There is opportunity to increase the Case Mix Index through management of Assessment Reference Dates. There is opportunity to manage future Assessment Reference Dates, in order to capture services that are provided throughout the quarter.
The MDS Coordinator should be vigilant in observing when patients develop skin ulcers. The presence of two or more skin ulcers of any stage, or one skin ulcer that is stage III or IV, will yield the Special Care category.
Another event to be watchful of that effects your Case Mix Index is a respiratory infection. A respiratory infection, either bronchitis or pneumonia, may include fever as a symptom. It is important to capture fever in conjunction with other symptoms, as was outlined above. Respiratory infection symptoms are often treated with nebulizer treatments. It is essential to place documentation in the treatment book that outlines the respiratory assessments that must be preformed in conjunction with giving a nebulizer treatment. Seven days and at least 105 minutes weekly of respiratory therapy by a licensed nurse will also yield the Special Care group.
The provision of Extensive Services will also increase overall Case Mix. The MDS Coordinator should be alert for the provision of IV fluids or IV medications. Coding these services, in addition to capturing the Special Care and Clinically complex groups, will yield the SE2 or SE3 groups.
A final area in which the facility could improve its overall Case Mix Index is in the capture of Mood Indicators on the daily CNA flow sheets. Mood Indicators are often not captured in documentation, because they are the "normal" for the patient. However, the RAI Users Manual instructs the assessor to "record the frequency of indicators observed in the last 30 days, irrespective of the assumed cause of the indicator (behavior)." (RAI Users Manual, page 3-61). Capture of these Mood Indicators could potentially increase the patients RUG score from a CC1 to a CC2. This represents a healthy increase in Case Mix of 0.163.
Case Mix Index needs to be managed proactively. It is crucial that the MDS Coordinator receives a copy of the Case Mix Index Rate Letter as soon as it is received by the Billing Office. The rate that is enclosed should be tracked and the HRH team should note any upward or downward trends in the Case Mix Index. However, it should be noted that the Case Mix Rate Letter comes to the facility after the Case Mix Index has gone in effect. Therefore, management of the rate in reaction to the letter is not adequate for proactive management.
A current Case Mix score is likely produced with each state submission. This calculation is useful, but again may not give a true picture of the expected Case Mix for the upcoming quarter. Harmony would suggest that the Case Mix be proactively managed by calculating it one month before the Case Mix rate quarter ends. This calculation can be done by the MDS Coordinator (or other designee) within the Hi-Tech System. This will give an accurate account of which residents have optimal Case Mix score and which should be on special alert for any additional assessments that can be done to enhance the current Case Mix rate.
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