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?
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‘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.
Data Integrity, Interoperability and New Payment Models
Healthcare providers understand too well that the patient’s clinical record documentation is based on the clinical situation; however, too often we get trapped in the mindset of ‘it’s too much or too little reporting.’ Data integrity is an integral part of the performance and quality metrics equation. Since the advancements of the electronic health record (EHR), interoperability remains a challenge for the ACOs. Yet, the goal of clinical data analytics is that it reflects coordination of care which equates to better care. In June 2018, CMS released the Data Elements Library (DEL) to enhance interoperability by standardizing data types for the purposes of communicating patients’ records using a universal language.
There is much on the horizon for Nursing Home providers and clinical documentation will play a major role in ensuring data accuracy. For example, the implementation of the new payment reimbursement system known as the Patient Driven Payment Model (PDPM), is driven by MDS assessments with emphasis on the ICD-10 CM codes to identify resident characteristics and conditions to place the patient/resident in corresponding payment components. But it does not stop here…
Defining PAC data sources!
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Clinical Documentation: What’s Ahead for ACOs
It’s too soon to tell what impact these changes will have on reimbursement and the effect that it will have on ACOs in determining a preferred provider network. Perhaps with a view through the looking glass, we can all hypothesize based on past theories and experiences; no doubt our thoughts and comments will vary. We can be sure of one thing – the importance and relevance of clinical documentation will never go away regardless of what clinical record format or EHR/EMR software platform is in place.
Lack of patient care documentation will continue to bear negative impact on many levels. So, it is prudent to say that documentation is here to stay and will continue to play an important role in the connection to key performance metrics.
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