Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Many SNF Providers are asking how they will report on the upcoming Quality Measure Data for Functional Assessments. They are seeking guidance on questions like:
- “Who is in charge of collecting the information?”
- “Who should code this section of the MDS?”
- “How will we get the necessary documentation in the medical record during the appropriate time frames?
SSHarmony Healthcare International (HHI) is constantly reinforcing the importance of preparing and training all staff members on the definitions and coding requirements of Section GG. Although Section GG is incorporated into the MDS, it has unique parameters that differ from the traditional Section G process. From our years of onsite auditing and troubleshooting, we know that the best methods for success include these five steps:
Harmony Healthcare International (HHI) recommends performing immediate and ongoing training sessions for all licensed clinicians who will be able to assist in assessing, observing and documenting in the medical record. This training is imperative to ensure that GG coding accurately depicts the Admission, Discharge Functional Assessment and Goal Setting.
Best Strategies for Success:
- Appoint a designated Trainer that will provide constant training on the new scoring system and reporting of usual performance.
- Do not wait for the final implementation details! Start training immediately to familiarize staff with this foreign terminology and scoring system.
While many of the questions within Section GG appear to be clinically driven and geared to a licensed therapist, it is vital to develop an interdisciplinary team approach to properly depict the patient’s usual performance within the designated functional performance areas.
Best Strategies for Success:
- Designate Team Leaders that assist in monitoring the documentation required to support the MDS Coding 3 day look back period.
- Identify Clinicians who will be responsible for assessing and documenting the clinical summary of the patient’s performance as well as the patients’ current status and anticipated goals.
- Time Management
- Pre-Admission Screen: Review pre-admission screening information including hospital discharge and or transfer summary, hospital therapy documentation and referral discharge to understand the patient’s prior level of function in order to develop accurate functional goals.
- Admission Communication: Make certain effective communication of Medicare Part A beneficiaries are reporting to all disciplines to ensure timely completion of evaluations within first three days of the stay at the skilled nursing facility.
- Evaluation: Include portions of Section GG within Nursing, Physical Therapy and Occupational Therapy clinical assessment tools. Document functional status for GG items regardless of whether these areas are addressed in the therapy treatment plan and goals.
- Daily Encounter Notes: Establish a reporting format that addresses the item sets defined in Section GG and incorporate this information into the daily therapy notes.
- Post-Admission Meeting: Establish a 48-72 hour post-admission meeting, to be conducted with the patient and family. During this meeting, the team will clearly outline barriers to discharge and focus on the functional achievements required for a safe discharge home. The patient’s usual performance (based on Section GG terminology) is a beneficial topic at this time.
- Pre-Discharge Meeting: Establish a 48-72 hour pre-discharge meeting, to be conducted with the patient and family. During this meeting, the team will discuss educational needs, discharge services and equipment needs as applicable. Also, discuss the patient’s usual performance per assessment. Be mindful that the observation period is for the last 3 days.
- Restorative Nursing: Initiate referrals for Restorative Nursing on admission when skilled rehabilitation is not warranted. Report functional performance of bed mobility, transfers, eating, grooming, hygiene, ambulatory and wheelchair mobility on the initial restorative nursing assessment.
- Documentation Sources
- Physical Therapy Notes: Consider reporting functional performance of bed mobility, transfers, ambulation and wheel chair mobility regardless of whether these areas are addressed in the therapy treatment plan and goals. Document in the PT Evaluation, daily encounter notes and discharge summary.
- Occupational Therapy Notes: Consider reporting functional performance of eating, grooming, hygiene and transfers regardless of whether these areas are addressed in the therapy treatment plan and goals. Document in the OT Evaluation, daily encounter notes and discharge summary.
- Skilled Nursing Notes: Consider reporting functional performance of bed mobility, transfers, eating, grooming, hygiene, ambulatory and wheelchair mobility. Documentation from nursing admission assessment packet, daily skilled notes, and discharge summary.
- Review All Shift Note: Closely review all skilled nursing and therapy entries over multiple shifts within the 72-hour look back period. It is not uncommon to see a patient requiring more assistance post therapy sessions or late in evening when the patient is fatigued. Consider reviewing the number of episodes the patient requires functional assistance throughout the 24-hour shift reporting period to determine most usual performance status.
- Team Meeting Documentation: Consider developing a reporting tool that will capture the resident’s usual performance over the 3 day look back period to reflect interdisciplinary team collaboration along with patient and caregiver interview to determine resident goal status.
- Determine how to score the functional performance per the new defined rating tool within Section GG. Make certain clinical documentation supports the rationale of coding for Section GG of the 5-Day Admission, Discharge and End of Medicare Part A Stay Assessments.
- Be certain that all participants fully understand the definitions and intent of each element defined within the functional scale. In addition, this tool is applicable for the:
- 5-Day Admission Assessment
- Discharge Assessment
- End of Medicare Part A Stay Assessment
We hope you find these steps helpful. Remember, the goal of the process is to accurately depict the functional performance of the patient population within your CARE. If you have questions about MDS Section GG, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.
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