Category Archives: Industry Insights/Hot Topics



The Heart of Health Care: The Many Roles of Nursing Leaders in Post-Acute Care

In today’s vastly changing health care environment, the role of nursing leadership is one thing that remains consistent. It is and always will be the heart of health care.

My role as an operational leader was to set the strategic direction of the organization while working side-by-side with my nursing leader. I found organizational success unattainable without the contributions of my nursing leader and her team.

Nursing leaders focus on setting standards, setting policy, dealing with compliance, and overseeing quality measures and clinical outcomes. They spearhead innovation and transformation within their teams and the organization as a whole.

As I reflect on my career, and the dynamic nurse leaders that I have had the opportunity to work with, I note the following are the cornerstones of successful nursing leaders:


Nursing leaders provide direction for their department while holding staff accountable. Nursing leaders oversee many responsibilities, including:

  • resident care delivery
  • customer and staff satisfaction
  • clinical processes
  • compliance
  • financial outcomes


Nursing leaders continually expand their knowledge and understanding of industry changes. Their main goal is caring for our residents. Staying on top of the changes that affect the organization can challenge nursing leaders. It is important that nursing leaders continue accessing education, tools and outside resources. Education provides a level of support for their organizations’ priorities, as well as expected outcomes.

Translating the information and knowledge into organizational best practice is another responsibility. Aligning industry changes with facility and department goals helps to relieve some of the pressure felt by nursing leaders. Implementing best practices allow nursing leaders to focus on targeted, high-level priorities and clinical processes for successful outcomes.

Align Talent and Clinical Success

Nursing leaders continue to work with their team at all levels. They identify the knowledge, skills and abilities of their team. Then, they align those talents with the clinical priorities of their organization. This allows for ongoing mentorship and development of future nursing leaders. Successful nursing leaders help build upon their success by surrounding themselves with an amazing team. Team building is essential to leading a diverse group of people with distinct personalities and skills. Fostering an environment of collaboration and professional growth is a key strategy for successful nursing leaders.

Motivate and Innovate

Given all the changes faced by nursing leaders, they possess a unique ability to motivate staff, especially in times of challenge. They know when to talk and when to listen. They are often confident and optimistic while inspiring enthusiasm in those around them. Today’s nursing leaders also spark and support innovation, knowing change is necessary to succeed in the new health care environment.


Being a leader is an amazing journey. It continues to provide opportunities for innovation, as well as personal and professional growth. Working next to dynamic nursing leaders in post-acute care is an honor and a privilege. Thank you for being at the center of our organizations, and for being the heart of health care.


Happy Valentine’s Day!


Lisa Thomson

Chief Strategy and Marketing Officer


Contact Pathway Health for more information on how we can expand the education and expertise of your long term care staff.


Wisconsin Director of Nursing Council Symposium 2019

Pathway Health representatives will attend the 25th Symposium at the Grand Geneva Resort for the annual WI Director of Nursing Council in Lake Geneva, WI. The event’s theme is Get Your Game On, a call-to-action for attendees and presenters alike as they congregate for the latest insights in nursing. Pathway Health leaders will be involved in discussions focused on:

  • CMS/Survey Preparedness,
  • Phase 3 Readiness,
  • Patient-Driven Payment Models and more!

Visit our industry specialists at booth #219 from February 25-27 and stay apprised of our progress on social media. Don’t wait for the Symposium! We have online educational programs available now.


A Case Study for Quality Outcomes with LeadingAge KS

Don’t miss the webinar presented by Pathway Health’s Leah Killian-Smith on culturally competent actions and procedures within nursing facilities.

The event, titled “QAPI– A Case Study for Quality Outcomes,” is part of a series hosted by LeadingAge Kansas that breaks down new regulations in order to prepare nursing facilities for changes that go into effect November 28, 2019.

Tune in on February 19 from 2:00-3:00 p.m., and gain the following insight:

  • Build upon lessons from earlier event titled, “5 Elements of QAPI Interactive Workshop,” presented in January 2019
  • Perform a root cause analysis of your existing procedures in quality assurance and performance standards
  • Identify an area of deficient practice and work through systems review and improvement.

Register for the event here.



Register now! Fireside Training Courses in February

Pathway Health offers multiple opportunities to bolster your professional education in the new year. Register now for guaranteed access to one of our Fireside Training classes.


By striving to improve yourself and your colleagues, your facility grows the quality of its care and the effectiveness of its staff. Explore the multiple options for furthering your education with Pathway Health on our Education page for more insight, expertise, and knowledge.


What Do You Really Need to Do Now to Prepare for PDPM?

When the Medicare payment model changes for nursing homes on October 1, 2019, the drivers of reimbursement will be dramatically changed. Under the current payment model, the amount of therapy provided to the resident in a seven-day period is the major determinant of the amount of daily payment the nursing home will receive from Medicare. Additionally, the resident’s level of dependence in activities of daily living (ADL) impacts the final payment category and amount. The higher the level of ADL dependence, the higher the payment rate. The nursing assistant staff documents the supporting charting of each resident’s ADL dependence level.

The new payment model, Patient-Driven Payment Model (PDPM), uses the resident’s clinical conditions as the main determinant of payment. The resident’s ADL dependence score is derived from an area of the Minimum Data Set (MDS) that is assessed and documented by the professional staff. There is no impact on the payment rate from the amount of therapy services provided. Payment is higher in the Physical Therapy (PT) and Occupational Therapy (OT) components of PDPM for residents who require some ADL help but are not totally dependent. These residents are more likely to be able to participate in and benefit from therapy services.

The PDPM system is comprised of six components:

  1. Non-Case-Mix Base Rate
  2. Physical Therapy
  3. Occupational Therapy
  4. Speech therapy
  5. Skilled Nursing
  6. Non-therapy Ancillary

Each component is scored separately and has federally established rates for each Case-Mix category in the component. The Case-Mix rates for each component are summed to establish the overall daily payment rate for the resident’s skilled stay under Medicare Part A.

There will be no transition period to PDPM. On September 30, 2019, Medicare payment will be from the RUG-IV classification system. On October 1, 2019, Medicare payment will be determined by a new MDS that established the PDPM payment rate. Because there will be no transition, nursing facilities need to perfect their systems that impact PDPM now.

The triad of systems, or M-I-P, that support PDPM are highlighted below:

  • MDS coding accuracy, especially in Section GG, functional performance and Section I, diagnoses
  • ICD-10 diagnosis coding accuracy and management
  • Pre-bill claim check review

MDS Coding – 

Section GG of the MDS was added in October 2017. Confusion remains about the best process for obtaining an accurate assessment of the resident’s USUAL performance in the first three days and last three days of their Medicare stay. The most effective approach is to have the nursing and therapy staff collaborate on coding Section GG. If the resident only performs the activity in therapy, that is the resident’s usual performance. If the resident performs the activity multiple times per day with nursing staff and only once with therapy, the resident’s performance with nursing staff best represents their usual performance.

ICD-10 Diagnosis Coding – 

Section I of the MDS is dependent upon accurate ICD-10 diagnosis coding and management so that the MDS and the Medicare claim contain the same information in the same order. There are few resources for staff education for ICD-10 coding for nursing homes. Most nursing facilities do not have a professionally certified medical coder on staff. Ensure that the staff responsible for coding understands the Official Coding Guidelines as published by the CMS and NCHS.

Download here.


Most clinical software used in nursing homes automatically enters the diagnosis codes onto the bill. There must be processes in place to ensure that the admitting and primary diagnoses are entered in the correct location on the bill and the coded conditions entered on the bill provide the clinical “story” that supports the amount being billed.

Pre-bill Claim Review – 

Pre-bill Claim Review involves an interdisciplinary team process that starts with the draft bill or claim and validates the information on the bill as well as the supporting documentation in the resident’s medical record. When this process is conducted effectively, the facility submits a “clean claim” that is a much lower risk for audit or medical review, thus is paid quickly and accurately.

PDPM Solutions to Start Preparing Now

Pathway Health PDPM experts can assess your facility’s M-I-P systems and provide a detailed action plan for enhancing or improving these processes. Our PDPM consulting services and tools can support your busy leaders and staff to effect a smooth transition to the PDPM system. Pathway Health also offers expert PDPM training – classroom, onsite and web-based. Contact us to learn more.

 PDPM Solutions

New! Complimentary PDPM Resource

Non-Therapy Ancillary Condition/Extensive Services Tool – PDPM – DOWNLOADABLE

The Non-Therapy Ancillary (NTA) component of PDPM presents an opportunity to capture reimbursement for resident comorbidities and special treatments. This one-page tool is a quick reference to those items that qualify in the NTA component of PDPM. Download now>


Karolee Alexander,
Director of Reimbursement and Clinical Consulting,
Pathway Health


Fighting the Flu is Nothing to Sneeze At!

The influenza season is hitting hard across the U.S.

In fact, the Weekly Influenza Surveillance Report indicates that influenza-like illness (ILI) shows an elevated activity of Influenza A (H1N1)pdm09, Influenza A (H3N2), and Influenza B viruses as they continue to co-circulate. (Source: CDC)

Check out the ILI activity as listed on the CDC Weekly U.S. Influenza Surveillance Report for the week ending January 5, 2019.

Vital indicators include:

  • Viral Surveillance: Influenza A(H1N1)pdm09 viruses have predominated in most areas of the country.However, Influenza A(H3) viruses have predominated in the southeastern United States (HHS Region 4).
  • Geographic Spread of Influenza: The geographic spread of influenza in 30 states was reported as widespread; Puerto Rico and 17 states reported regional activity; two states reported local activity; the District of Columbia, the U.S. Virgin Islands and one state reported sporadic activity; Guam did not report.
  • Influenza-associated Hospitalizations: A cumulative rate of 9.1 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported. The highest hospitalization rate is among adults 65 years and older (22.9 hospitalizations per 100,000 population).

Did you know?

  • 1 to 3 million serious infections occur every year in SNFs.[1]
  • Infections include urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others.[1]
  • Infections are a major cause of hospitalization and death; as many as 380,000 people die of these infections each year.[1]

Leadership Considerations:

Having a well-written and effective infection prevention and control plan is key to success. Preventing influenza and treating it promptly may reduce the risk of influenza-associated complications, including hospitalization and death.

It is estimated that 90 percent of seasonal influenza-related deaths and more than 60 percent of seasonal influenza-related hospitalizations in the United States each year occur in people 65 years and older.[2] Hospitalizations also are often sentinel events in this population group, precipitating disability and potentially resulting in loss of the ability to live independently.

Preventing transmission of influenza viruses and other infectious agents requires a multi-faceted approach that includes developing a system with policies and procedures for the following:

  1. Vaccination
  2. Testing
  3. Infection Control
  4. Antiviral Treatment
  5. Antiviral Chemoprophylaxis

Preventing influenza and treating it promptly may reduce the risk of influenza-associated complications, including hospitalization and death. Consider the following:

  • Policies: ensure staff members are performing appropriate hand hygiene and that appropriate infection control measures are being utilized facility-wide.
  • Procedures: prepare the staff for what to do in case of an outbreak and what steps can be taken to minimize the number of Influenza cases as the season moves forward.
  • Resources: Pathway Health has many resources to assist related to infection control and outbreak management, as well as online resources through the

For more information on preventing seasonal influenza and the 2018-2019 influenza Season, check out the CDC Resources available to health care organizations.



Need assistance with infection control processes, systems and training? Pathway Health’s team of experts and trainers are ready to assist. Contact us today.

Susan Lagrange

Director of Education

Pathway Health


Home Care and Hospice Month: Honoring Health Care Professionals

November is recognized as Home Care and Hospice Month. At Pathway Health we pause to honor the millions of nurses, home care aides, therapists and social workers who make a remarkable difference for the patients and families they serve.

Gain more insight on home care and hospice facts and statistics:

For more information, contact the experts at Pathway Health.


Announcing New INTERACT Training Option

Provide INTERACT Certified Champion training, anytime, anywhere!
Now available through The Learning Pathway, this on-demand course provides an in-depth description of the INTERACT™ QIP strategies, care processes, tools, and other resources to improve care of changes in condition and prevent hospital transfers when safe and feasible; and shares key lessons learned on successful Program implementation and sustaining the Program over time.
$499* until 11/30/18
(Regularly $629)
*Discount only available for online learning through The Learning Pathway.
10 CE credits have been applied for and are pending approval.

The Learning Pathway, powered by Pathway Health, provides a clear path to excellence in learning for your team 24/7.


SNF QRP Non-Compliance Letter Response

In the Skilled Nursing Facility Prospective Payment System Final Rule 80 FR (46427 through 46429) the Centers for Medicare & Medicaid Services (CMS) finalized the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) requirements.

Any SNFs found non-compliant according to the quality reporting requirements will receive a letter of non-compliance through the Quality Improvement and Evaluation System Assessment Submission and Processing (QIES-ASAP) system, as well as through the United States Postal Service. (source: CMS)

You need to take action if you receive a letter from the QTSO Help Desk stating that your facility has not submitted complete data for one or more SNF QRP measures.

Your facility will lose 2% of the overall Medicare Part A reimbursement for one year unless you can effectively complete a reconsideration process.

Recommended Actions For Developing a Reconsideration Response:

  1. Identify what caused the missing data.
  2. From the CASPER website:
    • Run the Review and Correct reports for the time frame indicated in the letter 
      • Identify which resident stays are included in the quality measure(s)
    • Run the MDS Validation reports for the same time frame 
      • Identify any warnings or rejected MDSs for those residents
  3. Some common issues that cause data to be missed:
    • Using a dash (-) in any Performance area of MDS Section GG.
    • Failing to code at least on goal in Section GG of a 5-day MDS.
    • Failing to code a fall in MDS Section J.
    • Failing to correctly code pressure ulcers in MDS Section M.
    • Failing to code “yes” in MDS A0310H whenever a Discharge MDS is completed (return anticipated/return not anticipated, planned/unplanned) for a Medicare Part A stay.
    • Failing to complete a stand-alone Medicare PPD End of Stay MDS when a resident’s Medicare Part A stay ends, and the residents stay in the facility for more than 24 hours after the Medicare last covered day.
  4. Review the MDS and make corrections if possible. Once a resident has been discharged from the facility, it is not allowed to open an MDS that was missed during the stay.
  5. Contact the QRP Reconsideration Help Desk –

Contact us to discuss your facility’s specific needs.


Karolee Alexander,
Director of Reimbursement and Clinical Consulting,
Pathway Health


The Progressive and Growing Role of the MDS Coordinator

Since the introduction of the Minimum Data Set (MDS) back in 1988, the role of the MDS Coordinator has evolved with increased complexity. In the early days, MDS Coordinators served as the coordinator of key data related to resident characteristics, conditions and acuity. Gathering data and information, managing the team for applicable input as well as transmission of required data were key elements of the earlier MDS Coordinators’ role in a skilled nursing facility.

The dynamic health care environment has transitioned the role of the MDS Coordinator to a key position within a skilled nursing facility. With the dependence on organization data to determine quality, regulatory and financial outcomes, it is vital that MDS Coordinators receive the support and resources to stay on top of all the changes impacting providers across the nation.


What are the key changes affecting MDS Coordinators? 

CMS continues to move toward value-based purchasing and standardized data collection across the post-acute care continuum. The IMPACT Act and PAMA legislation continue to drive changes in the collection and use of MDS data for quality metrics. Each post-acute care provider type is collecting and submitting comparable data to CMS quality programs. The Medicare Value Based Purchasing initiative is also using MDS data for risk adjustment of claims information.


How has the role of the MDS Coordinator changed?

The role of the MDS Coordinator is changing as CMS expands the content and use of the MDS. Not only must the MDS Coordinator be knowledgeable about how to correctly code MDS items, but they must also understand how the encoded information is being used by many government programs.

MDS Coordinators are typically RNs who may serve in a variety of roles in the nursing facility. They may be responsible to assign ICD-10 CM diagnosis codes to the resident’s medical conditions. They may be accountable for case management of Medicare Part A and insurance case management. They may also work shifts providing direct care because of the current staffing shortage. The job has grown beyond the scope of coding the MDS. The MDS Coordinator is often the Medicare coverage expert as well as the computer technology consultant within the facility.


What are three strategies for MDS Coordinators today?

  • Knowledge – CMS is rapidly publishing changes in both the content and use of MDS data. MDS Coordinators must keep abreast of this changing information as it is released as implementation times are typically within a few months of publication.
  • Data – MDS Coordinators have access to and often provide the CMS reports from the CASPER (Certification and Survey Provider Enhanced Reports). There are 13 MDS related reports, multiple reports for 17 SNF Quality Measures, the Review and Correct report for the SNF Quality Reporting Program (QRP) and the Confidential Feedback reports for the Value-Based Purchasing (VBP) program. Each of these reports provides valuable feedback to the MDS Coordinator about the accuracy and timeliness of MDS data and submissions. The reports can also inform the quality improvement efforts of the facility as a whole.
  • Monitor – It is critical that the MDS Coordinator understand how to correctly code the MDS and how the MDS data is being used in multiple government programs. Each facility can establish routines for monitoring their data based on the frequency of report updates; monthly or quarterly.

CMS allows a short window of time to correct MDS submissions for the QRP and VBP programs. Both programs have financial consequences for the facility. Ensure that the Review and Correct report and Confidential Feedback report are downloaded and examined routinely.

Quality Measure reports directly impact the facility’s Five Star Quality Rating. Download and analyze those reports at least quarterly.


What support and resources do you recommend for an MDS Coordinator?

  • Knowledge – Many MDS Coordinators are selected from the ranks of excellent nurses within a facility. Often the training and education they receive is on the job from their predecessor. The critical nature of this role supports an investment of formal education about the MDS process. An initial “beginners” education works best for new MDS Coordinators followed by national certification after about a year of experience.
  • Skills – Facilities are responsible for the accuracy and timeliness of each MDS. Conduct routine audits of accuracy and timeliness. Peer review of MDS coding is a practical and efficient way to perform validation audits. Alternatively, facilities with supporting documentation in their electronic health record can use an external consultant to perform accuracy and timeliness audits remotely. Many facilities engage an external consultant annually to complete an on-site assessment of the MDS process and outcomes.
  • Ability – The MDS Coordinator is now the facility’s data manager, as well as serving many other roles. A highly functioning MDS Coordinator is curious about the use of MDS data and is an active member of the leadership team of the facility. Support your MDS Coordinator by allowing them time to participate in training, read User Manuals and share information with your team. Promote and support external education for your MDS Coordinator to promote and support the success of your facility in government programs.

Author: Karolee Alexander
Director of Reimbursement
and Clinical Consulting
Pathway Health