Skilled nursing facilities have been receiving higher-acuity patients, with respiratory failure and pressure ulcers among the conditions being seen more frequently at admission. And while some operators have become adept at caring for these conditions, they are concerned that reimbursement rates are not keeping up with costs of more advanced care.
The proportion of SNF stays for respiratory failure increased from 6% to 14% during the Covid-19 pandemic, according to data shared by the American Health Care Association (AHCA).
However, some providers say that they were already beginning to see these numbers go up before then and planned ahead with staff training to deal with both the rising acuity of patients and more hospitals discharging to SNFs earlier. They do lament that Patient Driven Payment Models (PDPM) reimbursement rates don’t fully cover services related to these conditions.
“We have seen an increase not only in the number of residents being admitted to us with pressure injuries and respiratory failure, but also the increases in the overall acuity of the patient that we’re seeing being admitted to us,” Tyler Myers, director of clinical services at Ohio-based Foundations Health Solutions told Skilled Nursing News.
Myers said that Foundations has placed increased emphasis on staff training and development around these conditions despite the pandemic presenting some relatively unique challenges.
“We’ve remained steadfast in that approach that if our staff are equipped with the proper training and the right resources then that high quality of care is going to remain intact despite the negative impacts of the pandemic,” he said.
Foundations, which manages 59 nursing homes across the Midwest, opened several new respiratory and dialysis units since the pandemic began.
“If there’s one silver-lining to this pandemic, it’s that it’s helped us to adapt and better position ourselves to continue to be able to provide a high quality of care to match the high acuity of patients that we’re getting from these hospitals,” he said.
Best practices for treatment
Myers said during the pandemic, patients with Covid-19 who required mechanical ventilation and prolonged hospital stays were often placed in SNFs earlier due to the hospitals reaching capacity.
Today, although the Covid-19 infection rates are down, patients are still being discharged to SNFs earlier and with higher acuity.
“I think we’re still kind of learning some new things about Covid-19 and some of the short-term and long-term effects that it has on individuals,” he said. “It’s pretty clear that it affects not not just the respiratory system, but really every system in our bodies.”
In general, his team has had to adapt to higher acuity patients who are at a higher risk for sepsis and rehospitalizations. The key to success, he said, is early and routine assessments to identify conditions before they progress.
“In order to provide that quality of care that we’re talking about for these patients, again, it is necessary to approach each one individually, and each patient’s condition and plan of care, making sure it’s individualized,” he said.
Dr. Fatima Navqi, medical director at Holy Cross Health, said that patients who have these conditions typically already have compromised immune systems. But staff can be proactive and take simple steps that help prevent severe infections.
“What we can do with skin integrity, for older adults, the first thing that we try to do is keep their skin healthy,” she said. “Most of the time, in older adults that can break down because of just simple, excessively dry skin, because their skin is not making enough oil.”
She said that simply keeping patients’ skin moisturized, and helping them move and adjust to new positions to eliminate pressure, is a good form of preventative care. As far as respiratory care, she said that often older people can catch infections and remain asymptomatic while spreading the virus to others.
It is important to be persistent about encouraging visitors to use a mask, especially if they have been sick recently, she noted.
“They’re just simple things and it doesn’t cost any money,” she said. “But these simple things can really prevent these grievous conditions that cost so much money and also cause so many lives and morbidity.”
The impact of PDPM reimbursement rates
Myers said that current PDPM reimbursement rates don’t fully cover the services that patients with respiratory or skin conditions require.
“I think when you factor in the cost of nursing, labor and wound supplies, and potentially the specialty mattress, or the negative pressure wound therapy, the reimbursement that we’re receiving for these patients’ requirements, I’d say are rather unfavorable,” he said.
AHCA applauded CMS for implementing the PDPM parity adjustment over two years to help mitigate the impact a swift Medicare cut would have had on residents and staff during the ongoing pandemic.
Yet since pressure ulcers require specific time-intensive nursing treatments, patients with them typically are classified into the higher acuity PDPM nursing component special care cow case-mix group (CMG).
“As such, AHCA believes the currently proposed parity adjustment approach will not adequately mitigate for the observed shift in reported pressure ulcer conditions of non-Covid patients upon Part A admission that were elevated throughout the PHE, including low Covid months,” AHCA’s Associate Vice President, Therapy Advocacy Daniel Ciolek wrote last summer .
AHCA said as the country and nursing homes recover from the pandemic, they will continue to analyze whether there are permanent changes in the composition and acuity of the Medicare Part A patient population compared to pre-Covid.
“It is essential that CMS is aware of these changes so that PDPM can accurately cover the costs necessary for providing care to a population that may have more complex care needs than was originally envisioned when PDPM was designed,” Cristina Crawford, AHCA spokesperson, told Skilled Nursing News.
Myers said that the additional costs of caring for patients with these conditions should be taken into consideration.
“In regards to reimbursement for patients requiring ventilator care, under PDPM, there’s a potential to be reimbursed under the nursing and TA components,” he said.
But there are several other costs that should be considered, including the additional labor costs by employing respiratory therapists to assist the nursing team with the care of these patients, the initiating and maintenance of these ventilator units, utilities, wiring, and PPD and DME supplies.
“I think it all adds up,” he said. “Not to mention the liability insurance costs, as well.”
