The annual American Health Care conference held in Chicago in early October filled my head with much important new information. There are definite changes on the horizon that I became more aware of through attendance. I'd like to share two important take-away points with you to better understand how the specialized dementia services that we all deliver fulfill current and emerging needs in our industry that drive reimbursement.
Dementia Capable Care as delivered by a skilled Dementia Therapist and competent care partners is essential to meet future CMS initiatives for care and payment. I heard two repeating themes during the sessions I attended, which is Medicare has a directive to providers to (a) focus on reducing hospitalizations and (b) improve quality of care. Facilities may be incentivized and/or punished related to their outcomes.
Summary of these critical issues.
The future may see payment linked to quality outcomes. Specifically,
- A demonstration project began July 1, 2009 in 182 facilities in 3 states (Arizona, NY, and Wisconsin) offering financial incentives to participating nursing facilities that demonstrate:
- The ability to provide high quality care and/or
- Improve the level of care they provide
- CMS anticipates that higher quality of care will result:
- In fewer avoidable hospitalizations
- In decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays
- Quality will be measured by:
- Staffing (levels and turnover)
- Appropriate hospitalizations—rate of potentially avoidable hospitalizations (for both short-term and long-term stay clients)
- State survey based outcome measures (those with substandard quality of care or those that have one or more citations for actual harm or higher will not be eligible to receive a performance payment)
- MDS-based resident outcome measures including:
Chronic Care Residents:
CMS will use five of the quality measures (QMs) posted on Nursing Home Compare:
- Percent of residents whose need for help with daily activities has increased;
- Percent of residents whose ability to move in and around their room got worse;
- Percent of high-risk residents who have pressure ulcers;
- Percent of residents who have had a catheter left in their bladder; and
- Percent of residents who were physically restrained
Post-acute Care (PAC) Residents:
CMS will use three of the PAC quality measures that were validated in 2004:
- Percent of residents with improving level of Activities of Daily Living (ADL) functioning;
- Percent of residents who improve status on mid-loss ADL functioning; and
- Percent of residents experiencing failure to improve bladder incontinence
The Positive Influence of a Dementia-Trained Staff on Quality Outcomes
Clearly the goals of dementia-capable care which are to enable those with dementia to perform at the highest level of function possible, in activities of value, as supported by care partners and the environment, lends itself to the facilitation of the quality care outcomes named above.
The Allen Cognitive Levels/dementia stages are a road map for care. They tell us both "what is possible" for the person at a stage or level, and they alert us to the areas of highest risk. The dementia stage provides a plethora of information to facilitate maximum performance in ADLs and mobility, and they help us to proactively identify areas of high risk in order to reduce the incidence of hospitalizations.
ADL Function and Mobility:
Through our comprehensive assessments and treatment (in which the Allen level is prioritized), we identify the functional potential that exists and eliminate barriers to achieving potential, followed by training and collaboration with a dementia-capable care partner. As a result we can:
- Minimize ADL decline/loss (create the "just-right challenge" using stage-appropriate approaches)
- Improve current ADL levels (often related to excess disability due to the complex nature of the client)
- Minimize mobility decline/loss
- Improve current mobility status and safety
Hospitalizations cost Medicare a lot of money and therefore there is much attention being paid to providing care that reduces problems that lead to hospitalization. Through our comprehensive assessments and treatment (in which the Allen level is prioritized), we can identify the areas of highest risk for a person at a dementia stage as we clearly understand how cognitive deficits of a certain degree may create a risk situation. Through our unique skills we can develop a preventative plan of action that we share with our dementia-capable care partners to reduce the chance of a risk becoming a reality. A proactive approach can prevent many common occurrences such as a fall that often leads to a hospitalization.
If residents are enabled to perform at their best ability, leading to higher function and a positive emotional state, staff burden can decrease. Staff burden is one of the reasons that turnover occurs. The amount of staff turnover is yet another quality area being measured by Medicare that may eventually influence reimbursement.
It is not too many tomorrows before the light bulb will go off in which leaders of geriatric care environments will realize that they cannot conduct quality care without a dementia-capable care staff and dementia therapists. The skilled assessment and treatment of those with Alzheimer's disease and related dementias (ADRD) provided by a dementia therapist is the service needed to facilitate quality outcomes such as those named above that will be measured and tracked. The future seems to point toward a reimbursement system in which those who provide the best quality care will be rewarded and those who don't may be challenged to stay in business. I applaud Medicare for the focus on quality, and I encourage each of you to advocate for your dementia capable care skills being a solution to this emerging need. And in the end, we make life a better place for those LIVING with ADRD.