One of the greatest issues facing our skilled nursing facilities today—other than staffing and the COVID-19 pandemic—is the ability to capture revenue for the services provided in our communities. We often focus on accurately capturing service delivery for our short-term skilled residents but tend to lose focus on accurately recording the care provided to our long-term care residents. When it comes to reimbursement for those residents who are in our communities for more than 100 days, case-mix is the greatest determinant of the reimbursement received for provision of care delivery. With case-mix payment methodologies differing for each state, there are at least five things you can do now to improve your case-mix index (CMI) regardless of your state of practice.

1.   Hold CMI Review Meetings

Think of the Patient Driven Payment Model (PDPM) huddle, or the Prospective Payment System (PPS) meeting before payment methodologies changed, except look at it from the view of your long-term care population instead. Tracking your CMI is extremely important to knowing where your opportunities are so you can improve processes and documentation. The interdisciplinary team should be gathering on a regular basis to review all residents who reside in your community. These CMI review meetings should discuss clinical changes that may necessitate the completion of a significant change assessment. The discussion of therapy screening schedules and long-term residents who are receiving therapy services should also be included. For those residents who have an upcoming quarterly or annual assessment, review their diagnoses, medications, treatments, and conditions to ensure your documentation includes all care being provided so the Minimum Data Set (MDS) is accurately coded. During this meeting, it is recommended to have a tracking method for residents’ previous MDS assessments so any changes in the new assessments can be fully investigated.

2.   Communicate with Therapy

Therapy services are often provided to the long-term residents in our communities due to new issues with swallowing, a decrease in functional independence, or rehabilitation after a fall. The provision of therapy services is one of the main avenues to improve case-mix in nearly every state, but if there is not communication between therapy and MDS, these services may not be accurately captured on the next assessment for the residents. When it is determined that physical, occupational, or speech therapy services will be provided to a resident, the rehabilitation manager and the MDS coordinator should be discussing the potential need to schedule a significant change or quarterly assessment to ensure an accurate picture of care delivery is demonstrated.

3.   Capture the Complete Clinical Picture

Assessments are completed for your long-term care residents on a quarterly basis, so reviewing the clinical picture consistently and prior to the next assessment reference date during the lookback period ensures services, conditions, diagnoses, and care delivery are being accurately documented. Ensuring the MDS is portraying the entire clinical picture is crucial. For instance, if there is a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) who sleeps in bed with head elevated due to shortness of breath while lying flat, you will not be able to code the MDS correctly if these items are not documented in the medical record. The inability to capture these items together will negatively impact the case-mix index and ultimately result in a decrease in revenue for your community due to lack of documentation. Painting the complete clinical picture in your documentation will ensure the MDS assessment is completed accurately and allow you to realize an improvement in the case-mix index.

4.   Accurately Code Activities of Daily Living

Section G: Functional Status—the section calculating activities of daily living (ADL) scores for residents—was slated for removal from federal MDS item sets in October of 2020; however, the public health emergency had other plans, which resulted in a delay of a new item set release. Therefore, we must continue to document and calculate ADL scores for the foreseeable future. Ensuring the presence of late loss ADL documentation (bed mobility, eating, transfers and toilet use) from the direct care staff (primarily CNAs) is an important determinant for the CMI in your community. The adage “if it wasn’t documented, it didn’t happen” is highly relevant to this area. Review the point of care documentation to ensure ADLs are being coded and put processes in place to audit if necessary.

The next item of importance with ADLs is to ensure the documentation is being entered correctly. For instance, if you have a resident who needs weight bearing assistance to transfer and use the toilet, but the documentation paints the picture of the resident needing only supervision, the documentation is not only inaccurate, but it will negatively impact the case-mix index in your community. Observing the residents and interviewing the direct care staff in the community and documenting the findings in the medical record can immediately improve the CMI. Educating the caregivers on a regular basis can have lasting effects on the case-mix in your community. Accurate ADL coding can result in an increase of up to 0.28 points in the case-mix index for an individual resident, so ensure the documentation is happening and that it reflects the assistance the residents require to complete their activities of daily living.

5.   Complete Interviews Timely and Accurately

While there are a few interviews to be completed with the Resident Assessment Instrument (RAI) process, one in particular can have a significant impact on improving the case-mix index in your community. The Resident Mood Interview, or PHQ-9©, measures the presence of depressive signs and symptoms of those residing in your community and should be completed during the seven-day lookback period of the assessment window for all residents. If the interview, or staff assessment alternative, are not conducted during this window of time, there is a possibility of not capturing the resident’s conditions to plan care appropriately as well as the potential for a reduction in overall CMI.

Conducting the interview correctly is just as important as completing the interview timely. Building a rapport with the interviewee and helping them understand the importance of being open and honest about their feelings can help the community better plan for their care and result in an accurate interview score. If a resident does present with a sad mood and the interview is completed timely, the impact on the overall case-mix index could be an increase of as much as 0.41 points.

Improving the overall case-mix index in a community comes down to a few key processes:

  • Ongoing communication between disciplines
  • Timely and accurate completion of documentation and interviews
  • Accurately capturing the condition of the resident in the medical record so it can also be captured on the MDS assessments to determine the case-mix indexes.

Putting these processes into place will assist in providing higher quality of care for your residents while increasing the CMI to improve the resources available to the community. Doing what’s right by your residents will always ensure the community can provide the best possible care.

For More Information

Minneapolis-based Health Dimensions Group (HDG) is a leading consulting and management firm, providing services to post-acute, long-term care, and senior living providers, as well as hospitals and health systems across the nation. HDG has been serving health care organizations for more than 20 years with a firm commitment to its values of hospitality, stewardship, integrity, respect, and humor.

If you’d like to learn more about improving CMI in your community, please contact us at, visit our website, or call 763.537.5700.