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How will PBJ impact Five-Star staffing? Would you like one lump or two?

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Steven Littlehale
Steven Littlehale

We don't know when, and we don't know how, but when Payroll-Based Journal staffing data replaces the data currently being captured from CMS Form 671 for calculating Five-Star staffing, we are likely going to take several lumps.

Skilled nursing providers have been submitting PBJ data since mandated as of July 2016 and today 92% are compliant with this requirement. Compliance in this case means PBJ staffing data was successfully transmitted to the Centers for Medicare & Medicaid Services and on Nursing Home Compare a staffing domain star rating is present. (Although, the star rating doesn't comment upon the quality of the PBJ data itself, but let's leave that for another time.)

CMS has clearly communicated that this new data will be incorporated into Five-Star, but we don't know the When and we don't know the How.

We can only speculate, and put our efforts into what we can control, including the data quality I just mentioned and said we'd discuss at another time. OK, I mean it this time.

PBJ data offers greater specificity into actual staff hours spent on specific care related activities, and does a better job at not combining different types of nursing staff into one labeled category.

I'm referring specifically to the current CMS Form 671 (Facility Staffing) which combines Nurses (LPNs and RNs) whose principal duties are spent conducting administrative functions into a category referred to as Nurses with Administrative duties, which then contributes to the RN Five-Star rating.

PBJ is not perfect! Salaried employees exceeding 40 hours will not have their hours counted, unless bonus monies are provided for the extra hours. It's cumbersome, but thankfully no one in nursing homes works over 40 hours. (OK, OK, please pull yourself off the ground. Your clothes are liable to get dirty, rolling around and laughing like that.)

This month at NIC's Spring Investment Forum, I presented a study on the impact of current and future changes on Five-Star on the investment community. As we transition to a value-based healthcare environment, clinical outcomes are the key indicators of SNF financial stability and success; owner, operators, lenders and REITs are all monitoring these metrics. Anything that alters Five-Star ratings has a ripple effect that far exceeds its intended purpose of guiding consumers in making choices and monitoring care.

Rest assured that it's not just Five-Star that is being used, but it's certainly front and center.

The study focused on the switch over from CMS Form 671 to PBJ data. Included in the study were only SNFs who successfully submitted PBJ and CMS Form 671 data (14,153 SNFs). We did our best to control for differences between these two data sets, but they are quite different.

Row A) presents the average RN HPRD; included in this category are LPNs with administrative duties.

Row B) illustrates how different PBJ and CMS Form 671 data is. A drop in 0.10 HPRD simply by using one type of staffing data in place of the other.

Row C) is “true” RN HPRD with LPNs with administrative duties factored out.


What does this mean to Five-Star Staffing and Overall? Let's start here.

RN, Aide and Total HPRD go down. Again, not because there were fewer staff, just different rules on how they were counted.

Let's next see what happens to RN and Staffing Five-Star.

As expected, there is a significant decrease in 5- , 4- and 3-Star SNFs when LPNs with Admin duties are removed from the Nurses with Administrative Duties category.

Naturally, this ripple effect is seen in the staffing rating.


And finally, the impact on Overall Five-Star.

Here we see the downward shift again. SNF migrates downward to lower ratings. A total of 1,051 SNFs had a 3 or higher rating and went to 2 or 1 Overall star rating.

Take a deep breath.

Staffing has always been an important component of Five-Star, second only to complaint and standard survey results. It's highly unlikely that the methodology for calculating the RN and Staffing domains will remain the same. The analysis above shows the impact if the methodology were to remain the same. It would be unconscionable to consumers who use Five-Star for its intended purposes, to have such a significant shift in outcomes.

Consider stakeholders outside of SNF caregivers, such as the owners, hospitals, APM, payers, lenders and REITs; there is a clear call to action: education on impending changes, advance notice, and relaying information as it becomes available. A layer of knowledge to help them anticipate and later understand how this system is changing (yet again) is necessary.

We can never over-communicate and by all means share with all stakeholders, especially residents and families, what you're doing to be compliant. More so, reassure them how you ensure that staff are qualified to care for your residents, and how you measure and monitor this requirement.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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