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AHCANCAL 59th Annual Convention


Dianne De La Mare, Regulatory Affairs. Sandra Fitzler, Regulatory Affairs ... Dianne De La Mare. VP, Regulatory Affairs. 202/898-2830. ddmare_at_ahca.org ... – PowerPoint PPT presentation

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Title: AHCANCAL 59th Annual Convention

AHCANCAL 59th Annual Convention
Expo Regulatory Update
  • Peter Gruhn, Research
  • Dianne De La Mare, Regulatory Affairs
  • Sandra Fitzler, Regulatory Affairs
  • Janice Zalen, Reimbursement
  • Melissa Temkin, Membership

Trends and Medicare Update
  • Peter Gruhn
  • Director of Research
  • 202/898-2819
  • pgruhn_at_ahca.org

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CMS FY2009 SNF PPS Final Rule
  • Final rule published August 8, 2008
  • SNF market basket increase of 3.4
  • No forecast error adjustment of 3.3
  • 128 add-on which began on October 1, 2004 for
    HIV/AIDS patient remains
  • No market basket forecast error correction
    because error less than new threshold
  • The labor-related share will be 69.783 down from
    70.249 in FY 2008
  • CMS Financial Impact 780 million (11 ppd)

SNF Reimbursement and FY 2010 Look Out
  • The Deteriorating Federal Budget
  • SNF PPS Forecast Error Adjustment
  • The STRIVE project and SNF PPS Reform
  • Other

The Deteriorating Budget
Source OMB. 2008 and 2009 estimates from
Presidents FY2009 budget
The Increase in Debt is Far Greater Than the 410
Billion Deficit
Source OMB, SBC.
Forecast Error Adjustment - Round 2
  • In 2006, CMS refined the SNF PPS CMIs to better
    account for resource use of medically complex
    patients (RUG-53) using 2001 data
  • CMS adjusted the nursing weights so that payments
    under RUG-44 and RUG 53 would be the same
  • In the FY2009 SNF PPS NPRM, CMS reported that
    Medicare expenditures were higher under RUG-53
    than they would have been under RUG-44 based on
    actual 2006 data
  • CMS proposed to recalibrate the nursing weights
    such that payments would be the same
  • Payments for FY 2009 were estimated to decline by
    770 million

Forecast Error Adjustment (cont.)
  • AHCA commented extensively on the NPRM, and
    lobbied actively against the proposed adjustment
  • In the final rule, CMS
  • Decided not to proceed with the proposed
    recalibration at this time pending further
  • Was confident that it employed the correct
    recalibration approach
  • Would continue to evaluate the issue, and expects
    to implement an adjustment in the future (FY

STRIVE Project
  • Conducted for CMS by the Iowa Foundation for
    Medical Care (IFMC).
  • Purpose To determine the amount of time that
    nursing home staff spend caring for residents,
    and examine and evaluate changes to the SNF PPS
    RUG-III payment system.
  • First national nursing home time study update
    since the establishment of the RUG-III case mix
    weights back in 1997.
  • Data collected from over 10,000 residents in 205
    facilities in 15 states

STRIVE Project (cont.)
  • CMS expected to update the nursing and therapy
    weights for FY 2010 using STRIVE data
  • CMS is also reevaluating RUG-III and examine need
    for RUG-IV
  • Examine lookback, examine special populations,
    reexamine rehab ext srv categories, analyze
    NTAS usage, adapt to MDS 3.0, etc.
  • Phase 2 analytic report to be submitted to CMS in
    late 2008 / early 2009
  • AHCA expects that the Phase 2 work will be the
    basis for a major refinement to the SNF PPS for
    the FY2010 SNF PPS proposed rule.

Workforce Fraud/Abuse
  • Dianne De La Mare
  • VP, Regulatory Affairs
  • 202/898-2830
  • ddmare_at_ahca.org

Workforce Report
  • IOM Report, Retooling for an Aging America
    Building the Health Care Workforce.
    Recommendations include
  • Annual report monitoring the supply crisis
  • Encourage hospitals to train residents in all
    settings, including NFs, ALFs and home care
  • All licensure and certification must include a
    show of competence in elder care
  • Federal/State governments should increase the
    direct care staff minimum training standards
  • Public/private organizations should provide
    funding/training opportunities for informal

Workforce Report (cont.)
  • IOM Recommendations (cont.)
  • Public/private should provide financial
    incentives to increase the number of geriatric
  • All payers should enhance reimbursement for a
    geriatric specialty in clinical certification
  • Congress should authorize a Geriatric Academic
    Career Award
  • Federal/State governments should institute loan
    forgiveness, scholarship and direct financial
    incentives for becoming a geriatric specialist
  • State Medicaid programs should increase
    pay/fringe benefits to direct care workers.

Workforce Report (cont.)
  • IOM Recommendations (cont.)
  • Payers should promote and reward new models of
    care for older individuals
  • Congress/Foundations should increase support for
    research/demonstration programs that promote
    development of new models of care
  • Disciplines/regulators/employers should expand
    the roles of individuals who care for the older
  • Federal agencies should provide support for the
    development/promulgation of technological
    advancements that enhance capacity to provide
    care for the elderly.

Workforce Report (cont.)
  • MIV Report, 2007 National Survey of Consuemr and
    Workforce Satisfaction in NHs. Recommendations
  • Management must listen and care about direct
  • Focus should be on hiring and ensuring that
    employees are adequately trained/supported
  • Employers must determine how to retain older
    workers and attract younger workers.

  • OIG Draft OIG Supplement Compliance Program
    Guidance for NFs released in April 2008, and the
    final supplement guidance expected in October
  • The final document will supplement the prior OIG
    guidance released in 2000, OIG Compliance Program
    Guidance for NFs.
  • In the supplement, OIG focuses on quality of care
    issues, and mentions for the first time that an
    ALF may want to think about developing and
    implementing a compliance program.
  • AHCA is meeting with OIG on a regular basis, and
    has launched an educational program for all
    AHCA/NCAL members.

Survey Life Safety
  • Lyn Bentley
  • Director of Survey/Certification/Enforcement
  • 202/898-6304
  • lbentley_at_ahca.org

Five Star Quality Program
  • CMS presents this program as an improvement to
    NH Compare
  • Rating system will include three components
  • Survey Results
  • Staffing
  • Quality Measures

Five Star (cont.) - Quality Measures
  • Subset of current NH Compare
  • ADL change
  • Mobility change
  • Long-stay prevalence measures
  • Pressure ulcers
  • Physical restraints
  • UTIs
  • Long-term catheters
  • Pain
  • Short-stay prevalence measures
  • Delirium
  • Pain
  • Pressure Ulcers

Five Star (cont.)
  • Topic Expert Panel includes primarily
    researchers, one provider representative
  • Abt is meeting with the panel for their ideas
    about development of Five Star
  • Abt is developing the weighting formula will
    be complete in Oct. 2008
  • First phase of Five Star will be live on CMS
    Web site in Dec. 2008

Five Star (cont.)
  • Second phase of Five Star may include additional
  • Patient/family satisfaction scores
  • Add new quality measures
  • Include specific characteristics of nursing homes
    (e.g., specialty units languages spoken private
  • Staffing data collected from payroll sources

Quality Indicator Survey
  • Now (or soon to be) in
  • Responses from members are still varied love
    it hate it positives out-weight the negatives
    still too soon to make a decision
  • QIS no longer in CA resource issue per CMS
  • CMS hopes to continue to roll out in 3 4

Quality Indicator Survey (cont.)
  • Second evaluation by Abt showed that QIS did NOT
    meet any of the CMS-defined goals for the program
  • Improve consistency/accuracy of QOC/QOL problem
    identification using a more structured process
  • More comprehensive review of facilities
  • Enhanced documentation organize survey findings
    via computer
  • Focus survey resources on facilities with largest
    number of quality concerns

Quality Indicator Survey (cont.)
  • Caveats to the Abt report
  • Not yet released by CMS (although it was complete
    in Dec. 2007)
  • CMS committed to AHCA that they would release
    report w/CMS Action Plan to address concerns
    during summer 2008
  • AHCA remains cautiously optimistic that this
    process could improve survey consistency

Surveyor Guidance Revisions Update
  • F371 - Safe Food Handling- Mid 2008
  • F325 - Nutritional Parameters - Mid 2008
  • F309 Guidance for Pain Management 2008 or
    early 2009
  • F441 - Infection Control Fall 2009
  • F223 through F226 Abuse sometime in the
  • F309 Guidance for End-of-Life sometime in the

Fire and Life Safety
  • CMS issued new regulation all nursing homes
    must be fully-sprinklered by August 13, 2013 (a
    five-year phase-in)
  • AHCA continues to work with Congress to obtain
    grants or low-interest loans to assist providers
    who must install sprinklers

MDS, RAPs, PAC Demonstration Medication
  • Sandra Fitzler
  • Sr. Dir. of Clinical Services
  • 202/898-6307
  • sfitzler_at_ahca.org

MDS 3.0
  • Draft released in 1/08
  • New tool shows excellent/very good reliability -
    MDS 3.0 out-performed 2.0
  • Improved clinical relevance
  • Takes less time to complete
  • Improved tool technology, standardize terminology
    scales, link to STRIVE CARE

MDS 3.0 (cont.)
  • Not all look-backs are 5-days
  • Add self-report interview items more
  • Improved wording
  • RUGs QMs - items retained
  • Improved pressure ulcer assessment ends reverse
    staging coding for healing wounds allows
    identification of ulcers found on admission

MDS 3.0 (cont.)
  • Expanded return to community section to better
    identify those who can benefit from Money Follows
    the Person
  • Expanded section on Pain incorporated with
    assessment of health conditions
  • Adds- definition of restraint to tool and
    anticoagulant to medication section
  • Improves problematic coding elements no longer
    considers a resident with a catheter as being

  • No funds to update RAPs or to provide updates on
    a regular basis to ensure information is current
  • Even if funding is available, not sure if
    updating a process that is poorly utilized is a
    wise investment

RAPs (cont.)
  • In the fall of 2004, AHRQ pulled together a RAP
    workgroup, conducted a survey on RAP utilization
    and released a report
  • Survey encompassed 1,835 AANAC, MDS Coordinators
    and 56 VA respondents
  • 76 found RAPs are somewhat, rarely or never
  • RAP completion does not involve the
    interdisciplinary team as they are often
    completed separately by multiple individuals
    (30) or by individuals who do not participate in
    care (26) like MDS Coordinators having no
    clinical responsibility

RAPs (cont.)
  • 31 saw RAPs as too time consuming
  • 27 stated RAPs are done for paper compliance
  • Physicians often uninvolved in the RAP and do not
    consider the care plan when making resident
    treatment decisions
  • CNA work is not reflected in care plans

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RAPs (cont.)
  • Do not update RAP Utilization Guidelines RAP
  • Go back to the basics for care planning use
    interdisciplinary team
  • Consider retaining revising Trigger Legend
    renaming it Triggers for Analysis and Planning
  • Encourage the use of evidence-based practice
    guidelines information on clinical websites as
    resources for care planning

RAPs (cont.)
  • Independent effort underway to develop an
    electronic decision tree for depression.
  • There has been some discussion at CMS about the
    development of a RAP for Return to the Community

PAC Demonstration
  • Boston, MA
  • Seattle, WA (includes Portland, OR)
  • Lincoln, NE (includes Omaha) ? Sioux Falls, SD
  • Lakeland, FL
  • San Francisco, CA
  • Rochester, NY
  • Chicago, IL
  • Dallas, TX (includes Plano. Tyler, Fort Worth)
  • Louisville, KY
  • Columbia, MO
  • Wilmington, NC (newest market)

PAC Demonstration/QIO Overlap
  • All QIOs will strive to get 10 of providers to
    use the CARE tool
  • This is a separate effort from the PAC
    demonstration exception NE
  • Purpose To identify elements missing from the
    CARE tool needed to improve care transitions

PAC Demonstration (cont.)
  • CMS collecting care transition literature
  • 11/08, RTI plans to hold a TEP to start
    discussion on what additional items need to be
    added to the CARE tool
  • QIOs will nominate people to the RTI TEP
  • Concurrently, QIOs will be working on identifying
    transition of care items, needed on the tool, to
    improve care continuity

PAC Demonstration Key Contacts
  • Barbara Gage, Project Director RTI
  • Laura Coots, RTI lcoots_at_rti.org
  • Judy Abbate, RTI jabbate_at_rti.org
  • CMS staff involved in PAC demo Doug Brown, Tracy
    Archibald Judy Tobin
  • CMS involved in QIO efforts Debbie Terkay

Disposal of Unused Drugs
  • No federal law only guidelines on the disposal
    of controlled substances
  • Some states have implemented laws for drug
    disposal and/or redistribution
  • DEA will be releasing proposed regulation
  • EPA concerned about unused drugs in ground water
  • EPA survey for healthcare leading to potential

Disaster Planning Medicaid
  • Janice Zalen
  • Sr. Director of Special Programs
  • 202/898-2831
  • jzalen_at_ahca.org

Disaster Planning
  • Dept. of Health and Human Services (HHS)
  • Office of the Assistant Secretary for
    Preparedness and Response (ASPR)
  • Center for Disease Control and Preparedness (CDC)
  • Center for Medicare and Medicaid Services (CMS)
  • Department of Homeland Security
  • Federal Emergency Management Administration
  • Department of Labor
  • Occupational Safety and Health Administration

CDC/Influenza Pandemic
  • Challenging questions
  • Who receives the first vaccines from a limited
  • Who receives the limited supply of antivirals?
  • Who should be responsible for stockpiling medical
    countermeasures, e.g., facemasks, respirators,
    antiviral medications?
  • Decisions made with limited information.

CDC/Pandemic Influenza Vaccine
  • Draft CDC Guidance released late 2007 for
  • Tier 1(top priority) 25 of LTC facilities
    direct care workforce
  • Tier 5 (out of 6) residents of LTC facilities
  • AHCA/NCAL attended several stakeholder meetings
    and sent written comments
  • Results of 2008 stakeholders meetings and
    comment letters (not yet released)
  • Tier 1 75 of LTC facilities direct care
  • Tier 5 Residents of LTC facilities

CDC/Antiviral Drug Use and Stockpiling (cont.)
  • Stakeholder meetings in late 2007 and early 2008,
    including conference call with AHCA/NCAL members
    and survey
  • To determine who gets doses from national
    strategic stockpile
  • To identify barriers to employers purchasing
    their own stockpiles
  • Initial guidance containment and early
    treatment limited doses

CDC/Antiviral Drug Use and Stockpiling (cont.)
  • CDC released 2 guidance in 2008
  • Proposed Guidance on Antiviral Drug Use During
    an Influenza Pandemic
  • Considerations for Antiviral Drug Stockpiling by
    Employers in Preparation for an Influenza
  • Reflect increased manufacturing capacity
  • Recognizes potential value of prophylaxis (Px) to
    maintain healthcare and other critical services
  • Front-line HCWsoutbreak Px (12 weeks)
  • Other HCWsPost-exposure Px (10 days)
  • ResidentsPost-exposure Px
  • HHS recommends shared responsibility, i.e.,
    employer buys and stores their own
  • AHCA commented on both guidances
  • To date, no final guidances released

LTC Facilities
  • Ought to be planning for an influenza pandemic
  • CDC (AHCA/NCAL vetted) checklist
  • Pandemic Influenza Workbook for LTC (California
    Association of Health Facilities)
  • Disaster Planning Booth Exhibit

CMS/During an Emergency
  • HHS issued more than one public health emergency
    declaration in 2008
  • Allows certain waivers, e.g. waive the 3-day
    hospital stay requirement
  • CMS provides FAQs to help answer questions
    relating to the emergency
  • These FAQs are becoming consistent so in effect,
    we have CMS disaster policy
  • http//www.cms.hhs.gov/Emergency/Downloads/Medicar
    eFFS_Policy_Gustav_09102008.pdf (Medicare)
  • http//www.cms.hhs.gov/SurveyCertEmergPrep/Downloa
    ds/AllHazardsFAQs.pdf (Survey Certification)

CMS/Survey and Certification
  • No new regulations (yet)
  • Favors all hazards planning
  • Stakeholder group reviewing documents for past
    two years
  • http//www.cms.hhs.gov/SurveyCertEmergPrep/
  • AHCA role--To stress voluntary nature of the
  • Checklists
  • After Action Plans
  • Recommendations

Medicaid Reform/Rebalancing
  • Definition Take away institutional bias, i.e.,
    serve more people in the community
  • Result More Medicaid dollars to HCBS and more
    acute residents in NFs
  • Reason Cost containment changing personal
  • Vehicles 1915(c) and 1115 waivers, real choice
    systems change grants, aging and disability
    resource centers, DRA, MFP Demonstration Grants

Medicaid Reform (cont.)
  • Section 1115 waiver RI Application
  • State contribution would be capped at 23 of the
    state's general fund budget
  • Annual federal block grant
  • NF care only for highest need level
  • DRA In 08 CMS issued proposed rules for
  • Self-directed personal assistance services
  • Benchmark benefits provision
  • HCBS state plan services

AHCA/NCAL/Alliance LTC Finance Reform Proposal
  • Goal Help shape the future towards a
    sustainable array of quality LTC services
  • Currently Medicare Medicaid pay almost 70 of
    LTC and post acute care costs
  • LTC Finance Reform Proposal Highlights
  • Infuses private funding into LTC system
  • New Personal responsibility expectation federal
    catastrophic LTC coverage for Medicare eligibles
    major federal education campaign improved
    financial products to help prepare for LTC needs
  • Exemption for low income individuals
  • Benefits NF, ALF, HCBS, Medicare Advantage

LTC Finance Reform Proposal (cont.)
  • Post-Acute Care Highlights
  • Site neutral prospective payment system
  • National post-acute patient assessment tool
  • Status of Proposal
  • Released in January response favorable
  • Some common ground with other proposals
  • Bob Van Dyk presented to health innovations
    breakfast at the Republican Convention

LTC Finance Reform Proposal (cont.)
  • Next Steps
  • Contract to score the proposal
  • Estimate the budgetary effects of the proposal
  • To be completed late January
  • Continue to give presentations and to publicize
    the plan
  • Questions
  • http//www.ahcancal.org/advocacy/Documents/AHCA-Al
  • jzalen_at_ahca.org

OSHA, Hospice, VA DD
  • Melissa Temkin
  • Director of Membership and Regulatory Relations
  • 202/898-2822
  • mtemkin_at_ahca.org

OSHA/SST Inspections
  • Applies to NFs, ICFs/MR and ALFs.
  • For 2008 SST DART greater than/equals 11,
    DAFWII greater than/equals 9.
  • OSHA will randomly select and inspect about 175
    workplaces (with 100 or more employees and in
    industries that had higher than the national
    DART/DAFWII rates) that reported low injury and
    illness rates to review their actual degree of

OSHA/New Items
  • PPE final rule
  • Wicker rider defeated Enforcement of
    respirator fit testing for TB.
  • Safe patient handling legislation in New Jersey

OSHA/PPE Final Rule
  • Final released on November 15, 2007 8 years
    after rule proposed.
  • Items for patient safety and health (rather than
    for employee safety and health) do not have to be
    paid for by employer.
  • E.g., plastic /rubber gloves, self-sheathing
    needles, etc.
  • Infection control items are still required for
    CMS compliance.

OSHA/Wicker Rider
  • Prohibits OSHA spending on enforcement of annual
    respirator fit testing requirements for TB
    protection in healthcare settings.
  • Wicker Amendment not included in FY08
    Appropriations bill.
  • If score low on CDC risk assessment, OSHA fit
    testing requirements do not apply.

New Jersey Safe Patient Handling Legislation
  • Applies to NFs, general/specialty hospitals and
    county psychiatric hospitals.
  • Patients can refuse mechanical lifting,
    facilities cannot retaliate against employees.
  • Recommends three year capital plan.
  • January 2011 mandate to establish program.

Hospice CoPs
  • June 5, 2008 CMS released final rule on Hospice
    CoPs goes into effect on Dec. 2.
  • Hospices must formally contract with the facility
    in which their patients reside. Minimum
    requirements of the contract include
  • Hospice responsible to determine appropriate
    course of care.
  • Identification of services the hospice will
    provide, including medical direction and patient
    management, drugs for palliation, etc.
  • Hospice may use the SNF/NF or ICF/MR nursing
    personnel to assist as hospice would routinely
    use a patients family to implement the plan of

AHCA 2007 Hospice Survey
  • 423 respondents, mostly NF administrators and
    DONs, a few hospice professionals.
  • Surveyors questions to NF staff regarding
  • How is NF/hospice patient care coordinated?
  • Why are some patients on hospice for 6 months?
  • What are the differences between NF services for
    hospice patients and hospice contractor
  • If NF versus hospice services are not that
    different, why are hospice contractors needed at
    all? (F-490)

Shared Survey Results with NHPCO
  • Most Immediate Needs-- Educational Tools,
  • Differences in NF hospice staff services.
  • NF/ hospice care coordination.
  • Appropriate care planning.
  • Longer Term Needs
  • Appropriate expectations of patient outcomes.
  • Acknowledge unique, valuable skills and roles of
    NF and hospice staff.
  • Hospice and LTC staff work together, not against
    each other!

VA/CNH Agreement
  • AHCA is working with VA to revise the Community
    Nursing Home (CNH) provider agreement.
  • Negotiated items
  • VA agrees that CNHs are exempt from requirements
    in the Service Contract Act and E.O. 11246 (e.g.,
    prevailing wage rate, affirmative action plans,
  • Allow compliance with CMS version of the LSC with
    full sprinklering of facilities.
  • HIPAA is adequate to protect PHI business
    associate agreements not required.
  • New 10 VA RUG system must be used in conjunction
    with agreement.

Proposed VA Rate Setting Methodology
  • Combine 53 RUGs into 10 V/A RUGs.
  • Use therapy intensity and nursing CMI to define
    the 10 V/A RUGs.
  • Calculate weighted rates for each VA RUG using
  • PPS Rates and Local Wage Indexes published by CMS
  • Distribution of Medicare Days by RUG-53 for a
    sample of multi-facility operators

Next Steps
  • VA to reiterate the availability and benefits of
    new agreement to VA Medical Centers (VAMCs)
  • VA will work closely with VAMCs that have
    expressed interest in the agreement.
  • CNHs interested in serving VA patients can also
    contact their VAMCs.

DD Proposed Rule
  • Clarifies and proposes new requirements to
    implement the DD Act, which establishes
  • State Councils on DD.
  • Protection and Advocacy (PA) systems in states.
  • University Centers for Excellence in DD.
  • Funding for national initiatives.

DD Proposed Rule (cont.)
  • Rule could affect all LTC providers as
    individuals with DD reside in multiple settings.
  • Revised definitions in the rule do not
    appropriately identify thresholds used to define
  • Aspects of the rule dont recognize rights of
    individuals with DD to reside in ICFs/MR ICFs/MR
    are left vulnerable to closure.
  • Proposes inappropriate access by State PAs to
    individuals with DD, their records and service
  • Service providers are not guaranteed the right to
    be parties at hearings that address allegations
    of poor care to individuals with DD.

AHCA Recommends
  • PAs should have to notify ICF/MR residents,
    families, legal guardians or representatives
    before filing a class action lawsuit against an
  • PAs should give residents and representatives
    the right to opt out of the lawsuit.
  • Revise the definition of complaint so that
    residential placement alone (e.g., residing in an
    ICF/MR), if not related to quality issues, does
    not constitute a complaint issue.
  • Recommend further revisions to abuse, neglect
    and probable cause definitions to identify
    reasonable thresholds .

Recommendations (cont.)
  • Records accessed by PA should relate directly to
    allegation of sub-optimal care.
  • PA access to providers must be based on
    substantiated allegations of wrongdoing and only
    involve individuals with DD that are the subject
    of wrongdoing.
  • Parties addressed in a hearing should be
    guaranteed admission, as well as the right to
    testify on their own behalf.

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