Assisted Living

It's pretty ironic that one of our articles this month is about music --- for the dying. Well Matilda is a long-way off from that!

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The NJ Department of Health and Senior Services has joined with the Health Care Association of New Jersey (HCANJ) to enhance quality and consumer information about assisted living residences in New Jersey. This four-year pilot program, entitled Advanced Standing, will offer a designation by the Health Care Association of New Jersey Foundation, which verifies that an assisted living facility has satisfied all state licensing regulations and also meets quality benchmarks.

The Advanced Standing program will expand oversight of assisted living facilities and for the first time collect quality data on these facilities. It is a voluntary program that assisted living facilities choose to participate. There are 215 assisted living facilities in New Jersey. Forty HCANJ member facilities have already expressed interest in participating in the Advanced Standing program.

The reaction of the remaining 175 facilities will be interesting. Could non-participation signal disinterest in quality for residents? That would be a big consumer turn off. Then you have the 40 facilities and how they might couch participation and use it as part of their marketing efforts.

Said NY Health Commissioner Mary O'Dowd: "This program also represents a change in culture for state government--more often we are in the position of ensuring minimum standards, which are enforced with penalties and fines. But in this case, we are asking providers to go beyond the minimum--to strive for excellence and be awarded with a special designation." Interesting.

Within this pilot project, the Department would maintain full State oversight of assisted living services and facilities. It will continue to conduct complaint investigations for all facilities, but limit routine inspections to facilities without Advanced Standing. In addition, the Department will randomly conduct unannounced surveys at up to 25 percent of facilities with Advanced Standing in the first year of the project and up to 10 percent each year after to validate surveys performed through this pilot. Until the launch of this pilot, the Department was inspecting assisted living facilities every two years. So again it will be interesting to see how non-participants fare in all of this.

The Advanced Standing status will help consumers choose facilities by also providing information on programs offered at participating assisted livings. Potential residents and their families can ask to see a documentation that indicates the facility has been given an Advanced Standing status. The Department also will note on its website what facilities have the Advanced Standing designation.

So this will truly become a badge of honor and in turn become a marketing and sales advantage. As I have maintained in the past, the blurring of the health care continuum and the increased acuity levels of assisted living residents will cause increased scrutiny on quality. Providers in other states and national chains would be well served to keep an eye on The Garden State.

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The National Quality Forum (NQF) Board of Directors has approved for endorsement 14 quality measures on palliative and end-of-life care. The measures address a wide range of care concerns, including pain management, psychosocial needs, care transitions, and experiences of care.

"As the number of older adults in this country continues to grow, palliative and end-of-life care services are needed more than ever," said Janet Corrigan, PhD, MBA, president and CEO of NQF. "This set of measures will help promote the type of high-quality care older people and acutely ill patients deserve."

NQF sought measures focused on care concerns such as managing pain, weight loss, and depression. It also sought measures that would directly assess - and improve over time - the experience of patients undergoing palliative and end-of- life care, as well as the experience of their families. In all, 22 measures were evaluated against NQF's endorsement criteria by a panel of providers, measurement experts, and consumer representatives; 14 measures were endorsed. Twelve measures are new.

R. Sean Morrison, MD, director of the National Palliative Care Research Center and co-chair of the Palliative Care and End-of-Life Care Endorsement Maintenance Steering Committee stated: "This measure set will help support such efforts, such as enhanced treatment of pain and other symptoms, improved communication between providers and patients, fewer admissions to emergency departments, and increased patient satisfaction."

NQF is a voluntary consensus standards-setting organization. It operates under a three-part mission to improve the quality of American healthcare by:

• building consensus on national priorities and goals for performance improvement and working in partnership to achieve them
• endorsing national consensus standards for measuring and publicly reporting on performance
• promoting the attainment of national goals through education and outreach programs.

Palliative care is specialized medical care for those with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. It is not just for end of life care and that is an important distinction.

The measures were derived from a number of sources, including the RAND Corp., the National Hospice and Palliative Care Organization, and Deyta, a provider of healthcare quality measurement tools and benchmarks. You can view NQF endorsed measures here.

As palliative care becomes more understood and more players enter the market, it would be wise to track endorsed quality measures and use them as a guidepost for care. As we say it is the right thing to do but also becomes a marketing advantage when that higher quality standard translates into better patient experiences.

P.S. If there is a palliative care expert that would like to be a guest author for this site, please let me know using the contact form.

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Time is expiring!

According to a new proposed regulation, healthcare providers must report self-identified Medicare over-payments within 60 days of noticing the incorrect payment or face monetary penalties.

The deadline was instituted by the Affordable Care Act policies aimed at reducing Medicare fraud.

Prior to this, providers were not given a specific time frame for returning over payments to CMS, which include:

• Medicare payments for non covered services.
• Medicare payments in excess of the allowable amount for a service.
• Duplicate payments.
• Receipt of payment when another payer was primarily responsible for payment.
• A provider reviews billing or payment records and learns that it incorrectly coded certain services, resulting in increased reimbursement.
• A provider learns that the patient died prior to the service date on a claim that has been submitted to Medicare.
• A provider learns that services were provided by an unlicensed or excluded individual on its behalf.
• A provider performs an internal audit and discovers that over payments exist.
• A provider is informed by a governmental agency of an audit that discovered a potential overpayment and then fails to make a reasonable inquiry.

The Proposed Rule contains a lookback period of ten years, meaning that a provider has to report and return an overpayment if that overpayment is identified within ten years of the date that the overpayment was received. Yikes!

Providers might be wise to review current reporting and refunding policies to confirm that practices comply with the Affordable Care Act and refining audit strategies in light of the Proposed Rule.

As this rule was announced the Administration also shared that the Health Care Fraud and Abuse Control Program had recovered $4.1 billion in Fiscal Year 2011 from anti-fraud efforts, while the Department of Justice opened 1,110 new criminal health care fraud investigations involving 2,561 potential defendants.

From RAC to Red Flags to hospice marketing investigations to home health companionship exemptions, you need a scorecard to keep track.

It's time you hire a good lawyer!

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PHI, the Paraprofessional Healthcare Institute, has issued three new publications to dispute claims that the Department of Labor's proposal to narrow the companionship exemption--and require time and a half for overtime hours--is unaffordable.

Let's look at their side.

In Can Home Care Companies Manage Overtime Hours?, three agencies are profiled who have implemented similar staffing and scheduling practices to maintain continuity of care for clients while keeping overtime hours within a manageable budget.

In Home Care Jobs: The Straight Facts on Hours Worked it is suggested that even without incentives to manage overtime, the industry is not using excessive overtime hours. Less than 10 percent of home care aides report working overtime, according to their findings.

According to PHI, the home care industry is among the fastest-growing industries in the country. A third PHI fact sheet, Growing Labor Industry Can Afford Labor Protection shows that revenues for the industry have doubled from about $40 billion to $84 billion between 2001 and 2009. At the same time, home care workers have seen their wages stagnate. In 2010, the average hourly wage was $9.40 an hour, about equivalent in inflation-adjusted dollars to the $8/hour wage workers were making a decade before. As a result, nearly 50 percent of home care aides live in households that rely on some form of public assistance.

Ok, now the other side of the coin.

Criticism of the proposed regulations has focused primarily on the increased costs of companionship services, both to consumers and to taxpayers. There has been little discussion regarding the impact - both regulatory and practical - of the proposed regulations on the operations and record-keeping practices of agencies providing third-party companionship services. The proposed regulations would require providers to "make, keep and preserve a record showing the exact hours worked" by each employee. Until now, employers have been permitted to simply keep an agreement as the basis for establishing hours worked in lieu of maintaining time-records.

Live-in companions typically work unsupervised in their clients' homes for periods up to and sometimes exceeding twenty-four hours. All of this time, however, is not compensable. In most states, companions are not entitled to compensation for meal times and/or time spent sleeping during the shift. The employer, either an individual or agency, under the proposed regulations, will have the burden of keeping adequate records of these non-compensable periods and, in many states, the precise "clock-in" and "clock-out" times for each such break. Employers will have little ability to monitor or audit the time submitted for meal and sleep periods. Moreover, the failure to properly record times of these periods will not only constitute a violation of the recordkeeping requirements of the regulations, but will also be construed against the employer in any DOL investigation, litigation or quasi-judicial hearing.

It is easy to say that we need to meet in the middle. But it is true. I believe that consistent assignment benefits the patient with a better experience and gives the health care worker piece of mind of having consistent work. And while that can happen in part time situations, full time work in the industry would probably go a long way in improving experiences. That would probably reduce overtime costs but increase benefit costs.

But to achieve that, the industry does need to become more efficient. And to achieve that usually involves automation and that in turn involves modern technology to track staffing, care and quality. No matter how you slice it in home care, those who make investments in their workforce and their operations will stand out. Because the marketplace will become more crowded with competition and making these improvements will actually become good marketing and sales strategy too.

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