Five-Star Management Challenges NACs Are Facing

In this LTC NAC Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist for AAPACN, discuss the Five-Star management challenges nurse assessment coordinators are facing today. Additional Resource: GG Trivia Games LTC NAC Chat – Five-Star Management Challenges NACS Are Facing - Full Transcript(intro music) Amy: Hello, thank you for joining LTC NAC Chat, a podcast brought to you by the American Association of Post-Acute Care Nursing (AAPACN). I'm your host, Amy Stewart, Chief Nursing Officer for AAPACN, and I'm here today with Jessie McGill, Senior Curriculum Development Specialist for AAPACN. Jessie joins us to discuss the Five-Star management challenges nurse assessment coordinators are facing today. Welcome, Jessie! Jessie: Thanks for having me today, Amy. Amy: Jessie, let's dive right in. In a recent survey in the AAPACN Leader for the NAC newsletter, members describe difficulty understanding how the different parts of Five-Star work together. What makes this system so challenging for NACs to interpret and manage? Jessie: That's a great question. One of the biggest challenges of Five-Star is that we have a lot of different data coming from different areas and using different time frames. So we have the health inspection domain, which uses the two most recent standard surveys, so it's looking at your health inspections, and 36 months of infection control and complaint surveys. So, we already have a couple different time frames just with health inspections and a couple different data points that are impacting your health inspection. For the staffing domain, this looks at the hours that the facility self-reports in the Payroll-Based Journal, and it looks at 12 months of data and it's updated quarterly. The quality measure domain is also updated quarterly and uses four full quarters of data but with a delay. And the quality measure domain pulls from different quality measures that are both MDS-based as well as a few claims-based measures. So, a couple different data points with quality measures also. For the NAC, one of the ways to look at Five-Star and hopefully make it a little less challenging is to understand that they're not the sole responsible person for managing all aspects of Five-Star. They may be highly involved with the understanding and reporting when it comes to the QM domain because most of the quality measures used for that domain are MDS-based. But that should be more to understand the underlying data and then working with your entire team to understand how the domains work together for your overall Five-Star rating. Amy: Thank you for that. Another challenge noted by the survey respondents was documentation, especially for section GG. How can NACs overcome documentation challenges and ensure accuracy when coding the MDS?" Jessie: Oh, GG always gives us so many challenges. When we look at section GG, we have essentially two different processes that are going on. The first is the underlying documentation. This is what's actually happening during those three-day windows for each of those episodes of care, whether it's with the CNAs, the nurse, or the therapy team. And then you have the second part, which is the review of all of that documentation during the three-day window to determine the resident's usual performance. And so we have to have two strong processes in place. First is a strong process for that underlying documentation. And the second is a strong process to determine usual performance. The underlying documentation requires that we have really consistent and ongoing education with the staff members who are going to be documenting or charting those GG tasks, such as: How did the resident eat? How did they transfer? How did they move from sitting to lying? How did they transfer into the bath? So for all of those different GG tasks, the direct care staff needs to understand the RAI User's Manual definition—what is included as well as what is not included? And also understanding the performance levels. So what is partial-moderate assist, what is substantial-max assist, as well as supervision or setup help only? So there's a lot that goes into those performance levels as well as the different tasks. Now, one of the cool things that AAPACN has is a GG Trivia Game, which we actually have two versions now. And the GG Trivia Game is an education tool, it’s free for members, that you can use with your direct care staff to help reinforce in a game fashion different GG tasks in the different performance levels. So, creating education that's fun is a great way to reinforce your other training. Another thing that we need to do with that direct care staff is we have to validate that what is being charted is accurate. So, that may include different types of audits or validation processes. One of my favorite ways to validate if the charting is accurate is to, especially during the lookback period for an MDS so that that really has a good impact on the accuracy of that assessment, is going out and watching how the resident performs tasks with the nurse aide and then looking at how they charted that specific task. If there were inconsistencies or inaccuracies with how it was charted, that gives you the opportunity to provide real-time education. And whenever you are learning and you can apply what you learned to something that you experience, that is a great way to reinforce that education. When it comes to the usual performance determination, I think one of the best things the teams can do is to make this a team process. Put together a collaborative team of your qualified clinicians that can review that charting documentation and help to make those decisions. Some of your charting is going to be very clear and you won't need to have that additional conversation of what is usual. So, for example, if a resident eats independently every day, every episode during that three-day window, their usual performance is independent. But if you have fluctuations, that is when your team will need to look at all of the documentation from therapy, direct care staff, everyone who is involved and had documentation to support the performance during that period and then make that determination of the resident's usual performance. When we tie that back to Five-Star and QMs, when we focus on not the outcome of those quality measures, but when we focus on the accuracy of section GG, that's what's going to give us an accurate MDS and accurate quality measures. Now, if we identify there is a process we need to work on such as towards that discharge function score or ADL decline, that's something that we need to address outside of MDS accuracy once we’ve validated that the MDS is accurate. So, a lot of moving pieces there, but education and the focus on MDS coding accuracy are your key ways to make sure GG is accurate. Amy: Thank you for that. Several respondents emphasized a lack of ownership and communication across the IDT and leadership. How can stronger collaboration among nurses, supervisors, the DNS, and other leaders support the NAC's Five-Star management efforts? Jessie: Oh, I love this question. It goes back to how complex Five-Star is and it's so complex that oftentimes no one wants to own it. As the NAC, a lot of times because this is a quality measurement program, you're highly involved in it. However, the Five-Star program should never be viewed solely as the NAC's responsibility. And for that matter, QMs should also not be viewed as solely the NAC's responsibility. The quality measures are really a measure of the care that we provide. And the MDS is just the messenger. So, it's the way that CMS collects the data in an organized way. To be successful with Five-Star with your quality measure programs, we can't have the focus just on the MDS or just on those outcomes. We actually have to look back at that root cause of why did that QM trigger? What was the event or the condition that allowed that quality measure to trigger? So, for example, if we have falls, pressure ulcers, if we have readmissions, or emergency department visits, the focus cannot just be on how is the MDS coded to capture that, but what systems and processes does the facility have in place to prevent the falls, to prevent pressure ulcer development, or to heal pressure ulcers timely, to ensure safe discharges home, to prevent rehospitalizations, to prevent unnecessary emergency department visits? And when we focus on the prevention, and we focus on the systems and processes that lead up to that quality measure being triggered, that's where we're going to see ongoing quality improvement efforts. And it really takes the entire facility and a facility culture of process improvement. When we tie Five-Star into that, the Five-Star data is old. It is how your facility performed, not how your facility is performing right now. So, while it's important to know what your Five-Star rating is because a lot of different consumers are looking at that—you might have hospital discharge planners that are looking at this and sharing this with potential referrals; you may have Medicare Advantage plans looking at this as part of their contracting; you may have other residents looking to come in from the community looking at Five-Star as part of their facility selection process. And that's just one piece of the overall puzzle of what your facility is and how you perform. And again, it's more historical data. So, when you have that opportunity to share what you're doing today for quality improvement, what goals you've achieved, what outcomes you've achieved that maybe aren't yet reflected in Five-Star is how you can really help your team and your leadership understand you