Reform's new risks: risk management provisions long-term care operators should know about

While there are many tenets and facets of the new healthcare reform law that long-term care facility operators must know about, the risk management aspects are particularly important.

In essence, long-term care providers must have processes in place to ensure quality care for residents or face greater liability and lower revenues, experts note.

“From a policy perspective, healthcare reform and MDS 3.0 represent the greatest change in more than a decade for long-term care and healthcare overall,” says Kate McCarthy, business account manager for Lexington, MA-based PointRight. “In MDS 3.0, the scope of assessing residents has changed dramatically, as it is now patient-centric and intended to ensure that patient needs are met and outcomes improve.

“There have been incremental changes in recent years, but in terms of overhaul and thinking differently about healthcare, this is a fundamental shift in not only ideology, but design.”

Mary Chmielowiec, executive vice president of PointRight Insurance Group, adds that “a move to a holistic, resident-centric approach dramatically impacts both skilled nursing and corporate processes. Not only are their tools of measurement changing, but so will their payment systems.”

Known officially as the Patient Protection and Affordable Care Act, the national health reform initiative is the most sweeping legislative change since the establishment of Medicare and Medicaid in 1965. Because there will be so much change ahead, McCarthy and Chmielowiec are advising facilities to become more proactive from a risk management viewpoint.

Need to lead

Not only is this a cultural and ideological shift designed to improve quality outcomes and patient satisfaction, “but there is a significant tie-back to reimbursement,” McCarthy explains. “Healthcare reform calls for everything from bundled payments to value-based purchasing and penalties for not meeting quality measures. It behooves people to think now about ways to streamline the patient care system to ensure their ability to understand their performance, reduce unnecessary spending and improve or maintain their bottom line.”

From a risk management perspective, facilities have to search for the “just right” balance between providing exceptional clinical care and promoting resident independence in a safe and collaborative environment, says Eric Hunzeker, director of sales for Lincoln, NE-based Stanley Healthcare Solutions.

“This becomes more challenging as healthcare reform requires increased capacity while not necessarily increasing facility payments,” he says. “Efficient and standard care that utilizes effective technologies and manages employee turnover will have to be the priorities for facilities to succeed in this changing market.”

Anticipate changes

Healthcare reform measures will be implemented throughout the next decade and much of the legislation is focused on pilot programs that are designed to modify the current system. Many of these pilot projects kick off in 2012, and providers who opt to participate in these programs will have an opportunity to be a part of the process.

But just because long-term care providers likely will not see meaningful shifts from these efforts until 2015, does not mean they should become complacent, experts note.  

“Providers should be looking at ways to standardize documentation throughout the care continuum, with particular focus on transitions in care, such as re-hospitalizations, discharge to homecare and internal transfer to hospice,” Chmielowiec says

Ronda Christopher, Stanley Healthcare’s patient safety consultant, says that rather than adopting the same approach for all residents, all interventions need to be tailored to the unique needs of the individual.

“Essentially, risk management is most effective when there is a proactive approach to assessing the clinical and personal needs of the resident on a regular basis,” Christopher says.

“Facilities that manage and mitigate risks proactively position themselves for the most success. Both healthcare reform and MDS 3.0 clearly place ‘patients or residents’ as partners in their own care.

Promoting concepts of self-management and wellness are becoming essential strategies in ensuring appropriate and accurate healthcare.”

Utilize technology

Health information technology is an important catalyst for providers to gain control of their risk management processes, Chmielowiec explains.

“There are tools and analytics available to aid facilities in better understanding their resident case mix, associated risk and patient outcomes,” she says. “Having the tools to predict patient [health status] is a huge asset in reducing liability during these industry changes.”

In McCarthy’s view, long-term care providers are well-situated to adopt new IT systems by taking advantage of the Obama administration’s American Recovery and Reinvestment Act. The stimulus program has earmarked at least $20 billion for health information technology.

“While acute care providers have long been the benchmark setters for use and adoption of healthcare IT, new definitions around ‘meaningful use’ and access to grant money offer the long-term/post-acute care industry a unique opportunity to get in the game and be a voice in the standardization of documentation and language,” she says.

Security technologies also are essential for minimizing risk when it comes to protecting the health and safety of residents, adds Mark Rheault, president and CEO of Fargo, ND-based Intelligent InSites.

Real-time locating technologies can help minimize the facility’s risk of “wandering” patients by automatically verifying the identity of a person wearing a pendant or a bracelet. The ID displays the name, photo, and other relevant resident information on a portable device carried by staff when administrating medications.

“An RTLS system can tighten safety measures, confidentially confirm resident identity and make the environment safer by verifying the identity of contractors and visitors,” he says.

Follow up on issues

Nursing facilities have become “a lot more proactive” in addressing risk management issues and concerns in recent years, believes Chip Kessler, general manager for Johnson City, TN-based Extended Care Products.

“One innovation I’ve seen in regards to risk management is the attention being paid to resident and family concerns on a continuing basis. This communication typically occurs with a ‘family telephone contact’ program that begins a few weeks after the resident is admitted. A designated facility staff member calls the family and asks a specific series of questions geared toward making sure the family and the resident are satisfied with the way the admissions process was handled and if there are any issues or questions through these beginning days. Then at six-month intervals, the family is called back and asked another specific series of questions again to determine if things are going smoothly and if they have any issues to address.

“The idea behind this innovative program is to learn from families as soon as possible if they have any upfront issues rather than having the family ‘stew’ about things,” Kessler says. “Otherwise, these feelings can build up until they turn into something much larger and more serious, which can then fester into major headaches for the facility such as a potential lawsuit.”

To improve resident safety and lessen their exposure, providers  may want to update their quality assessment and assurance processes. Vendors can help, adds Barbara Peterson, business development director for Columbus, OH-based Risk Management Solutions.

“When the facility staff and support staff are educated and skilled in problem identification, root cause analysis, improvement strategies and the use of clinical care pathways in problem resolution, they are better at providing consumer-driven quality care.”

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Key risk areas:

-Falls
-Pressure ulcers
-Medication errors
-Improper staffing
-Wandering
-Resident-on-resident violence
Effective strategies:

-Adding physician “extenders”: Having nurse practitioners on staff provide another layer of oversight and a higher level of skilled care. Facilities can benefit greatly from having a clinician on the floor who not only can capture shifts in acuity, but who can generate orders for treatment before a pressure ulcer becomes worse or a patient needs hospitalization.

-Focus on crisis management: A sentinel event handled badly can instantly generate negative publicity that ruins a facility’s reputation. Having a process in place to deal with family members, media and local authorities is essential. Management should know how to properly design and implement a crisis communications plan.

-Partnerships & practices: The concept of care “bundles” and collaboration with other providers to solve problems increases a facility’s ability to provide exceptional care with good outcomes. Adopting industry and manufacturing approaches such as LEAN practices can assist a facility to recognize how to cut waste in systems and processes, allowing for more time to provide the right care for the resident. These concepts have been proven to help minimize the risk of mistakes and unnecessary errors.

Source: McKnight’s Long-Term Care News interviews, 2010