Lessons learned last year can help IRFs prepare for the next change cycle.
CMS’ annual updates to the IRFPAI drive significant challenges to IRFs who want to remain compliant and not suffer across-the-board penalties. From time spent planning and preparing, to workflow changes and provider training, it’s not unreasonable for an IRF to invest 500 to 750 hours of non-productivity time. Considering that there is no advantage to the IRF for this investment (beyond continuing to get paid), that’s a significant hit to the bottom line with no relief.
After the extensive changes that went live on October 1, 2016, Mediware conducted a survey of more than 2,000 IRF providers to assess how they dealt with the change cycle. This survey yielded several insights about how preparation impacted the results and the level of productivity that was lost.
The first finding related to the impact of management engagement on attaining a self-reported “good outcome”. The survey data indicated that 78% of the surveyed IRFs reported a good outcome. However, when considering the amount of time the management team invested in preparation, we can see that there is a wider range of outcomes.
Those organizations whose management team invested 20 or fewer hours of preparation under-performed the group. As expected, the more investment that was made by the management team, the higher the likelihood of a reported good outcome. We were slightly surprised to see the relatively small incremental improvement between the 20-40 hour category and the 40+ hours category. This suggests that either both groups were very closely grouped around the 40 hour metric or that the organizations which dramatically exceeded the 40 hour mark were not effective in using that time to improve their outcomes.
Overall, it is encouraging to see the 70% success rate for even the lower category of management time investment. However a 10% swing in good outcome likelihood does seem like a fairly wide swing given the impact on practitioners and patients alike.
The second finding related to the relationship between therapist and nursing training and outcomes. Again, the sample generated a 78% likelihood of good outcomes. We are pleased to see this high level of positive outcome. However the organizations which invested 2—5 hours per therapist/nurse reported the lowest likelihood of positive outcomes.
It is remarkable that every one of the 6-10 hour training responses reported a good result. However this category was a minority of the overall sample. The clear majority answer, 2-5 hours, under-performed the sample. Our conclusion suggest that the organizations who invested the extra time did so in a more effective fashion than the lower or higher category.
As with the management results, more is not always better. The highest level of training, 10+ hours, did not significantly out-perform the lowest level (77% vs 73%). The data does not offer a clear reason, but we suspect that the “overwhelming training” of 10+ hours lacked focus or timing needed to have the maximum impact on the staff.
A final observation from the data looks at the relationship between clinical staff training and the amount of extra workload that was experienced by the organization. 74% of therapists reported a meaningful increase in extra work and 49% of nurses reported the same.
With therapists we noted an unexpected inverse relationship between training and extra work load. Those organizations who reported lower levels of therapist training had a lower likelihood of experiencing additional work. However that favorable result was not far removed from the results experienced by the organizations who invested the most training. We believe that the nature of the IRFPAI changes had a greater effect on the amount of therapist extra work than did the amount of training provided those practitioners.
With nurses the result seemed a little different. While nurses experienced lower levels of extra work than therapists, training seemed to have a positive impact with the 6-10 hours of training experiencing a marked reduction of extra work compared to the lower or higher levels.
We believe that the distribution of impact was shifted toward the therapist community as opposed to the nursing community because of the natural workflow of completing the new QRP data elements. The data supports this conclusion given the overall difference in extra work impact.
Looking ahead to October 1, 2017, it appears that CMS has chosen to give IRFs a year of respite. The change load that we can expect (based upon the current proposed rule) is negligible compared to last year’s IRFPAI. However extending the vision to 2019, CMS will pick up the pace of change to at least the same level as 2017.
Given this one year reprieve, we believe that prudent IRFs will take advantage of the time to implement systems and workflows that can be leveraged to drive change and reduce the impact that is expected in 2019. Preparation over the course of a year will have less operational impact on organizations that a crunch-based plan implemented in a year. It will also allow for a more thoughtful set of changes to be planned and executed.