WHCA Spring 2015 WI Medicaid CMI Changes€¦ · WI Medicaid CMI Changes 4-2015 All materials are copyrighted. Copying and redistribution of these materials in any means including

WI Medicaid CMI Changes 4-2015All materials are copyrighted. Copying and redistribution of these materials in

any means including print or electronic is a violation of copyright laws.

5343 North 118th Court Milwaukee WI 53225414 476 1112 fax 414 476 6118

www.specializedmed.com

WHCA Spring 2015WI Medicaid CMI Changes

5343 North 118th CourtMilwaukee WI 53225414 476 1112 fax 414 476 6118www.specializedmed.com

The materials contained herein include information and facts and the opinions and recommendations of

Specialized Medical Services, Inc. (SMS) regarding governmental regulations, statutes and practices, and potential changes to same. Notwithstanding anything to the contrary stated or implied in any of the

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deemed the giving of legal advice by SMS or its employees. All participants should consult their own legal advisors, applicable regulatory entities and other sources of legal information and advice for any

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Specialized Medical Services, Inc.5343 North 118th Court

Milwaukee, WI 53225 414-476-1112 fax 414-476-6118

email: [email protected]

1





Presenter: Theresa Lang, RN, BSN, WCCVice President Clinical ConsultingSMS for 19 yearsOver 30 years LTC experienceAHIMA ICD-10 Approved TrainerAreas of Expertise

Clinical Operations and Training Medicare MDS Wound Care

[email protected]

RUG 48 Calculation Changes:Impact on Facility ReimbursementEffective 7/1/2104

CMI Basics

MDS 3.0 uses 108 items to calculate a RUG 44 score

The ARD (Assessment Reference Date) determines how the assessment is used in the revised Medicaid formula

Picture Quarter vs Picture DatePicture Quarter Data Available as

of Date:Rate Effective

Date

Oct - Dec 2013 June 30, 2014 July 1, 2014

Jan - Mar 2014 Aug 31, 2014 Oct 1, 2014

Apr - Jun 2014 Nov 30, 2014 Jan 1, 2015

Jul - Sep 2014 Feb 28, 2015 Apr 1, 2015

Which MDSs are included The assessment for each resident that is

RUG-able, dated on or before the last day of the quarter, and correctly included in the WI MDS database by the “as of date” will determine the case mix grouping for that resident for that quarter.

New admissions will not be included in the CMI unless they have received a RUG-able MDS assessment on or before the last day of the quarter.

Which MDSs are included

Re-entries will be included in the CMI with their last valid RUG classification from their prior stay, if they were discharged “with return expected” and actually returned the facility, if there is no more recent valid RUG classification.

2

RUG IV 48 Classification System WI MedicaidCMI Index Maximized

ExtensiveServices

ES33.00

ES22.23

ES12.22

Special CareHigh

ADL

SpecialCare Low

LE2 1.61LD2 1.54

LC2 1.30

LB2 1.21

LE1 1.26LD1 1.21

ClinicallyComplex

ADL

Depresed

BehaviorSX

Cognition

ADL

ADL

BB2 .81

BA2 .58BB1 .75

BA1 .53

2-5

2-5

0-1

0-1

ADL

Nursing Rehab

Nursing Rehab

Nursing Rehab

Nursing Rehab

Nursing Rehab

PE2 1.25

PE1 .17PD2 1.15

PD1 1.06

PC2 .91PC1 .85

PB2 .70

PB1 .65PA2 .49

PA1 .45

2+ 0-1

2+

2+ 0-1

2+ 0-1

2+ 0-1

15-1

6

11-146-102-5

0-1

0-1

Specialized Medical Services, Inc.5343 North 118th CourtMilwaukee WI 53225

414 476 1112 fax 414 476 6118Copyright 10/2010

Ventilator, Trach,Medical Isolation

Rehabiliation ADL

RAD 1.58

RAC 1.36

RAB 1.10

RAA.82

ReducedPhysical

Functioning

RAE 1.65

ADL

Depressed

NotDepressed

HE2 1.88HD2 1.69

HC2 1.57

HB2 1.55HE1 1.47

HD1 1.33

HC1 1.23

HB1 1.22

Rest. Nsg 2+

Rest. Nsg 0-1

ADL

NotDepressed

Depressed

LC1 1.02

LB1 .95

15-1

6

11-146-10

ADL

2-5

0-1

15-1611-14

6-102-5

15-16

6-1011-14

15-16

2-56-10

11-14

2-5

15-1611-14

6-102-5

ADL

NotDepressed

CD2 1.29CE2 1.39

CC2 1.08

CB2 .95

CA2 .73

15-16 11-146-10

2-50-1CE1 1.25

CD1 1.15CC1 .96

CB1 .85CA1 .65

15-1611-14

6-102-5

0-1

3






A RUG-able MDS assessment includes:Admission Assessments,

Annual Assessments,

Quarterly Review Assessments,

Medicare Assessments,

Significant Change in Status MDS, and Significant Correction to Prior Comprehensive MDS Assessments.


The average quarterly CMI for the facility shall include all valid RUGS scores, which may include multiple distinct RUGS scores for an individual resident, subject to the limitations described above.

Medicaid CMI for entire quarter vs. "picture date"

Picture Date

6/30/2014MDS closest to the

picture date is used

Example 4/15/14 RAB 1.10

6/1/14 PA1 .45

The PA 1 would be used

Picture Quarter

Effective 7/1/2014 All MDSs during the 3

month window will be averaged by days

Example: RAB 1.10 x 47 days

PA1 .45 x 30 days

51.7 + 13.5 = 65.2

65.2/77 = .8767

CMI to Dollars

Every .01 in the CMI is equal to $.85 to $1.05

60 Medicaid residents at .85 per day $51 a day

$4590 per 90 day quarter

60 Medicaid residents at .85 per day with a .04 increase$204 a day

$ 18,360 per 90 day quarter

Impact of the ARD Medicaid CMI calculations are based on

the MDS ARD

The ARD determines the # of days of a given CMIExample:

April 1 ARD- with not additional MDS

RUG CMI of the 4/1 MDS will be used for 91 days

Impact of the ARD Days in SNF prior to the ARD will not be

used in calculating the CMI

ExampleResident is admitted on 4/1/2015

First MDS ARD is 4/10/15

81 days will be used to calculate the CMI

Example:Resident is sent to hospital on 3/28/15

Readmitted to SNF on 4/4/15

4/1 to next MDS CMI will be based on

last MDS in prior quarter

4





Should we not do all MDS on day 1? NO- you will have insufficient data to

complete the MDS and a low RUG score

Example:ARD 4/1/15 RUG Score CC1 CMI: .96

90 days at .96

ARD 4/10/15 RUG Score RAB CMI 1.10 80 days at 1.10

Identify Strategies for calculating Medicaid CMI for entire quarter vs. "picture date"

Watch MDSs due in the first 1-2 weeks of January, April, July, October

Would it benefit for the quarterly MDS to be done “early”? In the prior quarter

Watch Individual MDS CMI

If RUG is going to go down:Set ARD as close to day 92 or 366 as

possible

If RUG is going to go upSet ARD as soon as it the change is identified

MDS Schedule Requirements

OBRA Requirements

First MDS ARD must be on/before the 14th

day of admission

Then quarterly MDS at least every 92 days

Annual assessment at least every 366 days

MDS scheduling is based on ARD

Early Quarterly: Example 1

10/15/14 RAB 1.10

12/1/14 CC1 .96

Quarterly MDS needs an ARD no later than 1/5/2015 done 12/20

RUG will drop to PC1 .85

October 16 days at 1.10

November 30 days at 1.10

December 19 days at .96

December 12 days at .85

CMI: 1.0278

Example 2 10/15/14 RAB 1.10

12/1/14 CC1 .96

12/31/14 Picture quarter this resident will be a 1.03

At $.85 x 90 day

$76.50 for the quarter

Quarterly

Quarter July- September

5/20/14 PB1 .65

8/1/14 CC2 1.08

The 5/20 MDS is used to calculate the first 31 days of July

July: 31 days at .65 = 20.15

August/September: 62 days at 1.08 = 66.96

Quarter CMI 87.11 or .9468

5





Early Quarterly

Quarter July - September

5/20/14 PB1 .65

7/15/14 CC2 1.08

July 1 to July 14: 14 days at .65 = 9.1

July 15 to September 30:78 days at 1.08 = 84.24

Quarterly CMI: 93.34/92= 1.0145

Calculating CMI Daily

Yes it can be done but it may not be a reflection on your quarterly CMI scoreWhy: Residents in house today may not have

a claim submitted in September 2015

If daily CMI is calculated remember If the resident will be used in the quarterly

sample

All days in the quarter will be averaged

Watch for Significant Change in Status Assessment MDS Criteria Improvement or decline in 2 or more areas

Will not improve with normal interventions

UTI, Pneumonia, etc. are not reason to do SCSA- as they are expected to improve-IF THEY DO NOT then a SCSA would be appropriate

Watch for Significant Change in Status Assessment MDS Criteria Improvement or decline in 2 or more areas

Will not improve with normal interventions

Resident has declined in ADL- therapy is started

If a SCSA is done due to the decline- then another would be indicated when therapy ends

Watch for Significant Change in Status Assessment MDS Criteria:When a resident is in therapy and improving

SCSA are not required as long a process is being made

SCSA is required when the resident reaches his/her maximum potential

Key Factors

MDS staff must know and understandCMI and how CMI’s are calculated

Ability to estimate a CMI without doing an MDS

Impact of ARD selection on quarterly CMI calculation

“Early” quarterlies if RUG/CMI is going up

IF RUG/CMI is decreasing – set ARD as close to 92 or 366 days as possible

6





Key Factors

Facilities that do quarterly MDS every 70-77 or 84 days may have more MDS to averageWIN SOME- LOSE SOME

Behavior Incentive

Only MDS 10/1/2010 or after are included

Behavioral Incentive: MDS 3.0 and ICD -9 Codes Incentive is based on:MDS scoring

Diagnosis database (CHRSA) SNF claims

Physicians claims

Does your Medicaid claim reflect a mental health/cognitive diagnosis?290.00 to 331.00

Portal only requires 2 diagnosis

18 are allowed

3.657 Behavioral/Cognitive Impairment (BEHCI) Access and Improvement Incentives

The funding available for the SFY2015 BEHCI Incentive will be distributed as two incentives. Each is 50%Access Incentive

Improvement Incentive

5.460 Behavior/Cognitive Impairment Incentives The Behavior/Cognitive Impairment

Access Incentive Base Rate is $0.380

The Behavior/Cognitive Impairment Improvement Incentive Base Rate is $0.369

3.657 Behavioral/Cognitive Impairment (BEHCI) Access and Improvement Incentives The Department will apply two scores, an Access Score

and an Improvement Score, to each resident based on values defined by:

The MDS elements listed in section 5.971; and

Acuity categories ranging from 0 to 5 based upon psychiatric and related diagnosis codes under the International Classification of Diseases, version 9 (ICD-9), as organized via decision rules promulgated under the nationally-recognized Chronic Illness and Disability Payment System (CDPS).

7

TN #14-019 -65- Supersedes Attachment 4.19-D TN #13-015 Approval Date Effective Date 7-1-14

5.971 BEHCI – MDS Behavioral Score VARIABLE MDS 3 CODE BEHAVIORAL SCORE WEIGHT WANDERING: E0900 Wandering Presence & Frequency 1 .4 2 .8 3 1.2 E01000A Wandering Impact 1 1.5 E01000B Wandering Impact 1 1.5 BEHAVIOR SYMPTOMS: E0200A Physical directed toward others 1 .6 2 1.2 3 1.8 E0200B Verbal directed toward others 1 .6 2 1.2 3 1.8 E0200C Other symptoms 1 .6 2 1.2 3 1.8 E0500A Risk of physical injury 1 1.5 E0500B Interferes with care 1 .75 E0500C Interferes with activities 1 1.5 E0600A Others at risk 1 1.5 E0600B Intrudes on others 1 .75 E0600C Disrupts care 1 .75 E0800 Rejects care 1 .6 2 1.2 3 1.8 SEVERITY SCORE: D0300 Resident Mood Interview 15 or greater 1.5 D0600 Staff Assessment of Mood 15 or greater 1.5 LOCOMOTION: G0110E Resident movement 0 1.0 1 .75 2 .75

8





WI Behavior Index The BEHCI Access and Improvement Scores

are based on index values aggregated at the facility level, calculated using data available for Title 19 FFS Non-DD residents present in the facility on the last day of the second quarter of the fiscal year (December 31, 2013) that also had a RUGable MDS assessment on or prior to that date.

The BEHCI Access and Improvement Scores are only calculated for individuals when they have both a RUGable MDS assessment and a CDPS score greater than zero.

BEHCI Access Incentive

The Access Score for each resident is calculated by subtracting 1.00 from the higher of the resident’s first two available MDS Behavioral Scores and setting any negative results to zero.

The first and second MDS behavioral scores are defined as the resident’s first and second scores after whichever of the following Starter Events occurred most recently:.

BEHCI Access Incentive

Starter EventsAdmission to the facility;

A change in the PopID;

A break in stay of more than 30 days;

October 1, 2010.

The BEHCI Access Incentive is determined by multiplying the BEHCI Access Score by the BEHCI Access Base Rate in Section 5.460.

BEHCI Improvement Incentive

The Improvement Score for each resident is calculated using the six most recent RUGable MDS Behavioral Scores since the Starter Event determined for the BEHCI Access Incentive.

If fewer than six RUGable MDS Behavior Scores exist, all available scores are used.

BEHCI Improvement Incentive First, an Improvement Baseline is set.

If the Starter Event occurred far enough in the past that the resident has more than six available MDS Behavioral Scores, the Improvement Baseline is set to the fifth most recent MDS Behavioral Score.

If six or fewer MDS Behavioral Scores are available, the Improvement Baseline is set to the greater of the two earliest available MDS Behavioral Scores.

BEHCI Improvement Incentive Next, the Improvement Score is

determined by a) calculating the change from the

Improvement Baseline to the average of the MDS Behavioral Scores that remain after excluding the two earliest MDS Behavioral Scores;

b) setting negative results to zero; and

c) multiplying the calculated change by a CDPS factor ranging from zero to five.

9





BEHCI Improvement Incentive The CDPS factor is the CDPS score that

the individual had on the date of the MDS Behavioral Score used for the BEHCI Access Incentive.

The BEHCI Improvement Incentive is calculated by multiplying the Improvement Score by the BEHCI Improvement Base Rate in Section 5.460.

Behavior Incentive Must have at least 3 MDS in the database

First 2 MDS are used as the base

Remaining MDS up to 4 (average) are used to determine improvement

CDPS Score has to be greater than 1 but can be no greater than 5

Behavior IncentiveMany facilities will loss behavior incentive

How to get it backDiagnosis on the Medicaid Claims

Accurate MDS CodingTracking target behaviors

Changing target behaviors

Role of the MDS in CMI calculation

MDS Scoring Hot Spots for Medicaid Reimbursement

Restorative Nursing .04 to .08 CMI increase

Respiratory TherapyTrained nurses

Capture minutes

Documentation

Isolation (overcoming)

Part B therapy – Section O

Evaluating your CMI

Quarterly Review the CMI listing found in the rate notice

Look at the following areas

10





Report Changes

Picture Quarter is a date rangeAdj T19 Inhouse Res Count: is patient days

Report Changes

Review Line 51:This is the # of days that there is not an RUG score available for such as new admissions up to the ARD for the first MDS

Most facilities will have a number in this field- previously the goal was 0

Extensive Services

Do you have residents that really meet this criteria? Isolation, Trach, Vent

Isolation is a 14 day look-back may conflict with MDS Section G coding

What do the nurses say about the isolation?Does it specify day started and ended

Do weekly or daily notes contradict

Rehabilitation

This should be an indicator of the # of residents who are receiving Part B therapy

If you have no residents in this category ask? Is therapy getting the quarterly MDS

Schedule?

Are SCSA MDSs being done?

Does therapy begin after the MDS is completed not before?

11

Picture Qtr = Census Apr - Jun 2014

134 1334

69 327 48 56

PC1 Pt2 PD1 PD PEi PE2

0.85 0.91 1.06 1.15 1.17 1.25

29 13 8 0

31.90 17.68 12.64 0.00

' v v' RAB RAC RAD RAE

1.10 1.36 1.58 1.65

1.1'1

CONFIDENTIAL! Per HIPAA regulations this information is deemed confidential and not f

. . . POP-ID:

1 BA1 2 BA2 3 BB1 4 BB2 5 CA1 0.65 6 w CA2 0.73 7 CB1 0.85 8 CB2 0.95 9 CC1 0.96 10 CC2 1.08 11 CD1 1.15 12 CD2 1.29 13 CE1 1.25 14 CE2 1.39 15 ES1 2.22 16 ES2 2.23 17 ES3 3.00 el. 18 HB1 1.22 19 HB2 1.55 20 HCi 1.23 21 FIC2 1.57 22 HD1 1.33 23 HD2 1.69 24 HE1 1.47 25 HE2 1.88 26

a■Trrjr.

27 28 29 LO2 1.30 30 'Di 1.21 31 LD2 1.54 32 Lei 1.26 33 00,„ LE2 1.61 34 PA1 0.45 35 PA2 0.49 36 PB1 0.65 37 PB2 0.70 38 39 40 41 42 43 44 45 46 47 48

0.53 0.58 0.75 0.81

LB2 LC1

1.21 1.02

AlsololaWalfilirt

O 8.00

161 1305

0 0.00

300 288.00

0 0.00

48 55.20

0 0.00

99 123.75 O 0.00

U.00

0 0.00 O 0.00

'616 U. O 0.00

197 242.31 O 0.00

0 0.00 O 0.00

83 122.01

0 0.00

0 0.00

239 243.78

0 0.00

7 8.47

0 0.00

8 10.08

0 0.00 iU.DU

0 0.00

91 59.15 93 ' t 65.10

113.90 1,213.94

73.14 76.05 56.16 70.60(;

j: 19 .01100030C owht0.0.

85 45.05 0 0.00

226 169.50 193 156.33 Til U5.15

49 Non-DD In House

4,128 3883.69

50 Non-DD Bedhold

na

51 w/o RUGable MDS

6

52 Total Non-DD

4,134

53 NonDD_T19_RUGCMI

Line 53 (Weighted /Pds) 3883.69 / 41.408IR

To page 4, line 9

BNHS - Rate1_012015FinalvlAsm

CONFIDENTIAL! Per HIPAA regulations this information is deemed confidential and not

Cognition and Behavior

Clinically Complex

Extensive Services

Special Care High

Special Care Low

Reduced Physical Functioning

Rehab

12





Special Care High

Is respiratory therapy being coded on the MDS?

Why are residents sleeping with HOB elevated? Does it relate to diagnosis (Asthma/COPD) and

SOB?

Enteral Calorie requirements>26% of calories

>501 cc of fluid

Respiratory Therapy

Trained nurses or RT’s

Actual minutes spent with resident

Nebulizer count- inhalers do not

Pre-Post treatment assessment counts

Definition is in Appendix A of the RAI Manual

Services that are provided by a qualified professional (respiratory therapists, respiratory nurse).

Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function.

Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse.

A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws.

Cannot count- nebulizer treatments done by med techs. Nurse must do pre-post assessments

Special Care Low

13





Do not focus on depression- near impossible to achieve

Skin alterations with 2 treatments

Parkinson's Disease 332.0 Paralysis Agitans

Clinically Complex

Chemotherapy

Oxygen

IV meds

Cognition and Behavior

ADL score is 5 or less

Are ADLs coded correctly- could they be 6 or higher

BIMS is 9 or less

CPS is 3 or more

Reduced Physical Functioning

14





How many PA, PB, PC, PD, PE end in a 2? Indicator of strength of restorative nursing

PA and PB residentsDo they have cognitive issues not reflected on

the MDS that would move to a BA or BB?

Is ADL Score is 5, 10, 14 is it correct?

ADL Scoring

Late Loss ADLsTransfers

Toileting

Eating

Bed Mobility

Are MDSs being coded accurately Is the Rule of 3 being applied correctly If not may result in underscoring

Is scoring being done on # of opportunities for an event versus # of shiftsTransfer- there may be 5 or more transfers in

a day

Are the Nursing Assistants charting frequency on every shift not just most dependent on a shift

Are MDSs being coded accurately 8 means it never occurred

7 means in happened 1-2 times in the past 7 days

Staff support is based on most dependence – even if only happened onceSoftware issue

Restorative Nursing

Key in Behavior/Cognition as well as Physically Reduced Functioning RUG categories

2 Restorative Programs

6 days a week

At least 5 minutes a day

Toileting programs are considered a restorative program

Implementation Steps

Establish a philosophyPrint on small cards- laminate- distribute-

CARRY THEM

Include concepts in orientation

Have philosophy imprinted on plaques- post in locations visible to visitors and staff

15






Community education regarding long term care

Policies/ProceduresOrders

Physician Communication Educate Boards/Owners Train staff Add philosophy to admission packet


Reinforce restorative during administrative rounds

Develop themes that can be used on posters, stickers, buttons

Develop specific activities every month-HAVE FUN

Incorporate into QI processes

Implementing a Restorative Program TEACH-TEACH-TEACHNurses

Therapists

Aides

Physicians

Administration

All departments

Implementing a Restorative Program TEACH-TEACH-TEACH CONTENTAccurate assessments

Hands on- patient content Not a nurse in an office ADL Scoring- actual ability

MDS Coordinator is a clinical leaderBe enthused about the MDS

Appreciate the tools it provides Instill ownership and confidence in the process

Implementing a Restorative Program TEACHMDS is not paper compliance

Standardize assessment procedures- reduce paperwork Standards of care versus Care Plans

Maximize skilled therapy Coverage days/times

Flexible ARD’s

Implementing a Restorative Program TEACH

Teach physicians Role of rehab versus maintenance programs

How to write orders

How to write progress notes which support skilled services

If physicians are a problem What is the role of the medical director?

Consider establishment of a credentialing process which affects admitting privileges

16





Implementing a Restorative Program Policies and ProceduresRAI/MDS

Scheduling- notification

Diagram the process Section responsibility

How is data obtained over 24 hours

Implementing a Restorative Program Nursing Assistants

How are NA’s assigned Consistent assignments with flexibility

Frequent change Unreliable data from the NA’s

More difficult to instill accountability

Documentation THINK MINUTES

Nursing

Rehab

Implementing

It takes time and perseverance If staff are not excited and enthused the program is

mediocre and is a paper compliance tool only

Don’t expect 100% immediately Cooperation and understanding will not happen at the

same time for all employees

Walk the talk DON/Administrator do rounds together

Why Programs Fail

Failure to realize that successful implementation of the program entails extensive interdisciplinary planning and work with the mistaken belief that the restorative nurse coordinator can implement the program independently

Lip service from the administrator/DON, showing no real support or belief

Why Programs Fail

Failure to make training mandatory Lack of a concrete plan to present initial

training Lack of team approach- “It is a nursing

program” Assignment of duties(responsibility) but

lack of time and authority to make it happen

Why Programs Fail

If rehab aides are usedReassignment to NA duties

Not 7 days per week

Not at least 12 hours per day

17





The Restorative Aide

SkillsPatienceSlow movementsGood communication skillsPersuasive skillsAbility to documentAbility to identify changeWillingness to interact with families


SelectionLong versus new NA’s

Willingness to change

Enthusiasm


TrainingADL techniques

Promoting self-involvement

Continuous/On-going Patient specific


MentoringCharacteristics of Mentoring

Role modeling Role clarification Role rehearsal

Advantages of Mentoring Gradual integration of a new philosophy Improved career ladder Increases interdisciplinary collaboration

Why Programs Flounder

Personnel problems do not disappear-they get worse and compound

Rounds and monitoring is need to assure strong reliable personnel remain that way

10% of your employees take 80% of your time


Staff watch the actions of administration-they see how you really feel even if you do not say it

Speak the language of the staff Laissez-faire is not a form of management Shift reports are a way to monitoring

progress

18






Inconsistent rounds by management Not telling staff what is expected of them Inability to diagnosis the cause of a

situation as Process/SystemPerformanceEducational


Nurses who refuse to accept supervision duties and responsibilities

Inconsistent meetings and progress reports

Lack of accountability and authority

Inconsistent and unequal treatment of staff


Outdated job descriptions

Policies and procedures which are not current

Restorative is a day shift only program

Restorative is a second priority

Lack of respect for management/ leadership

Nurses do not know how to make rounds to supervise the work of the NA’s

Program Success

Orientation to new and existing staff

Involvement of all departments

Participation in communication

Utilization of the care plan

Utilizing novel approachesHumor

Themes

Program Success

Maintaining interest and enthusiasm

Track progress monthlyBe proud of the progress

Report the progress

Program Evaluation

MDS Validity

Restorative Nursing CQI Tool

QMPhysical Functioning Domain

Late Loss ADL Decline

Incidence of Decline in ROM

19





Program Evaluation

Charge Nurses/Care Plan CoordinatorsUse QI/QM’s when care planning

Administration/DONUse QI’s as basis for quality rounds

All department managersUse QI/QM’s as basis for weekly rounds

20

©Specialized Medical Services, Inc. 5343 North 118th Court Milwaukee, WI 53225 414-476-1112 fax 414-476-6118 www.specializedmed.com 3/10/2015 1

RUG 44 Estimator This assessment can be used to estimate the RUG 44 used for Medicaid Reimbursement .

REHABILITATION RAE: ADL score 15-6 5 days or more (15 min per day minimum) in any combination of SLP,OT or PT in last 7

days AND 150 minutes or greater in any combination of SLP, OT, or PT in last 7 days OR

3 days or more (15 min per day minimum) in any combination of SLP, OT, or PT in last 7 days AND 45 minutes or greater in any combination of SLP, OT, or in last 7 days AND

at least 2 nursing rehabilitation services (see details on Page 2)

RAD: ADL Score 11-4 RAC: ADL Score 6-10 RAB: ADL Score 2-5 RAA: ADL Score 0-1

Extensive Care (ADL Score 2-16) Will the resident be receiving these services in the SNF? Tracheostomy care AND ventilator/respiratory ES3 Tracheostomy care OR ventilator/respiratory ES2 Infection isolation ES1

Special Care HIGH (End Split with/without depression) HBx-HEx Depression Criteria Total Severity Score >= 10

Coma and ADL dependent COPD and SOB while lying flat Septicemia Fever with one of the following:

- pneumonia - weight loss - vomiting - feeding tube* Diabetes with daily injections (7) and insulin order changes (2) Parenteral/IV feedings (within 7 days- can be prior to

admission) Quadriplegia and ADL score >= 5 Respiratory Therapy (7 days) * 51% or more of total calories OR 26% to 50% of total calories and 501cc fluid intake per day

Special Care LOW (with/without depression) LBx-LEx Depression Criteria Total Severity Score >= 10

Cerebral Palsy and ADL >= 5 Stage 3 or 4 pressure ulcers with 2+ ulcer treatments Multiple Sclerosis and ADL >=5 Stage 2 pressure ulcer (1) and venous/arterial ulcer (1) with 2 +

ulcer treatments Parkinson’s Disease and ADL >=5 Foot infection, diabetic foot, or other open lesion of foot with

dressing Respiratory Failure and Oxygen Radiation while a resident Feeding Tube(see criteria special care high) Dialysis while a resident 2+ Stage 2 pressure ulcers with 2+ ulcer treatments 2+ venous ulcers with 2+ ulcer treatments

If the patients TOTAL ADL Score is 0-2 the patient will not qualify for Special Care although the patient will meet the criteria for Clinically complex.

Clinically Complex (with/without depression) CAx-CEx Resident with Extensive Services, Special Care High, or Special Care Low with ADL Score 0-1

Depression Criteria Total Severity Score >= 10 Pneumonia Chemotherapy while a resident Hemiplegia/hemiparesis and ADL >= 5 Oxygen Therapy while a resident Surgical wounds or open lesions with treatment IV medications while a resident Burns Transfusions while a resident

Behavioral Symptoms and Cognitive Performance BAx-BBx BIMS score of 9 or less AND an ADL score of 5 or less OR Defined as Impaired Cognition by the Cognitive Performance Scale AND an ADL score of 5 or less (See description of BIMS and Cognitive performance scale) ♦ Hallucinations [E0100A] ♦ Delusions [E0100B] ♦ Physical behavioral symptoms directed towards others (E0200A = 2 or 3) ♦ Verbal behavioral symptoms directed towards others (E0200B = 2 or 3) ♦ Other behavioral symptoms not directed towards others (E0200C = 2 or 3) ♦ Rejection of care (E0800 = 2 or 3) ♦ Wandering (E0900 = 2 or 3)

Reduced Physical Function PAx to PEx No Clinical Conditions Exist

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DETERMINING ADL SCORE FOR RUG IV CLASSIFICATIONS ADL: Bed Mobility, Transfer and Toilet Use From the MDS Section G

ADL SCORING for Bed Mobility, Transfer and Toilet Use

MDS Item Self- Performance

Support RUG IV SCORE

If self performance equals ___

If support equals ___

RUG IV ADL SCORE IS

G1a: Bed Mobility -, 0 or 1, 7. or 8 Any # 0

G1b: Transfer 2 Any # 1

G1I: Toilet Use 3 -, 0, 1, or 2 2

4 -, 0, 1, or 2 3

3 or 4 3 4 TOTAL ADL SCORE FOR

Bed Mobility, Transfers and Toilet UseCannot exceed 12

EATING ADL SCORE MDS Item Self-

Performance Support Eating

Score RUGS SCORING FOR EATING

Eating If self perform-ance equals ___

If support equals ___

RUG III ADL SCORE IS

-, 0, 1, 2, 7, 8 -, 0, 1, or 8 0

TOTAL ADL EATING SCORECannot exceed 4

-, 0, 1, 2, 7, 8 2 or 3 2

3 or 4 -, o, or 1 2

3 2 or 3 3

4 2 or 3 4

TOTAL ADL AND EATING SCORE (0-16)

Restorative Nursing Programs 2 or more required to be provided 6 or more days a week for at least 15 minutes

Passive range of motion (O0500A) and/or Active range of motion (O0500B)* Bed mobility training (O0500D) and/or walking training (O0500F)* Splint or brace assistance ( O0500C) Transfer training (O0500E) Dressing and/or grooming training (O0500G) Eating and/or swallowing training (O0500H) Amputation/prosthesis (O0500I) Communication training (O0500J)

No count of days required for: Current toileting program or trial (H0200C) and/or Bowel toileting program (H0500)* * Count as one service even if both are provided

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