The objective of nursing restorative care (NRC) programs in nursing homes (NHs) is to engage residents in structured activities that maintain or improve functional abilities (Gingerich, 2006; Resnick, Galik, & Boltz, 2013). The NRC philosophy encourages a transition from caregivers doing for older adults to caregivers providing supportive assistance to older adults (Resnick et al., 2013). Although this philosophy can be integrated into nursing care practice in any setting, it has been most formally addressed within NH settings in response to the Omnibus Budget Reconciliation Act of 1987, which mandated that residents receive nursing care to attain and maintain their highest level of function (Resnick et al., 2013).
In the United States, the Centers for Medicare & Medicaid Services (CMS) determines the components and defines the parameters of participation for NRC programs in NHs. These parameters include the type, duration, frequency, and documentation of the provided NRC and determine a resident's case-mix classification for reimbursement purposes using the Resource Utilization Group IV (RUG IV) for Medicare and Medicaid reimbursement (CMS, 2017). Currently, two or more of the following types of NRC must be provided ≥6 days per week for a minimum of 15 minutes each for the NH to receive reimbursement within a NRC RUG IV classification (CMS, 2017; Minnesota Department of Health, 2015): range of motion (passive), range of motion (active), splint or brace assistance, bed mobility, transfer, walking, dressing/grooming, eating, amputation/prosthesis care, communication, bladder toileting, and bowel toileting programs.
NH providers must meet the RUG IV requirements, as monitored by State agencies, to receive the additional reimbursement allocated to the NRC RUG IV groupings. If during a State-administered case-mix audit it is determined that the required documentation of type, duration, frequency, and evaluation of goals is not present, reimbursement for NRC may be denied to NH providers. There is evidence that NRC programs have some positive effects on resident function (Resnick et al., 2013). The ability to achieve reimbursement for NRC activities may encourage NH providers to participate in NRC programs, thus promoting functional abilities of older adults. Conversely, the prescriptive structure of NRC requirements for reimbursement may discourage the type of individualization necessary to achieve person-centered goals and care.
The objective of the current study was to investigate the perspectives of NH providers regarding the requirements to achieve reimbursement for NRC services and propose recommendations to State agencies to assist NH providers to conduct NRC programs that are person-centered and able to achieve full reimbursement for NRC services.
There is evidence of a downward trend in the use of NRC in recent years, which may be related to an upward trend in the use of reimbursable licensed therapies within U.S. NHs (Jung, Trivedi, Grabowski, & Mor, 2016; Temkin-Greener, Lee, Caprio, & Cai, 2019). Factors influencing resident participation in NRC programs may include physical factors (e.g., strength, gait, balance, contractures) and cognitive and psychological factors (e.g., cognitive impairment, low self-efficacy, poor outcome expectation) (Resnick, 1998, 2000, 2001; Sabol et al., 2011). Refusal of residents to participate and lack of motivation are also barriers in providing NRC (Resnick et al., 2006). System-level barriers include lack of comprehensive evaluation of residents' underlying ability, difficulty building NRC into daily tasks/activities, poor cooperation and consistency between care providers, and low administrative support of NRC (Resnick et al., 2008). System-related facilitators in implementing NRC include sufficient supplies (e.g., gait belts), consistent assignment of nursing assistants, and encouraging teamwork (Resnick et al., 2006).
NRC has been found to improve or maintain resident function in the areas of dressing (Engelman, Mathews, & Altus, 2002), walking (Bonanni et al., 2009), eating (Coyne & Hoskins, 1997), grooming (Lim, 2003), mobility and balance (Engelman et al., 2002; Morris et al., 1999; Resnick, Gruber-Baldini, Zimmerman, et al., 2009; Shanti et al., 2005), and overall performance of activities of daily living (ADL) (Bonanni et al., 2009; Kerse et al., 2008; Morris et al., 1999; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2009; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011; Shanti et al., 2005). Several studies indicated a positive relationship between NRC and psychosocial outcomes, such as decreased depressive symptoms (Galik et al., 2008), decreased agitated behaviors (Galik et al., 2008; Rogers et al., 1999), personal goal attainment (Mezey et al., 2000; Peri et al., 2007; Tappen, 1994), improved quality of life (Peri et al., 2007), and improved interaction with caregivers (Mezey et al., 2000). However, participation in NRC was not found to influence the number of falls (Bonanni et al., 2009) or emergency department visits (Gruber-Baldini, Resnick, Hebel, Galik, & Zimmerman, 2011).
It is important to note that the studies examining outcomes associated with NRC tended to address a single NRC component, and there was variability among studies regarding the type, duration, and frequency of NRC provided. Only one identified study evaluated the overall effectiveness of NRC programs as defined by the RUG IV case-mix classification system. In a longitudinal study comparing the rate of decline in ADLs between residents who were categorized in a NRC RUG IV grouping and not categorized in NRC RUG IV grouping, there was no difference between groups in their rate of ADL decline. This finding suggests that NRC programs, as defined through the RUG IV case-mix groups, may not have their intended effect (Talley et al., 2015). However, no research evidence was identified to support the intensity and frequency of NRC as stipulated in the RUG IV case-mix classification system, or for the types of NRC programs that can be considered for reimbursement.
Data for the current mixed-methods study came from a survey of Minnesota NH providers and a subsequent stakeholder focus group discussion. Data were collected in 2017 and approval was obtained from the University of Minnesota Institutional Review Board prior to data collection.
Survey of NH Providers
An online survey was developed to gather information from NH providers in Minnesota regarding perceptions, attitudes, and self-reported use of NRC programs. Survey development was informed by preliminary, information-gathering interviews conducted by the research team with representatives from the two NH provider organizations in Minnesota (i.e., Leading Age Minnesota and Care Providers), as well as national leaders in NH care quality. Survey constructs included use of NRC, perceptions of NRC requirements, perceptions of the case-mix auditing process, and thoughts on how the NRC system could be improved to better meet resident and NH needs. Each survey culminated with an opportunity to provide open-ended comments regarding the NRC case-mix process.
The Minnesota Department of Human Services provided the e-mail addresses for the administrators of the 368 Minnesota nursing facilities and an e-mail list of 314 individuals employed in Minnesota nursing facilities who held titles such as Director of Nursing (DON) or Quality Assurance Director. The two lists were cross-checked, and duplicates were deleted, resulting in a final list of 516 individuals who were sent an e-mail with a link to complete the survey. Respondents were informed of their right to refuse participation and that their responses would only be shared in aggregate form.
Stakeholder Focus Group
Following analysis of the survey results, a stakeholder group was convened to propose recommendations to support NRC as a reimbursable service/care intervention. Survey results were presented to attendees prior to the discussion. The group comprised individuals from the provider organizations in Minnesota, NH administration, and representatives from the Minnesota Department of Health and Department of Human Services, including case-mix reviewers. The 15 participants were selected by the provider organizations and the State and included individuals in leadership positions such as executive director and quality assurance director for health care organizations, as well as State program directors and staff members.
Survey of NH Providers
One-hundred thirty-two respondents completed all or most of the questions on the survey and were included in the data analysis. These 132 respondents were from 119 unique facilities. Thirteen facilities had more than one respondent. The facility response rate was 32% (119 of 368 facilities), the individual response rate was 26% (132 of 516 unique individuals). Of 132 respondents, 23% were administrators, 33% were DONs, and 24% were Minimum Dataset (MDS) coordinators/nurses. Twenty percent indicated other titles/positions such as nurse manager, rehabilitation coordinator, and RN. Respondents had extensive experience in long-term care and significant tenure in their current facility, with an average of 9 years in their current position. The primary payer source for the facilities represented by the respondents was Medicaid. Table 1 displays respondent characteristics.
Characteristics of Survey Respondents (N = 132)
Use of Nursing Restorative Care
Approximately all (96%) respondents reported their facilities provided NRC to residents and more than one half (61%) indicated they had formal NRC programs in place. However, only 45% of respondents reported seeking reimbursement for NRC through the RUG IV case-mix classification system. The majority of respondents (84%) noted that their facility provided some NRC without documenting the program on the MDS or seeking reimbursement through the case-mix process. Among those who performed NRC, the most frequent types of care programs were walking (98%) and active/passive range of motion (94%). The least frequent types were communication (36%) and amputation/prosthesis care (32%).
Perceptions of Nursing Restorative Care Requirements
Approximately all respondents agreed that NRC contributed to the quality of life for participating residents (99%) and prevented functional decline (98%). When asked about the primary motivation to begin a resident in a NRC program, the most frequent reasons given were discontinuation of a licensed therapy program (77%) and desire to prevent or delay functional decline (73%). Providers reported that the greatest challenge in meeting the case-mix requirements for NRC was providing the documentation to support duration and frequency requirements (80%). Other challenges included meeting the intensity of requirement of 6 days per week (73%), providing documentation that the NRC is preventing decline (63%), specifying measurable goals for each resident's NRC components (63%), nursing assistant turnover (62%), and having enough staff to carry out the NRC program (60%).
Perceptions of Case-Mix Auditing Process
Most providers (>80%) agreed that the NRC documentation requirements were too complex, the intensity requirements for reimbursement were too complex and/or not realistic, and the requirements for NRC reimbursement were not clearly communicated. Approximately one half (53%) believed their staff had a clear understanding of the reimbursement requirements. For each type of NRC program (e.g., walking, toileting), more than one half of providers indicated that it was challenging to perform the reimbursement requirements for NRC in that area of care. One half (49%) believed that the case-mix reviewers' understanding of what was needed for NRC documentation was similar to the understanding of NH staff.
Open-Ended Comments on How to Improve the Nursing Restorative Care Process
The survey concluded with the open-ended question: What recommendations do you have to improve Minnesota's case-mix auditing process for nursing restorative care? There were 103 comments received from the NH provider survey sample (N = 132). Research team members each read and reviewed the comments, one team member identified emergent themes, and all team members met and discussed the final thematic categories.
The most frequently identified theme among the provider comments was that NRC was being provided, but not coded on the MDS due to the difficulty of meeting documentation requirements for reimbursement. Respondents noted the importance of NRC programs for residents and expressed frustration when they were not able to achieve reimbursement for a care service that they believed had been adequately provided. A frequently noted and related theme was a perception that documentation requirements are not clearly communicated by case-mix reviewers to providers. In addition to concerns regarding clarity of documentation requirements, providers expressed concern regarding the clarity of NRC program intensity requirements. Providers commented that the intensity and necessity of the NRC program requirements (i.e., 6 days per week, two types of NRC, 15 minutes per session) were often more intense than is realistic, necessary, and useful for many residents' well-being.
Stakeholder Focus Group
Based on the survey findings, the convened stakeholder group completed a root-cause analysis exercise centered on the question: Where does the process to achieve reimbursement for NRC go wrong?
Two root causes emerged from the day-long extended focus group discussion. First, the NRC program is focused on process (i.e., frequency and duration of care) and not resident-specific outcomes. Participants noted that the case-mix review focused entirely on meeting the frequency and duration requirements for NRC as well as the requirements for specifying goals, documentation, oversight by RNs, and training of nursing staff. The review did not focus on whether residents maintained or improved functional status through NRC, regardless of meeting the multiple and rigid requirements for a NRC program. The focus on the processes for NRC was used to deny reimbursement of NRC. It was believed that this focus creates a risk for denial of reimbursement for NRC because the NRC requirements are multiple, rigid, and, at times, unrealistic. The rigidity of requirements also reduces the likelihood that some residents who cannot tolerate the intensity requirements, but would potentially benefit from NRC activities, will not be included in the program.
The second root cause was associated with the first, in that the knowledge and training staff need to ensure they are meeting all requirements of NRC is time consuming and costly due to staff turnover rates in NHs. Given competing demands for staff time, particularly when low staffing levels pull staff away from NRC and to direct care, the complexity discourages development of a formal NRC program due to risk of not being able to meet the required duration/frequency of NRC each day.
There was extensive discussion that providers have a strong desire to provide NRC services to residents, and examples were shared of successfully achieving positive resident outcomes in increasing or maintaining functional ability and/or mobility. These outcomes were often achieved without adhering to the NRC frequency and intensity requirements. This discussion continued to underscore the perceived lack of evidence for the intensity and frequency requirements for NRC, as well as the advantage of focusing on outcomes versus process. Stakeholders were asked to use the results of the root-cause analysis exercise to generate and propose recommendations that would support NRC as a reimbursable service/care intervention. Each member of the group proposed a recommendation that they believed would address one or more aspects of the root causes of the problem and then the full group reviewed each and anonymously rated the enthusiasm for the recommendation. After this exercise, three themes of recommendations emerged:
Base reimbursement for NRC on outcomes (maintenance or improvement of functional status) rather than the process of meeting all NRC program requirements. For example, if a goal for a resident related to training and skill practice for walking is not written in a specified format, case-mix reimbursement could be denied, even if the resident has shown improvement or not declined in his/her ability to walk.
Reconsider the frequency and intensity requirements for NRC components.
Increase availability of NRC training/education and resources for providers and case-mix reviewers. Additional training opportunities and resources could be developed and provided by State departments that focus on quality of care and reimbursement for NHs, provider organizations, and organizations that provide consulting services to NH providers.
The current findings demonstrate that NH providers perceive value to residents from the provision of NRC. Findings also demonstrate that providers do not associate these benefits with the stringent RUG IV reimbursement requirements, and often provide NRC that is individualized, based on resident goals and activity tolerance, as well as realistic given competing demands on staff, even when doing so means forgoing reimbursement for NRC services. To the best of the current authors' knowledge, there is no substantiated evidence that the current 12 NRC components (e.g., passive range of motion, splint training) and the associated frequency (6 days per week) and intensity (15 minutes per day) result in the desired outcomes. There are situations where a resident may not be able to or want to participate in NRC (e.g., influenza, chose to attend an activity) and the result could be that the NRC case-mix group is denied during an audit. Requirements for reimbursement could potentially be modified based on the individual needs of the resident. Research addressing the type and dose of NRC and its impact on preventing functional and mobility decline or maintaining function/mobility may result in a more individualized, person-centered, resource-efficient, and effective NRC approach.
Another common theme in the findings is the desire of NH providers for evaluation (and reimbursement) based on outcomes, not processes, in regard to NRC programs. To transition from a process to outcomes approach for NRC, the focus of a NRC program needs to identify the resident's baseline assessment (what the resident cannot do), what the resident wants to do (the individual goal), and if the resident achieves that goal. Periodic evaluation of the progress toward the resident's individual goal and documentation of that progress, as well as adjustments made to the individual goal and the NRC intervention(s), would be necessary to substantiate reimbursement for NRC. A focus on outcomes will require case-mix reviewers to pay less attention to the finer requirements for NRC and look for evidence that the NRC interventions are improving or maintaining the resident's function and/or mobility, and ultimately avoiding decline in the resident's functional status.
Outcomes for NRC could also be addressed through the Minnesota Quality Indicators (QIs). There are QIs specific to improvement or decline in functional status and mobility. The MDS items that are part of these QIs could be used as evidence of the effectiveness of NRC for individual residents. The QIs could be built into a NRC program and the case-mix audit process. For example, one Minnesota QI is Walking as Well or Better than at Previous Assessment, and the QI result is based on the mobility item in Section G0110 of the MDS—walking in room or corridor—and the resident's functioning at Time 1 and Time 2.
Increasing the emphasis on outcomes, versus processes, may allow nurses more flexibility to provide individualized care based on their nursing assessment and evaluation of progress.
There are limitations to the current research and the subsequent recommendations. First, this small sample study took place in one U.S. state. Examination of this problem using larger, more geographically diverse samples would benefit policymakers in this area. In addition, focusing on outcomes for NRC reimbursement poses the risk of facilities “cherry-picking” residents for NRC who will likely succeed and lessening the chance that the least functionally able residents will be part of a NRC program. It is also difficult to measure a lack of decline and that may be the best outcome for some residents, although using the MDS items related to functional status and mobility provides a consistent approach for monitoring decline, maintenance, and improvement. Another issue is that making program requirements more fluid and individualized presents difficulties for case-mix reviewers, who must evaluate program compliance systematically and with limited resources.
Further research and discussion with NH providers and policymakers are needed to expand the person-centeredness of the current NRC program as defined by the RUG IV case-mix classification criteria and to encourage NH providers to participate in NRC processes.
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Characteristics of Survey Respondents (N = 132)
| Administrator||30 (23)|
| Director of nursing||44 (33)|
| Minimum Dataset coordinator/nurse||32 (24)|
| Other||26 (20)|
|Mean (SD) (Range)|
|Years in facility (n = 128)||9 (9) (0 to 40)|
|Years in current position (n = 128)||9 (6) (0 to 32)|
|Years in long-term care||22 (11) (1 to 49)|