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Nursing Home and Home Health Agency Staffing Under New Scrutiny

By Rebecca Adams, CQ HealthBeat Associate Editor

October 6, 2014 -- The Obama administration will use payroll data starting next year to find out how many workers each of the nation's 15,000 nursing homes employs to help patients, federal officials said last week. The process is part of an effort to improve the quality of care offered by nursing homes, home health agencies and other medical providers.

Part of the initiative comes from a bipartisan law that President Obama recently signed. The legislation, known as the IMPACT Act, could lead to significant long-term changes in the way that the providers are paid. The rest of the efforts are being done through rulemaking and executive actions.

Consumers have long been frustrated by the difficulty of comparing nursing homes and home health agencies. The administration said the new requirements would give consumers more tools. Besides more accurate information about staffing levels, the Centers for Medicare and Medicaid Services (CMS) also will beef up requirements for states to inspect nursing homes regularly and post results online.

Federal officials also will expand the current ratings system, which is presented in an online tool known as Nursing Home Compare, with additional quality measures. The website allows consumers to compare nursing homes within a geographical area based on quality ratings that federal officials award based largely on data supplied by the institutions. The administration also said it would expand the use of nationwide surveys of nursing homes as another way to check the information that nursing home provide.

And the conditions of participation for home health agencies will change for the first time since 1989. The nation's approximately 12,500 agencies will face new requirements, outlined in a proposed rule released early last week, that aims to improve quality assessments and communications systems. The rule is designed to improve patients' rights by clarifying the process for conducting violation investigations, and addressing verified problems.

"We are focused on using as many tools as are available to promote quality improvement and better outcomes for Medicare beneficiaries," said CMS Administrator Marilyn Tavenner. "Whether it is the regulations that guide provider practices or the information we provide directly to consumers, our primary goal is improving outcomes."

Consumers often are particularly skeptical about self-reported staffing data from nursing homes. The lack of verification "raises the possibility of gaming the system," one administration official acknowledged in a recent call with reporters. Some providers have been accused of inflating the number of nurses and other staffers temporarily before a reporting deadline in order to win a higher quality rating that is then touted in marketing materials.

The administration will use funding from the IMPACT Act to install an electronic system that will use quarterly reports that can be traced back to payroll data from the providers. The information will reveal the number of employees at each facility, the amount of turnover and retention among workers and the mix of personnel.

The nursing homes will report the staffing data to CMS in 2015, and the public is expected to be able to see it in 2016.

Federal officials also are evaluating whether the current ratings system needs to be adjusted. An unusually high number of nursing homes have better than average scores, which raises questions about the reliability of the ratings. The new methodology is expected to tap more independent sources instead of self-reported data.

And nursing homes will have to add some measures. Starting in January, facilities will report on the amount of antipsychotic medications they give to patients. Other metrics that are planned to be added later include information on how many patients are re-admitted to hospitals after being discharged.

The American Health Care Association and National Center for Assisted Living, a trade group which represents more than 11,000 nursing homes, assisted living homes, and facilities for people with disabilities, already encourages its members to track similar data.

"We believe the improvements we are making to the Five Star system will add confidence that the reported improvements are genuine, are sustained, and are benefiting residents," said Patrick Conway, deputy administrator for innovation and quality and CMS chief medical officer.

The law (HR 4994) that Obama signed, which authorized some of the funding for the federal changes, was a noncontroversial measure that built off recommendations from the Medicare Payment Advisory Commission.

The law requires providers to submit standardized data on the care they give to nursing home patients and those that have had a hospital stay. MedPAC and the Health and Human Services Department will report back to Congress with new proposals for post-acute care payments, such as using bundled or site-neutral payments that would reduce differences in the payments that different kinds of providers get for similar types of patients. MedPAC commissioners pushed in their March report for a common, uniform assessment tool of post-acute care providers.

Mark Parkinson, the president and chief executive officer of the American Health Care Association and National Center for Assisted Living (NCAL), said the law "opens new opportunities to enhance the quality care we deliver every day" and called it a "critical step forward in improving lives for millions of Americans."

Parkinson said the providers look forward to helping to implement the law and would work "to ensure the new quality measures are helpful to those we care for and their families."

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