By Paola DiNatale, MSN, RN, NHA

Why is it important for Accountable Care Organizations (ACOs) to understand the connection between clinical documentation and key performance metrics?

—

‘If it hasn’t been documented, it hasn’t been done.’ 

Lessons learned and forever rooted in our clinical training.  Clinical documentation must meet level of ‘attention to detail’ to achieve optimal reimbursement, meet all regulatory and reporting requirements, and accurately reflect the level of care provided. Documentation is critical for patient care, not only because it supports the care that was provided to mitigate risk, but also because it shares key performance metrics both at the facility level and at the patient care level.

The Focus of ACOs

The focus of Accountable Care Organizations (ACOs) as a group consisting of doctors, hospitals, and other health care providers is to ensure that patients get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

Nursing Home providers must demonstrate that they meet certain quality standards during each year of participation with ACOs. These standards are demonstrated through four key domains:

• Patient/caregiver experience
• Care coordination/patient safety
• Preventive health
• Identifying at-risk population

Although these key performance metrics are derived from claims activity, ACOs are beginning to realize the impact poor documentation can have on reimbursement and performance indicators as ACOs continue to identify a preferred provider network.

Role of Five-Star Ratings

Based on the ACO models which incentivize providers to participate in the Medicare Shared Savings Program, ACOs look to partner with post-acute providers who deliver highest quality care with most favorable outcomes and lowest cost. Usually, ACOs link the Nursing Home Provider Five-Star Rating to identify providers with 3 stars or less since these may not qualify for partnership opportunities. The Five-Star Quality Rating system, introduced in December 2008 by The Centers for Medicare and Medicaid Services (CMS), was created to enhance its Nursing Home Compare public reporting site. 

The intent then as it is today is to report on quality ratings for each nursing home that participates in Medicare and/or Medicaid.  The Five-Star Rating system encompasses an Overall Quality Rating of 1 to 5 stars based on the nursing home’s performance for three types of domains:

• Health Inspection
• Staffing
• Quality Measures

These performance metrics are derived from an unannounced onsite health inspection visit by the state designated survey team, from self-reported staffing information submitted through Payroll Based Journal, and through patient/resident level assessments conducted by utilizing a standardized assessment tool known as the Minimum Data Set (MDS).

These various performance metrics collected both at the facility and at the patient level are used to construct the scoring methodology rules devised by CMS to determine the Five-Star Overall Rating. More specifically, all three of the Five-Star Rating domains require several main ingredients from the Nursing Homes such as documenting, reporting and coding, which relies on accuracy and exactness.