The truth about risk management PointRight by alicejenny



 The truth about
 risk management
     Mary Chmielowiec and Paola DiNatale of PointRight discuss the changes
     that the long-term care sector of the healthcare industry in the US is facing,
     and outline how captives can best respond with risk-management initiatives

             ong-term care facilities have            acute settings. While the implementation            electronically from payroll records
             embarked on a journey of change,         date for this is not immediate, voluntary pi-       and other verifiable sources for the
             lots of change. From healthcare          lot programmes will begin in January 2011           public reporting of hours per resi-
             reform to RUG-IV and MDS 3.0,            for implementation in 2013. Long-term               dent day of care with turnover and
 facilities across the US face the most sig-          care facilities risk losing out on reimburse-       retention rates. (March 2011).
 nificant and sweeping change in decades.             ment dollars by not positioning themselves      •   Improved information available on
 Obscured by the immediate demands of                 properly during the pilot studies.                  Nursing Home Compare including
 implementing these new systems and new                  Of more immediate concern to captives is         more timely and extensive staffing
 programmes await the unprecedented op-               the section of PPACA titled “Nursing Home           data; facilities’ survey reports and
 portunity to advance risk-management ini-            Transparency and Improvement Act”.                  plans of correction; summaries
 tiatives, improve resident care and improve          This act requires nursing homes to provide          of complaints against facilities,
 the satisfaction level for every stakeholder.        consumers with a substantial amount of new          including number, type, severity
 On the other hand, these changes also                information regarding ownership and oper-           and outcome; a standardised com-
 have the potential to expose long-term care          ating performance designed to encourage             plaint form; adjudicated criminal
 facilities to greater risk of litigation. As such,   improvements in quality standards. These            violations by facilities and their
 from a captive’s perspective, it is important        changes can dramatically alter insurance            employees including civil monetary
 to understand the changes taking place and           coverage requirements and increase loss             penalties levied against the facility,
 how to best leverage these changes for the           costs. The key provisions of this act and           its employees, contractors or other
 overall advancement of facility performance          their implementation dates are as follows:          agents. (March 2011).
 and preservation of capital.                            •    Revamped staffing data submitted        •   A requirement for nursing homes

 Healthcare reform

 The goal of healthcare reform, known as
 the Patient Protection and Affordable Care
 Act (PPACA), is to control spending while                  From a captive’s perspective, it is
 increasing access to affordable care for all
 Americans. To this end, the overriding
 theme of reform is efficiency. Theoretically,
                                                       important to understand the changes
 by breaking down the silos of care and
 building a more comprehensive, integrated,                    taking place and how to best
                                                      leverage these changes for the overall
 case-managed and client-centred delivery
 system, both savings and improved out-
 comes will be achieved. One mechanism to
 allow for increased integration is bundled
 payments. For certain episodes, a patient
                                                       advancement of facility performance
 will be allocated a set amount of funds that
 would follow the patient from acute to post-                    and preservation of capital”
 26 CAPTIVE REVIEW                                                                                              WWW.CAPTIVEREVIEW.COM
                                                                                                                               CAYMAN REPORT

        to make three years of surveys and                                                           training must be implemented so that the
        complaint investigations available                                                           correct plan of actions are taken every time.
        upon request, and post a notice in
        a prominent location at the facility                                                         The captive’s response
        that this information is available.                                                          For many facilities, the challenge of these
        (March 2011).                                                                                new systems will be in the change itself,
  •     Streamlined complaint handling,                                                              and the magnitude of these changes. As
        including a voluntary standardised                                                           such, it’s critical for captives to understand
        form for filing complaints with the                                                          underlying risk-drivers, such as commu-
        survey agency and protection of                                                              nication between resident/family and staff,
        residents’ legal representatives and                                                         counselling on end-of-life issues, immuni-
        other responsible parties from re-                                                           sations, handling of internal complaints,
        taliation when they complain about                                                           participation levels in resident surveys and
        quality of care. (March 2011).                                                               the percentage of residents with advanced
  •     Institution of training programmes                                                           directives. These indicators speak volumes
        for dementia care and abuse                                                                  about actual risk within the four walls of
        prevention in nurse-aide training                                                            any facility. This is an opportunity to come
        programmes. (March 2011).                                                                    alongside the membership and facilitate
  •     Public disclosure of nursing-home                                                            risk-management initiatives. For example, if
        owners, operators, and other enti-                                                           one facility has a 90% success rate in obtain-
        ties and individuals that provide                                                            ing advanced directives, inquire as to their
        management, financing, and serv-                                                             methods. Then, share the lessons learned
        ices to nursing homes (June 2012).                                                           and provide a mechanism for facilities to
  •     Establishment of compliance and                                                              share best practices and allow the entire risk
        ethics programmes that are reason-                                                           pool to benefit. This is an ideal opportunity
        ably designed, implemented and                                                               for captives to stand out from traditional
        enforced to prevent and detect civil/                                                        insurance carriers by providing risk-man-
        criminal violations, while improving                                                         agement services through, and an increased
        quality assurance. (March 2013).                                                             awareness of underlying risk drivers.

   As these provisions are implemented,
long-term care facilities will become increas-                                                       Invest in the future
ingly transparent not only to residents                                                              To maintain loss ratios in the midst of these
and family members, but also to plaintiff                                                            changes, it is important to invest in risk-
attorneys. Accordingly, this transpar-             this change will struggle to reap the same        management practices. Leverage existing
ency will breed closer scrutiny and subject        advantages. Even worse, they may inadvert-        tools, such as MDS 3.0, to broaden and
facilities to greater risk of litigation. From     ently expose themselves to increased risk.        deepen your understanding of how each fa-
a captive’s perspective, the simple demand            It is important for every facility to recog-   cility operates on a day-to-day basis. Learn
for full disclosure of ownership will hinder       nise that MDS 3.0, in addition to the many        to interpret, benchmark, track and trend
the opportunity to hide deep pockets. Add          advantages, also introduces new areas of          available data to monitor the effectiveness
increased accessibility of survey results,         exposure. Accordingly, there should be a          of risk-management programmes.
complaints, and prior offences and it is easy      plan in place to manage that risk. Through-
to see how this act could fuel a fire of litiga-   out MDS 3.0, for example, residents are
tion that may require a revised analysis of        interviewed and expected to respond to
existing coverage levels. As the saying goes,      very targeted and scripted questions about
the best defence is a good offence. For long-      their mental status, mood, and preferences
term care facilities, that offence starts with     of daily routine, pain, long-term goals and
leveraging new tools to build an impenetra-        overall satisfaction. While resident inter-
ble risk-management programme.                     views may not appear risky at first glance,
                                                   consider the following questions: “Have
                                                   you ever thought of hurting yourself?” or
MDS 3.0                                            “Have you ever thought you’d be better off
Effective October 1, 2010, MDS 3.0 intro-          dead?” Now, consider what happens when a
duces a radical shift in assessment philoso-       resident answers with a “yes”.
phy from an observational approach to a               Obviously, such questions open up a             Mary Chmielowiec (left), executive vice-
resident-directed approach. Like any major         facility’s responsibility to provide additional    president for insurance and Paola M
change in systems, the transition period           services immediately. In this example, the         DiNatale MSN, RN, NHA, RAC-CT (right),
from MDS 2.0 to MDS 3.0 will introduce an          facility would have a responsibility to report     national account manager, risk services
                                                                                                      are with PointRight, based in Lexington,
element of risk for all facilities. However,       that event to the proper authorities, allocate     Massachusetts. PointRight is a company
for facilities that took the initiative and        additional mental-health resources, and            committed to improving the quality
developed a thorough implementation plan           make sure that the plan of care addresses          of care in long-term and post-acute
with adequate staff training, the transition       this risk. Not asking these telling questions      settings by providing information-based
                                                                                                      clinical management tools and services.
to MDS 3.0 will deliver more informative           is not an option with MDS 3.0. Everything          By harnessing the power of information,
assessments, better-quality care plans, more       is documented and measured according to            PointRight creates analytical solutions
positive survey results, improved public           built-in severity scores. Of equal importance      that combine advanced technology,
relations and higher quality measures. Al-         is the fact that this type of staff/ resident      comprehensive data resources and
                                                                                                      professional expertise.
ternatively, facilities that are unprepared for    interaction is entirely new, and proper

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