by James C. Sherlock
A pending new federal rule defining strong nursing home staffing minimums has finally accomplished something that I thought unlikely in my lifetime.
It has in a single stroke aligned the interests of patients and their loved ones, nurses, nursing homes, state and federal governments, and taxpayers in finding ways to make existing nursing home staffs more efficient and effective.
That alignment brings the miracle of the loaves and fishes to mind.
It takes some explaining.
- The value of the new regulations to patients and loved ones and nurses is clear. Better quality of care for patients and better working conditions — less stress and better job satisfaction — for the nurses.
- The nursing homes and their lobbyists oppose the new rule, but it appears that it will happen. They face a significant shortage of registered nurses in Virginia and competition for nurses from hospitals with deeper pockets. So, they very much want to somehow reduce the new minimum federal requirements.
- The state and federal governments, and thus the taxpayers, will inevitably see demands for Medicare and Medicaid payment increases to pay for the new staff. So, it would benefit taxpayers and the national debt to reduce those ratios as long as the desired levels of care could be maintained.
One answer to address all of those interests is extensive automation of processes in which nurses are involved. Just some of the requirements:
- Integrate electronic health records (EHR) and nurse support apps for real-time data entry on mobile devices;
- Remotely pre-screen, prioritize and automate alert and alarm workflows;
- Alert to medication administration requirements and help prevent medication errors;
- Enable nurses to notify the appropriate responders to crises with one click on a mobile device.
A potential solution is available. EHR can be fielded with compatible nursing support software, patient-wearable emonitoring devices and Bluetooth-enabled mobile devices for the nurses. Such systems must be intuitive, integrated and easy to use.
Those types of productivity improvements have been available for at least 25 years with increasing levels of sophistication.
But most nursing homes, especially for-profit facilities, do not even have EHR’s, much less compatible nursing support software and mobile devices.
CMS now seeks comments:
… on the effectiveness of a minimum staffing standard in maintaining quality and safety and ways to minimize administrative burden, both for LTC facilities and for CMS in maintaining and enforcing such a standard and enhance compliance among LTC facilities through the use of automated data collection techniques or other forms of information technology. [Emphasis added.]
They ask:
What alternative policies or strategies should we consider to ensure that we enhance compliance, safeguard resident access to care, and minimize provider burden? Are there other alternative policy strategies we should consider? [Emphasis added.]
Hundreds of billions of federal and state dollars are at stake in Medicare and Medicaid.
I recommend that Virginia during the comment period on the rule notify CMS that it intends to seek a federal grant to provide, test and evaluate implementation of EHRs and nursing support software and mobile devices among Virginia nursing facilities of all types.
The test would be the subject of separate RFPs
- for test items with vendor support; and
- for contractor support to the government in the design and conduct of the test.
It would be designed with goals to include measurement and assessment of the value of those solutions to serve the needs of all stakeholders.
Nursing support informatics have been deployed for at least 25 years. They now typically include the features requirements described above.
One vendor claims 57% time saved per measurement and 160 hours saved per month based upon a 120-bed SNF/NF facility, with 20 vital sign measurements per resident per month.
To that and similar claims I respond — maybe. Such assertions need to be examined and verified. But if even close to true they could transform the quality and nursing staff requirements for nursing homes.
A primary output of any test would be measures of nurse efficiency and effectiveness improvements with a goal of reflecting them in adjustments to federal nurse staffing requirements to incentivize investments.
The objective of the implementation and test over, say, a three-year period, the same period in which the new rule will be phased in, would be to determine which solutions are best in improving both patient health and well-being and nurse job satisfaction, and how much.
One piece of very good news is that the value of the systems can be measured with considerable precision using the vast array of data already collected from each nursing facility by CMS and the state.
Because a positive result from such a test can lower future Medicare and Medicaid costs and result in better patient care with fewer nurses, I predict that CMS will be very willing to make the money available to Virginia in return for participating in the design and monitoring of the test.
The Virginia Health Care Association and its members should be highly motivated to cooperate with the state in finding volunteer facilities for the test. They would get the technology and its installation and training for free and benefit from the value of the technology and from the findings.
Test standardization would require systems engineering support to ensure that processes in the nursing homes participating in the test are aligned with federal requirements laid out in the surveys in the State Operations Manual to in turn ensure that apples are being compared to apples.
That would provide additional benefits to the participants. And that Manual itself would be subject to change based upon lessons learned in the test.
The Virginia Nurses Association, the American Nurses Association and the Alliance for Nursing Informatics would be vital and willing test participants.
With the federal funding in hand, the state, with the help of the other participants, can issue an RFP to vendors for potential solution packages.
All of the major EHR providers have such offerings, but there are extensive industry technical interoperability standards to allow various commercial versions of EHR and nurse support software and patient monitoring devices to be tested in different combinations if desired.
The RFP standards for acceptable proposals should be set high enough to ensure proven field experience with and technical compatibility among the offerings.
If the test proves of sufficient value, the state can mandate one or more solutions for every nursing facility taking Medicaid patients.
The Virginia Department of Behavioral Health and Developments Services (DBHDS) has already selected a Cerner EHR as a requirement for its facilities. Thus such a requirement would not be breaking new ground.
CMS could do the same for Medicare and Medicaid payment recipients nationwide.
Bottom line. The new proposed rule will be published in the Federal Register on September 6.
The best time for initial state action on this recommendation, if accepted, is during the 60-day comment period.
It seems like the right thing to do for all of the stakeholders.
