Episode 5: Nursing Home Strategy Part 1 – Strengthening Oversight
Today's 5th edition of the Beyond the Policy podcast focuses on the first of the Centers for Medicare & Medicaid Services’ 5-pronged strategy on strengthening oversight in nursing homes. This podcast features CMS Administrator Seema Verma, Dr. Kate Goodrich, CMS Chief Medical Officer and Director of our Center for Clinical Standards and Quality and Matt Hittle, Senior Advisor to the Administrator discussing agency efforts regarding nursing home oversight.
Male Speaker: Welcome to CMS Beyond the Policy episode five. Today's edition of CMS Beyond the Policy will focus on the first of the Centers for Medicare and Medicaid Services' five-pronged strategy on strengthening oversight in nursing homes. Check back soon for additional podcasts on this topic.
Matthew Hittle: Hi. My name is Matt Hittle, and I'm a senior adviser for Administrator Seema Verma here at the Centers for Medicare and Medicaid Services, or CMS. One of our roles here at CMS is to develop and enforce health and safety standards across the country for health care providers. One of our top priorities is ensuring safety and quality in America's nursing homes. Our goal is essentially to ensure a consistent minimum level of safety and quality across the entire system. Of course, providers are encouraged and incentivized to go above and beyond those federal standards and provide patients with the highest possible quality of care. As we conduct this work, we’ve developed a five-part strategy to guide us and we're going to discuss that today. I'm joined today by CMS officials to discuss it, and we’ve got of course, Administrator Seema Verma, as well as Dr. Kate Goodrich, who is CMS chief medical officer and director of our Center for Clinical Standards and Quality. Thanks for joining me today.
Kate Goodrich: Absolutely.
Seema Verma: Our pleasure.
Matthew Hittle: Now, would you like to kick it off administrative Verma.
Seema Verma: Sure. Well, we're excited to talk about our new approach to nursing home safety. This issue is a very important one. The president takes it very seriously, and that's why in his budget, his 2020 budget, he asked Congress to provide CMS with the authority to adjust the frequency of mandatory nursing home surveys and to actually put more resources into nursing home reviews. You know, from a high level, I think we can all sympathize with the plight of people being in nursing homes. It's a difficult time for families, where they're turning over care to somebody else. For the person in the nursing home, they're there because they can't take care of themselves. And it is so disheartening for me and the rest of the team when we hear about the stories of abuse and neglect. We've heard stories from people that are participating in hearings. I think there was Patricia Blank of Shell Rock, Iowa, whose mother in Virginia was allegedly left in severe pain, may not have had any water for several days, and eventually died in the nursing home. And we do hear those stories from time to time, and so from our standpoint, we want to make sure that we are doing everything we can to prevent abuse and neglect and from hearing stories like this.
And so, as you said, we have a five-part strategy to ensure that the care provided in America's nursing homes is of the highest possible quality. Our five parts to our strategy is strengthening oversight, and that's oversight of our state agencies. In fact, we work in partnership with state agencies across the nation and they're the ones that actually go out to the nursing homes and do surveys. And then enhancing enforcement. We want to make sure that we have the appropriate regulations and guidelines in place to make it very clear what type of standards a nursing home has to have in place. And then, increasing transparency. This is really about making sure that the public understands what's going on at these nursing homes, so if we do find something, I think it's very important that we share that information with the public. That's important to families. It's important to people that are selecting a nursing home. And people that have a loved one that's in a nursing home, they need to understand what's going on at the nursing home, and so we want to make sure that we're putting out as much information as possible. We also have a product called Nursing Home Compare website, where we actually have quality ratings and we're trying to work hard to improve that website, provide more information, and make sure that it's easy for people to use.
And then improving quality. I think that as we go on, we sort of -- as we look at nursing homes, we see areas where we know we need to make improvements. One is in the area of dementia care. And then at the last area, but certainly not least, is what we call putting patients over paperwork. And this is part of a larger initiative that the president asked us to work on. His initiative was called cutting the red tape, and it's really about getting rid of unnecessary burdensome regulations. And in the case of nursing homes and all providers, getting rid of regulations that get between providers and patients, we call ours putting patients over paperwork. And so, certainly, in the nursing home area, we want to make sure that we have appropriate regulations in place, but we're also reviewing those regulations to make sure that they're not actually creating unnecessary work that keeps providers away from providing high-quality care to their residents.
Matthew Hittle: That's interesting you say that Administrator Verma. Just recently we at CMS, as you know released a burden reduction rule focused on putting patients over paperwork, saving providers time and money and other resources they could put toward the residents instead of complying with burdensome government rules. Now Dr. Goodrich would you mind going into more detail about that first piece of our strategy, oversight?
Kate Goodrich: Absolutely. So, the first part of our nursing home strategy, as Admin. Verma described, is really strengthening our oversight of state survey agencies. And this is definitely one of the most important actions that we can take because it involves the boots on the ground, people who visit the nursing homes throughout the country each year. You know, state survey agencies are required to survey every nursing home in the country at least once per year. And so, this is a critically important function that we're very focused on to ensure that the survey agencies are detecting problems appropriately, but that they're also surveying those agencies in a standardized and uniform way, so that everybody knows what to expect.
Matthew Hittle: So, we've a really interesting kind of set of relationships here. Admin. Verma could you go into some detail about how we've interface with them?
Seema Verma: Sure. So, we have over 5,000 surveyors across the nation, but they're managed by state survey agencies, and they're the ones that are, as Kate said, boots on the ground, they're identifying serious issues. But what we have found is that some of these reviews are inconsistent and we're hearing about in some places in the nation one incident will occur that nursing home will be cited and that may not necessarily happen in another region. And so, one of the things that we really try to work on is consistency, making sure that we have the same quality standards and that the reviewers are applying those guidelines in the exact same way across the nation, so we can make sure that there's a consistent level of quality.
Matthew Hittle: That makes perfect sense. Kate could you go into some detail about some steps we've taken with these states or the agencies just to make sure that they're all -- that nursing homes are evaluated on kind of a level playing field.
Kate Goodrich: Absolutely. We've done quite a bit lately, in fact. So, first of all, we are revising our oversight of the State Survey Agency performance and really examining hard the ways in which surveyors identify issues, like abuse, facility staffing levels, and appropriate dementia care. So, we're really working hard on sort of a total overhaul of how we oversee the performance of the State Survey Agencies. We're also working to clarify expectations about when abuse must be reported to the state and law enforcement. What this means is setting very clear and assertive timelines for agencies to review any allegations of abuse and neglect. And state survey -- state surveyors actually, if a nursing home has not reported a clear incident of abuse or neglect, the surveyor must report that to law enforcement.
And in March, we issued updated streamlined guidance about how to determine a looming or existing patient safety risk, called immediate jeopardy. We knew that immediate jeopardy was not necessarily being applied consistently across regions, but we also recognized that the guidance that we were giving our state surveyors was maybe too complex. And so, we streamlined it, we simplified it, we made it very, very clear, so everybody can levy that citation appropriately in the same way. But these safety risks that are immediate jeopardy can cause serious harm. Patients must be protected from dangerously poor quality no matter where they live, so, it's important that we're very clear about that definition. So, going forward, when a State Survey Agency discovers a dangerous issue, they will have much clearer procedures on how to identify that for the public, report it to CMS, so that appropriate enforcement actions can take place.
So, this not only helps with increasing safety for residents, but it also helps to ensure fairness across the different nursing homes. And, you know, it's also so important that we constantly look for new ways to identify abuse and stop it immediately. So, we're currently exploring a number of ways to do exactly that. So, for example, we have a treasure trove of data here at CMS. So, we are mining those data to note large patterns and identifying workers within nursing homes with a previous history of abuse. We're also updating Nursing Home Compare, the website that Admin. Verma referenced, which is on medicare.gov. We want to make it easier for anybody who is looking for a nursing home to see specific issues of noncompliance related to abuse or neglect. That needs to be very easy for people to find.
You can also find out about any of the enforcement actions that CMS has taken against nursing homes on Nursing Home Compare. I highly recommend that our listeners take a look at that website and share with us any feedback, so that we can continue to improve.
Matthew Hittle: It sounds like Nursing Home Compare is really a robust and fulsome tool to help folks as they're considering nursing home care. But one other aspect here, you we're talking a lot about oversight, and I want to bring in another facet of the five part plan, and that's reducing burden on providers because no matter what we do there is going to be some effect on burden here. So, Admin. Verma, could you go into a little bit more detail about some of the things CMS is doing to reduce paperwork burden in nursing homes?
Seema Verma: Sure. So, one of the things that we're doing is trying to leverage innovation and technology to help us do a better job. And part of that is moving to a single computer-based survey process. So, that way everybody's using the same tool, and it allows us to analyze those results. It also offers us the opportunity to not only look at a specific nursing home, but it also allows us to look at the review of the state agencies that are using that tool, so it really allows us data on both realms in terms of not only the nursing home, but also how the state agency has reviewed that nursing home, and that way we have the ability to examine the data for outliers and determine when we may need to follow up with the state. If we see a particular state having, you know, citations in a particular area that seem out of the norm from other regions, then that gives us the ability to analyze that data and a follow up with them. So, by having it computerized it really gives us the ability to do those analytics.
Matthew Hittle: You referenced regions. My next question is focused on -- CMS is not just Baltimore. It's not just Washington, it's also several regions throughout the country. And those are boots on the ground folks as well. So, we have 10 regional offices here at CMS with thousands of people across the country. They've played a role in this, as I understand it. Administrator, can you talk a little more about how we've been collaborating with them?
Seema Verma: Sure. Our regional offices across the country play a very pivotal role in our efforts to strengthen oversight. They're the ones that are working directly with these state agencies, and they're working with providers, especially when there's serious quality issues, like abuse. And they're essentially our eyes and ears across America because we can deploy somebody from the regions immediately to a specific area when there's a problem. And so, we're always thinking about the best way to leverage these relationships, and how we can provide better feedback to state agencies. And we meet monthly with our regional offices and state officials to get great valuable input to improve the survey process. So, one of the things that we're looking at is how can the central Baltimore office work in a more coordinated fashion with these regional offices. And we're looking at ways of kind of restructuring that relationship as well. We're also -- we've already revised the federal oversight survey process for nursing homes, and that's where our regional offices reviewed the state survey agency performance. And so, we're going to continue to monitor those results and use them to continually make improvements, as well as to modernize our IT systems so that they're more user friendly and flexible.
Matthew Hittle: Well, it sounds like that relationship is kind of forward looking, much like the rest of the work that we're doing in this in this area. So, it sounds like we've already taken several steps kind of in the right direction.
Seema Verma: That's right. This is just a start. It's the beginning of an effort that's going to constantly evolve as we work with stakeholders, as we work with state agencies, and we work with the regions, and how we work with nursing homes. And we're also asking Congress to do its part as well. Currently, CMS is required by law to survey each of the 15,000 nursing homes in America annually, while other providers, like hospitals, are usually surveyed only once every three years. And we're actually thinking that it might be better to do a more frequent survey in some cases where there are quality issues. And there's -- you know, we want to have a little bit more flexibility because there could be providers that are doing a really good job, and we're not getting complaints surveys, so it's possible that those don't need to be done as frequently. And maybe directing our resources to those facilities where we are getting a lot of complaints and we do investigate every time we get a complaint. And we're seeing those numbers go higher and higher. And so, we want to make sure that A, we have the appropriate level of resources, but that we're able to target those resources more appropriately.
Kate Goodrich: And I think also, Admin. Verma, we've asked Congress for the authority to transition, like you said, to a risk-based survey model, but we've also asked Congress, through the president's budget in 2020, for more resources to be able to really focus more on these low performing nursing homes.
Matthew Hittle: As I understand it, complete surveys have increased something like 20 percent over the last several years, but yet our survey and certification budget, which goes to State Survey Agencies, has remained largely flat.
Kate Goodrich: That's right. That's right. We really would like to be able to deploy these resources in a smarter and more focused and targeted way.
Seema Verma: And that's exactly it. It's not just about having more resources but doing it in an appropriate way. We always try to be very conscious in how we use taxpayer dollars. And I think there is a better more efficient way that we can ensure that we have the highest level of quality in nursing homes across America.
Matthew Hittle: Well, it's been a really enlightening conversation. Thank you both so much for joining. Admin. Verma do you have any closing thoughts?
Seema Verma: Sure. You know, I think as we look at this, we've talked a lot about the operational changes that we're making, the policy changes that we're making, but at the end of the day this is about putting patients first. It's about ensuring that every person that goes to a nursing home can expect a high level of safety and quality, and that we are doing everything we can to prevent abuse in nursing homes.
Matthew Hittle: Thanks Administrator Verma, I couldn’t have said it better myself. As someone who has had a loved one in a nursing home, I can say that I am excited to see what changes come out of CMS to ensure safety and quality. I’m really excited that we are going to be able to touch a lot of lives in a positive way through this effort. Listeners, please join us again, we are going to continue these podcasts, we are going to eventually discuss all 5 pillars of our nursing home strategy, and the next will be enhancing enforcement. Thanks for joining us.
Male Speaker: You can subscribe to this podcast through iTunes or whatever podcast service you use. We'll be back soon with another edition of CMS Beyond the Policy. This podcast is produced by the U.S. Department of Health and Human Services at taxpayer expense and is posted on the CMS website.
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