Major changes to the Minimum Data Set (MDS) later this year will have “huge ripple effects,” but skilled nursing leaders are still struggling to understand the full implications given a lack of information.
This is the perspective of Joel VanEaton, EVP of post-acute care regulatory affairs and education at Broad River Rehab.
“All of my questions are unanswered at this particular point,” he said of the MDS transition, speaking on the Skilled Nursing News RETHINK podcast.
The Centers for Medicare & Medicaid Services (CMS) got ahead of itself in releasing the updates to the comprehensive data set last fall and then the full data set just before Christmas, with little by way of education or additional resources, VanEaton believes.
Major changes include the removal of Section G, as well as the addition of standardized patient assessment data elements (SPADEs).
VanEaton offered insights into these and other changes, advice for how to prepare, and his takes on other recent moves from CMS, including increased enforcement related to psychotropic drugs and the move to post citations under dispute to Care Compare.
On CMS antipsychotic oversight:
Joel VanEaton: I don’t think anyone was surprised at the announcement … maybe it did catch us a little bit by surprise – the penalty was the surprise. Other conversations that CMS has been having has led up to this sort of action.
The penalty piece seems to be a bit overbearing. Reducing the long stay quality rating, downgrading it to one star for six months, of course, will have a negative effect on the overall rating. The short stay quality measure rating will be suppressed for six months, and then the long stay antipsychotic quality measure will be suppressed for 12 months. That’s a long time to have that quality measure be impacted for something that can be remedied.
Let’s hope that it has the impact that CMS intends for it to have. It’s interesting that the conditions of participation, as well as the RAI manual have really pressed us into this. As we move through the changes to MDS version 1.1 8.11 coming up this fall, clearly the new section or revised section ‘N’ will require us to have an indication there. This will press the issue even more, in terms of coding antipsychotic medication.
Pay attention to the one thing that drives all of us in this industry – put the resident at the center. I think that will win the day in terms of being able to comply with this new regulatory guidance.
Wider CMS oversight with behavioral health
The push for home and community based services (HCBS) has materialized, certainly through the Covid-19 pandemic, but even before that in the state of Tennessee, it’s been a big push here from the Medicaid side of things. That has led to a different sort of acuity that ends up in skilled nursing facilities. Seeing the way that behavioral units have materialized, memory care units have materialized – patients that are truly long term, their behavioral health needs have risen to the surface. Behavioral health is something that nursing homes are definitely going to be paying attention to, and are paying much more close attention to, as time moves forward.
Publicly displayed citations
This was less of a surprise to me. This is something that consumers, or CMS at least intends for consumers, to utilize. As [CMS has] made changes to Care Compare over the last couple of years, it’s still a complex conglomeration of information. You got five star ratings out there, you got staffing and you’ve got the survey process or health inspections, and unless you really understand fully how those complex pieces work together, that five star rating may not be the thing that best represents that nursing home.
If you dig deep into the health care citations or the survey citations portion, you can dig to your heart’s content; it goes on forever and ever. While I think it’s important to have this kind of information out there, I think it only adds to the complexity, and makes that five star rating even more complex of an idea for people to digest – even for people that are in the skilled nursing facility world. It’s amazing to me, even at the provider level, how much information still needs to be understood about what is out there and how it works, and how that all fits together. I think it’s important to have this information out there for transparency, but I think it does add to the complexity. It may be helpful, it may not. We’ll see what happens.
MDS changes and Section G removal
The fact is, all of my questions are unanswered at this particular point. CMS put the cart before the horse by releasing the comprehensive dataset in September, and then the full item set Christmas Eve.
Section G is the most significant or dramatic change. The broad, reaching ripple effects are huge, and that’s why my questions are unanswered. I’ve been on a few of the open door forums asking for training materials. We have been promised training materials in Q2 this year. We’re all looking forward to those.
We need to be thinking about and paying attention to the big areas that Section G will impact like the care area assessments, triggers for call five, call six, call 11 and call 16. All rely on items from Section G. They can’t be triggered without those Section G items. How will that happen? In one of the open door forums, CMS mentioned sort of quickly, a G to GG crosswalk.
Those of us that teach this and do it understand that there is no quick crosswalk. We’re going to have to know more about that and hopefully, CMS will provide that information to us. There are 17 care area resources that will need to be revised in some way because they have some reference to Section G. Only three of the current care area assessments don’t rely explicitly on Section G in some way.
We need instructions on that. That’s one area where a lot of people are asking what’s going to happen. We did a national conference call late last year in October when the dataset came out, an item by item breakdown of the changes. Most of the questions we got on the conference call were, where are the instructions for completing these [care area assessments]. We’re waiting on that. This will be something that we’re all going to have to learn and grow into, understand that change from G to GG in relation to care area assessments and the quality measure specifications, including risk adjustments.
Quality measures that impact the five star rating, three of them rely specifically on Section G in order to be calculated. Those are going to have to be retooled in some way. Those three are: the percent of residents whose ability to move independently has worsened – that’s a long stay quality measure. Also, the long stay percentage of residents whose need for help with daily activities has increased. And then, the short stay percentage of residents who improved in their ability to move around on their own.
Again, these can only be calculated by Section G data. Furthermore, the section that we deal with in relation to high risk residents with pressure ulcers is adjusted with covariates coded in Section G. So that’s another area related to the five star rating that we’re going to have to deal with in relation to Section G.
The other question I have about the quality measures specifically is the transition period. Once we move from G to GG, what is the meaningful way that we’ll be able to look at a four-quarter average of these quality measures? Is this something that we’ll have instruction on? Are they just going to continue to look at the percentages and add those percentages together until they’ve got all four quarter percentages that have been adjusted by Section GG? In my mind, at least at this point, those comparisons can’t be made. We’ll see what CMS gives us on that.
Also, staffing acuity adjustments rely on RUG scores from the Staff Time Resource Intensity Verification Project to calculate the staffing stars, and without Section G, you can’t calculate RUG scores. What is cms going to do when we don’t have Section G anymore? If there’s a crosswalk, then I guess we’ll learn that. But the fact is, that’s a question we still have.
Even bigger than all of that is, the states that rely on a CMI calculation for their Medicaid reimbursement typically use a legacy RUG-type system. States like Tennessee, for instance, have to make a choice about how they’ll calculate their case mix index absent Section G. These methodologies currently rely on RUGs-based CMI calculations, again, which requires Section G.
There was a letter that went out to state Medicaid directors last year. CMS made the following statements, I’m just going to quote this quote here: ‘CMS will no longer support the Medicare RUG system after Oct. 1, 2023.’ And then further, in that letter, it says ‘absent available RUG MDS data from CMS, states will likely have to consider collecting data independently from providers to support state plan payment methodology.’
States are going to have to decide what they’re going to do with this. Our folks in the state of Tennessee, they still haven’t given us any definitive word as to what’s going to happen. I know of three states that are making the transition – Wisconsin did this last year, Ohio is in the process of setting that transition up; they’ve made it very clear, they are going to change over to a PDPM construct. Illinois is in a five-month period of transition at this point.
MDS changes and SPADEs
The biggest portion of the update to the MDS has to do with SPADEs – Standardized Patient Assessment Data Elements. This is a term that’s universally used for the elements that will be utilized in each of the post-acute care tools for skilled nursing facilities. Of course, we have the MDS, home health has the Oasis. Inpatient rehab facilities have the IRF-PAI, [patient assessment instrument], and then the [long-term care hospitals] LTCHs have the long-term care hospital data set, or LCDS. Each one of those tools is being revised and revamped to include what are considered to be standardized patient assessment data elements to revolve around the capture of information in three areas.
First of all, of course, is the Quality Reporting Program, or quality measures. The quality reporting programs for each of those standardized interoperable data goes to each assessment tool. Each of the tools has been updated, and is using the majority of these quality measure data elements now. In relation to the quality measures, this is standardized data that’s also being collected out of the majority of those tools. Most of the quality measures that we are collecting in the skilled nursing facility for the Quality Reporting Program are or will be collected on those tools as well.
The IMPACT Act from 2014 mandated this quality measures payment reform. This payment structure was designed with standardized patient assessment data elements out of all of these tools, in order to have a unified payment system that would apply to each of the post acute care destinations.
One of the things we need to remember about SPADEs – it does impact our quality measures, and eventually, most likely will impact payment. This area of SPADEs, interoperable data that can be standardized and shared among the post acute care settings I think is so important, particularly this area of social determinants of health. Social determinants of health is really incorporating a lot of the principles that CMS is forwarding and in many other areas, a broader range of initiatives that are pursuing things like health equity, health disparities, social determinants of health … things that will become part of what a skilled nursing facility will have to evaluate for in their day to day, caring of their residents.
SPADEs take on a much broader influence in relation to these broader initiatives that CMS is pursuing. One of the things that we have to remember, we’re used to the Quality Reporting Program, the fact that we have to report 100% of the data necessary to calculate these quality measures on at least 80% of the MDS, and we have to report 100% of the data necessary to calculate the NHSN data as well or we lose 2% to our market basket update. These new SPADEs that are coming along this year that increase the MDS to 58 pages will also be included in that threshold. So 100% of that information will have to be reported on at least 80% of the MDS, or you will risk losing 2% of your market basket update. Important implications for us are that CMS wants to press forward with relation to these other initiatives in the space.
Preparing for MDS transition
We are trying the best we can to utilize the tools we’ve been given. Of course, no RAI manual is a little bit difficult, but reminding folks that the dataset in its entirety is now available … I think is tremendously helpful as well.
One of the things we have to consider also is, this is still a draft. It’s possible that there’s still going to be additions, changes, revisions to it within the rulemaking process this year – we’ll see. We’ve blogged extensively, we’ve provided a reflections call, an educational session that dealt specifically with the item by item changes in our learning platform, so our customers can join in on that, and be able to get a heads up.
Hopefully in Q2 we will be ready as much as we possibly can. Even the dataset we have currently contains some instructional information embedded within the actual dataset itself. Things like the new [Patient Health Questionnaire] PHQ-2 to PHQ-9 has specific skip pattern instructions in there for us, depending on how we answer the first two questions whether we actually complete the interview or not. It’s very specific. Getting familiar with those kinds of things is very important.
Click below to listen to the entire episode, including discussion of changes to the SNF Quality Reporting Program and value-based purchasing: