CMS strives for accurate reimbursement.

STRIVE, the Staff Time and Resource Intensity Verification project, is a Centers for Medicare & Medicaid Services (CMS) study initiated in October 2005. STRIVE is the fourth national study of nursing home resource intensity CMS has conducted, and the first since the RUG III-based Prospective Payment System (PPS) went into effect. This study will recalibrate the RUG algorithm based on current medical and nursing home practices and the resident mix. RUGs will then change to better reflect the current nursing home environment. The original PPS was based on data collected in the former system. The enhanced system resulting from STRIVE will improve payment equity and support quality improvements in nursing home care.

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Nursing homes will need to have their software updated to support changes in the payment system. Moreover, CMS has expressed interest in improving the information technology (IT) used by nursing homes. To that end, CMS is collecting a set of clinical technology-related questions to be answered by participating nursing homes (see "The CMS IT Survey," p. 91). The National Association for the Support of Long Term Care (NASL) contributed to the development of the questions. The survey is designed to elicit information about nursing homes' actual use of clinical IT. If the use of IT to improve the quality of care or the efficiency of nursing homes is documented, more efforts to promote the use of clinical information systems could be seen.

Building on earlier research, CMS (at the time the Health Care Financing Administration, or HCFA) funded the development of the Multistate Nursing Home Case-Mix and Quality Demonstration in 1989. The project relied on three staff time-measurement studies (conducted in 1990, 1995, and 1997) to create a nursing home prospective payment. In those time studies, field researchers measured the number of minutes that nurses, nurse aides, therapists, and other staff spent caring for nursing home residents. Each case-mix group was assigned a weight that approximated the relative nursing/personal care resources needed to meet the resident's needs. The weights were used to compute the SNF PPS rates for each case-mix group.

A national time study has not been conducted since 1997, and CMS has not recalibrated the RUG-III case-mix weights since that time. Since the introduction of PPS, SNF utilization and practice patterns have changed, at least partially because of the introduction of Medicare and Medicaid RUG-III systems and the use of MDS data to monitor the quality of care furnished in nursing homes. STRIVE will reflect current care protocols and resource needs. It will also evaluate the effectiveness of new potential MDS data items and the RUG-III Grouper methodology used to classify residents into payment categories. In this way, CMS plans to recalibrate the RUG-III case-mix weights that help to determine rates paid to nursing homes.

The Iowa Foundation for Medical Care (IFMC) has designed and coordinated the study, which plans to collect data from approximately 240 nursing homes randomly selected from at least 15 states, with a target of 12,000 residents.

The STRIVE study is collecting data on the time staff members spend with each resident over a two- or seven-day period, using Pocket PCs carried by the clinical staff. Staff document both resident-specific time (time the staff spend with or on behalf of each resident) and non-resident-specific time (time the staff is doing other activities necessary for care but not for a specific resident). An MDS 2.0 assessment is completed near the time of the data collections.

Some additional assessment items are collected to improve the ability of RUGs to predict the resource use of residents and their care. Also, data relating to culture change activities are being collected. Data collection is minimally invasive, and data security exceeds HIPAA and Privacy Act requirements.

The STRIVE study started collecting data in April and expects to have data collection completed by spring or summer 2007. The data will be analyzed by CMS and used to frame policy and legislative proposals.

David M. Oatway, RN, MPH, is a subcontractor to IFMC and is the database manager for the STRIVE study, supplying the hardware, software, and data processing for the STRIVE data collection. He is president of CareTrack Systems, LLC. For further information on STRIVE, visit www.ifmc.org. To send your comments to the author and editors, e-mail [e-mail].

Resources

www.cms.hhs.gov/SNFPPS/10_TimeStudy.asp

https://www.qtso.com/strive.html

BY DAVID M. OATWAY, RN, MPH

RELATED ARTICLE: The CMS IT Survey

Participating nursing homes are receiving this survey:

"The Centers for Medicare & Medicaid Services (CMS) is interested in the impact of clinical information systems on resident care. Please answer the following questions regarding your facility's use of information technology for clinical purposes. Your answers will be used for analytical purposes only."

 1. Does your nursing home use information technology            Yes  No
    (computers) for clinical purposes beyond entering the MDS?

If your answer to 1 is Yes, please answer the following questions about
the extent of your use:

                                                                 Yes  No

 2. Does your facility have an all-electronic record?
 3. Do your clinicians use electronic assessments?
    a. Are your assessments predefined by your vendor?
    b. Do you define your own assessments?
 4. Do answers from your assessments flow to the MDS and other
    assessments?
 5. Does your computer present a draft care plan from the
    assessments?
    a. Do changes in resident condition cause updates to the
       care plans?
 6. Do you enter physician orders into the computer?
    a. Does the computer generate medication and treatment
       sheets?
 7. Does the computer detect drug, food, and allergy
    contraindications?
 8. Does the computer generate staff daily assignments?
 9. Are results of care captured at the bedside or other point
    of care?
10. Is staff alerted to possible issues from care
    documentation?
11. Do nursing assistants document their care on a computer
    when they give the care (at the point of care)?
12. Are incidents, accidents, and infections documented in the
    computer?
13. Are nursing notes and other clinical documentation in the
    computer?
14. Is medication administration recorded in the computer at
    the time it is given?
15. Are treatments recorded in the computer at the time they
    are given?
16. Does the computer alert nurses to possible issues when care
    is documented?
17. Do therapists record their care in a computer as it is
    being given?
18. Does the computer help therapists develop and update plans
    of treatment?
19. Does the computer alert therapists to CCI edits as a result
    of therapy?
20. Does your computer system use an electronic signature and
    security that makes the records acceptable for legal and
    billing purposes?