residents to receive a Level 11 evaluation, explained Jared Nyagol, a doctoral student in the Department of Sociology, Kansas State University.

“It's one thing to say someone has a mental illness but it's another to decide what kind of level of care they need,” Nyagol noted. Generally, around 25% to 30% of residents are recommended to move to Level 11.

The problem was the traditional paper system created a turnaround time from Level 1 to Level 11 of 53 days, far off the federal requirement of seven to nine working days. The goal was to eliminate faxed Level 1 forms and reduce the time.

Within the first month, the turnaround time was knocked down to 21 days, compared to the standard of 53 days with the traditional paper method, Nyagol said. In a study of 8,084 referrals from the post-implementation in 2015, the mean turnaround time was 8.3 days.

The important thing for providers to realize is the state and federal government are working to increase access to the resident receiving the right care, at the right time, Nyagol said.

“The key thing I'd love for providers to know is that this is about providing the right information, and while people think ‘I have to submit,' they are focusing on compliance rather than the care for the resident,” he said.

The move to electronic from paper records also was covered in a session on Health IT Safe Practices, presented by Lorraine Possanza, DPM, JD, MBE, of the ECRI Institute, Plymouth Meeting.

In electronic health record systems, there is a risk of alarm and alert fatigue, she said. She also noted staff need to sometimes push back on vendors that say mistakes happen because managers haven't “trained people well enough."

“Sometimes it's not user error,” she said. “Sometimes there's something about the system that may not be right. If you're not reporting that, no one will be working on that. You need to work together to make care safer.”