What Does Acuity Mean for Nursing Home Care?
Is acuity in nursing homes affecting care quality? Understanding its impact is crucial. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Nicole Snapp-Holloway to talk about what acuity means for nursing home care and how it influences resident health and services.
Schenk: What does the term acuity mean in nursing homes? Stick around.
Hey out there. Welcome back to the nursing home abuse podcast. My name is Rob. I will be your host for this episode. We’re going to be talking about the concept of acuity, what it means and why it’s important in nursing homes for the nursing home to understand acuity themselves.
We have the fantastic attorney, Nicole Snapp-Holloway joining us to talk about that.
As I mentioned, we’re going to be talking about acuity, what acuity is in a nursing home, why it’s important, what purpose does it serve in the long term care setting? But we are not doing that alone. We have the fantastic attorney, Nicole Snapp-Holloway, who I many years ago saw speak at a seminar about this topic, which is why I wanted to have her come on and talk about it with us.
But Nicole is an Ohio native and a Miami University alumna. Obtained her law degree from Oklahoma city university in 1999, specializing in long term care. She’s also adept at appellate work, notably contributing to landmark cases on forced arbitration in Oklahoma’s healthcare industry. Nicole’s husband, Carl, is her rock outside law.
She finds joy in traveling, cooking, and caring for her beloved furry companions, Gia, Atticus and Finch. So happy to have her on the show. Nicole, welcome.
Holloway:
Oh, thank you so much for having me, Rob. I’m excited to be here.
What does acuity mean in a nursing home setting?
Schenk:
Man, I’ve been looking forward to this episode. Really glad to finally have you on because I would say that everybody that comes on the show is a professional, they are experienced or whatever, but very few, I would say are nursing home geeks, geek out on things.
So I appreciate that. Today I wanted to just pick your brain, to talk about the concept of acuity. And I’m going to give you the floor to explain in a nursing home context, what does acuity mean?
Holloway:
Okay. Acuity means a lot of I’ll say it means one thing, but it has a wide range of effects in a nursing home context. Acuity is simply the medical status or condition of an individual and basically, it helps to determine what their needs are, medically speaking, or even just care wise, because in a nursing home and long term care, we’re not necessarily talking about hardcore ICU medical needs.
We’re talking more about what we call ADLs, which are activities of daily living. What do these individuals need help with? And that’s the whole reason they’re there. They’re there because they cannot do everything that we can do ourselves on their own. Going to the bathroom, taking a shower, brushing your teeth, putting your clothes on.
Eating by yourself, cooking, especially that half of us can’t cook or shouldn’t be cooking. So we’ll burn the house down. But yeah, so the acuity of a particular resident determines what they need to be, the best condition that they can be. It just tells the nursing home what they need to do to help the resident and in turn, how much help they need and what kind of help they need.
And then ultimately it also tells Medicare how much that person is worth to the nursing home. I would say how much they get paid, but the nursing homes only think in terms of value, they’re all cash cows.
Schenk:
So I guess in a short, in a shortened form, you have the spectrum on one end of the spectrum, you might have somebody that is cognitively impaired and immobile.
And then on the other end of the spectrum, you’ve got a 30 year old linebacker that might’ve broke his arm in a motorcycle accident, but otherwise can do most everything himself and is there for short term rehab. And…Oh, wow. That looks like a gigantic cat.
Holloway:
Sorry.
Why is knowing acuity important?
Schenk:
No, that’s perfectly fine. For those that are not watching this, a giant tiger just leaped up behind the coal and I thought that was the end. Um, and so I guess acuity is going to be the clinical conditions that tell us the amount of care. And I guess that gets to my next question: Why is that important? What, why would it be important to know the acuity of one resident to the next?
Why not? Why doesn’t everybody get the same amount of care?
Holloway:
Because just as you described, different people are going to need different things. The one who’s cognitively impaired and immobile. They have to have everything done for them. They need somebody to bathe them. They need somebody to turn and reposition them, to feed them, to monitor their vital signs more acutely, no pun intended, because they simply can’t do anything for themselves.
On the other hand, the person who just has a broken arm. They can probably feed themselves just fine, may need some help getting dressed because they can’t move their arm in a certain way, that type of thing. So it’s very important that the nursing home understands the acuity of each resident so that they can assign or provide the right types and amount of care.
Help that person to make sure that part of the regulations meet the highest level. What is it? Physical, mental and psychosocial, be the best they can be.
Schenk:
You say that like you’re guessing, but that is literally what it is. That’s how we know that you are a geek of the regulations because you can literally say the regulations.
Anyway, I hope that you’re not offended. I keep calling you a geek. You’re not a geek. You’re perfectly wonderful.
Holloway:
I take it as a compliment.
What are the ways that acuity is measured?
Schenk:
So let acuity in a nutshell. But, what are the ways, if any, that the nursing home does or should calculate acuity? Like, how are we figuring out, what’s the measure?
Holloway:
Do and should are two very different concepts.
Schenk:
Exactly. That’s why I asked.
Holloway:
It’s want and need, right? Very different things. Um, how should they do it? There are a number of Commercial formal tools out there that could help them determine the acuity for the purposes they need it for.
In fact, there are software programs. There’s things built into point click care, which is one of the big electronic health record systems that a lot of nursing homes use. There are things built into those that would help them to quickly derive a kind of measurable acuity. For more information visit www.fema.gov.
For a resident at the very least, it would give them a laundry list of the activities of daily living that they’re supposed to be helping with. So it’s very important that they have a ton of tools at their disposal, but they don’t want to use them because the more they know about the actual acuity, the more they have to admit that their staff is not sufficient in number, type, quality, supervision, et cetera.
To provide all of the care they’re supposed to be providing. As far as what they do, I can’t tell you how many directors of nursing that I have deposed when you ask them, so how do you determine the acuity of my residence? Oh, I just, I know my residence. Oh, really? You know all 80 of them? You, off the top of your head, you can tell me everything about all 80 of them.
I walk around the facility every morning and I just look at everybody and I’m like, okay, so you can look at somebody and tell me whether or not they can move their left arm, whether or not they can feed themselves, do they have dysphagia, which is a condition that affects your ability to swallow.
And we all know that’s just, silly, right? Nobody has that kind of cognitive processing power immediately. And then, and if you think about it, that’s counterintuitive, because if she’s walking around the building that morning determining the acuity she’s already determined how much staff she has.
So obviously her staff that morning isn’t based on the acuity of that morning, is it? So it’s just so frustrating to hear them try to say that they know what the residents need when there’s no measurable of it. You can’t get them to give you anything empirical at all. And for a fact that their staffing is never going to be based on the actual acuity of the residents.
Schenk:
You mentioned software programs like point click care that would, that you boop, punch in the numbers of things that they need, and maybe I’ll pop say a number or a range or some type of concept in which you can understand an acuity level versus the next resident. What does the MDS process, how does that factor in?
And is the RAI assessment process. Is that a way in your experience that the nursing home could generate an acuity number for each resident?
Holloway:
Absolutely. The MDS itself is the form that they use to report the condition of each resident periodically to Medicare for very, for a number of purposes, reimbursement being one acuity being another.
And the RAI manual is the very specific set of instructions that tells the people in the facility how to assess a resident, how to complete that MDS properly. The primary section that the MDS can help us with, and if they wanted to help the nursing home, would be section G, I think now it’s actually section GG, the functional status, which has that laundry list of ADLs.
For each resident and an assessment of how much. Help they need with those, are, they depend fully dependent moderately dependent or mildly. Are they independent? It will tell you. And so we know they do assess the residents for that purpose because they have to complete the MDS, but they will never remember that and they will never go and use the MDS data to gauge what their actual acuity is, because then again, they would have to be accountable for providing sufficient staff for all of those necessities.
Schenk:
So at the end of the MDS process, at least if I recall correctly, used to be that you get a rug score and the rug score would range from, roman numeral one to whatever now is it what is it now? Do you know?
Holloway:
It’s PDPM, Patient Driven Payment Model. And actually, to some extent, I like PDPM better because its components can be extracted individually. And there is a nursing component by itself that you can pull out, and it tells you what types of nursing care is needed. And I, if I remember correctly, I’m not sure if they apply STRIVE to that or not, but it gives us a lot of information by itself, the nursing component of PDPM. And again, it’s taking a subset of the MBS information and compiling it through Medicare’s algorithm and putting this together. There’s a ton of information available.
Schenk:
But does it spit out a number like the rug score or is it some other different? I really haven’t…
Holloway:
It spits out a code and it’ll be a four letter code.
Schenk:
Sure.
Holloway:
One four. Actually, maybe it’s, I can’t remember off top.
How do nursing homes use acuity for staffing?
Schenk:
It’s some type of code, but I guess what I’m, what I guess at the end of the day, when you got a code or a number that represents X. And so my next question to you, and we’ve been hitting on staffing a little bit or a lot. How, in your opinion, how does that code or that number then become something where this is the amount of nurses that we should have on staff?
This is the amount of CNAs we should have based on those numbers from the MDS or whatever their system is like, how do we bridge that gap?
Holloway:
How do we bridge that gap? Or how should the nursing home bridge?
Schenk:
This is so awesome. Cause it’s, you’re right. Like how should it be done in your opinion versus what actually happened?
Holloway:
The nursing home should be reverse engineering or backtracking on the data that created that number because it’s more of the list of ADLs and the ranges for each resident. That’s what they need. They need a list of their residents, like, to me. I don’t know if you remember the 672s and 671s.
I think that the 671 is what should be done twice a week, three times a week in every facility by a DON or an administrator. Because what that does, it says we have 38 out of 60 residents that need toileting help. We have 14 residents out of, X residents that have peg tubes that need ADL of walking, they can’t get into their wheelchair themselves.
They can’t, they’re not mobile. They’re, and it really breaks that down. And I loved that report so much because it gave you a snapshot of what the real acuity in the facility was. And so if they would look at that type of information, which is what you compile through the MDS process. So the PDPM code itself, is there anyone other than the MDS coordinator that’s going to really have any concept of that?
Probably not. But it’s more the bulk of information that is compiled in that process to, to derive that number that they should know.
Schenk:
So in a typical case in which you’re making the argument that based on the resident population acuity level as a whole, they should have had X staff are your experts in yourself.
Are you looking at the PDPM numbers? Is that what’s driving what you’re going to argue if you can argue that at all?
Holloway:
It’s not as easy or we’re not as good at it as we were with the rug scores yet. I’ve tilted it a little bit because I haven’t nerded out on the PDPM stuff enough in my opinion.
Schenk:
Me neither. Obviously. Like I’m like, as I’m asking you these questions, Nicole, I’m like, I don’t even think I’ve updated my discovery. Like, I’m probably confusing the hell out of the attorneys in my new cases. But, anyway.
Holloway:
They probably don’t know what they’re doing either. I promise you, you probably know a heck of a lot more.
I feel like we’ve stepped back a little bit and gone to some more anecdotal information trying to figure out, focusing more on asking the CNAs, how many residents were you caring for? How many of them do you recall needing toileting assistance? That kind of thing. If I still, if I had my druthers, I would just have a 671 for, every week, and then we would know exactly what’s going on.
It still is possible to calculate some of what we used to call expected staffing using the PDPM model. It’s just a little bit more complicated these days. But what you can do and still should try to do is get the section Zs. The section Z of the MDS is the kind of ultimate, and game code basically.
And if you have those for every resident of the facility at a specific point in time, you have a gauge. Those, they can be, we can analyze the codes and extract what we know to be certain levels of acuity.
Schenk:
We’re a few minutes into our conversation. And I forgot to ask you this, we’ve talked about what acuity is, but is there anywhere that you’ve found where we can derive a definitive definition? Has it been defined in the regs as far as you know, where can we find that?
Holloway:
It is the watermelon book. I’m not sure if your listeners are familiar with that. That’s the surveyors Bible. Yeah, exactly.
There you go. That has a definition of acuity. I can’t remember it verbatim. But the thing about acuity, it never changes. The definition doesn’t change what you think acuity is, what I think acuity is, what a CNA thinks acuity is, it is really all the same thing. It’s simply, how sick is this resident?
How much help do they need to be the best they can be? So the words, a lot of times you and I know that you have to find the regulatory language to send to the defendants because otherwise they, I don’t know what you’re talking about. So yeah, you, you want to use as much of the regulatory stuff to pry, the information from the defendants so that they don’t get to play dumb, but contextually.
I think it’s important that when you’re talking to a CNA or an LPN or LVN or an RN, they understand acuity to be what you and I commonly would understand it to be. You don’t need to use the regulatory language with them. That would probably confuse them a little bit, but using the common definitions of it, the common context, that’s what they’ll understand.
Schenk:
I think the bottom line at the end of the day is that we have to understand. And when we’re going against the nursing home, when they say staffing to census is enough, that is absolutely incorrect. You can take census into account according to the regs, but acuity is in there. It’s just a matter of how big of a factor it is for the nursing home.
But acuity has to be in there. Several, many of my cases, I have one where I deposed the, I deposed most of the staff last week where it was like, Hey, we, the census is what we look at. Maybe I’ll throw an extra person if somebody’s sick or whatever, but that’s about it. And that’s just not, that’s not right. That’s not what the regs require.
Holloway:
No, it is not that the regulations specifically say meet the needs of the residents. And in Oklahoma we have an interesting one because we do have a minimum ratio, which is so low. It’s criminal. In my opinion, it’s 2.9. And that’s, they raised it a couple of years ago. So it’s just, it’s embarrassing.
But we have a corresponding administrative code regulation that says the nursing home has to provide enough staff to meet the needs of the residents without regard to the minimum ratio in statute. So thank goodness we have that because otherwise we would be violating the federal regulation, which does say meet the needs of the rest.
Schenk:
Yeah, that’s another concept that’s just oftentimes foreign to the nursing home where we’ve met the minimum staffing for Georgia and it’s that’s irrelevant if your acuity is such that you need twice as much like that’s just the baseline. So these are just concepts sometimes that no one at the nursing home level is going to know.
And maybe if you depose somebody up at the, they, at that corporate. They know what’s going on, but I don’t know. But, anyway.
Holloway:
On that point though, I feel like to some extent we forget that in my opinion, nursing home cases, not to be a legal nerd, they’re re ipsa cases.
Schenk:
Right.
Holloway:
These people have a duty to take care of these residents with whatever needs that resident has. And the evidence that they’re not doing it is the, that the resident fell, that the resident got a wound, that the resident got an infection. That’s the evidence that says they’re not meeting their needs and if they’re not meeting their needs, you and I both know the number one reason is because they’re not staffing to meet their needs.
So it’s we give them too much credit sometimes.
What should a family of a nursing home resident understand about acuity?
Schenk:
That’s an interesting point. I don’t, I’m not sure if I’ve ever heard that analogy. It’s a re ipsa case. That’s interesting. Definitely we’re being legal nerds now. So in the last couple of minutes here, Nicole, if you don’t mind, what would be something that a family of a nursing home resident should know about acuity?
Like what’s a, just some, what’s a piece of advice that you would give them?
Holloway:
Know your loved one. Definitely. And I would say, I hate to say this, but you have to check them for wounds periodically. I can’t tell you how many cases I’ve had where the family didn’t know they had a wound until they were taken to the emergency room.
And then it’s stage four, and stage four doesn’t happen overnight. So I know it’s not the most dignified or fun thing to do, check your loved ones for wounds, trust what your loved one is telling you, if they’re, even if they have a little cognitive impairment, if they’re telling you things that seem odd.
Talk to the staff, figure out what your loved one needs and help the staff understand that if nothing else, you might be able to save your loved one a little bit of pain and discomfort may not be able to save everybody in the facility, but the more you can communicate with the people on the floor.
And I don’t want to say suck up to them, but sometimes you’re going to have to suck up to them. It’s it takes a lot and I’ll tell you this. I really never blame the people on the floor. I try to befriend them in depositions and get them to tell me the truth because it’s not their fault.
If you think about the standard of care, they’re supposed to do what a caregiver in their position would do well when you’re in a position in your CNA and you got 60 residents to the toilet. There’s no way you can do that. You have to triage people. So they’re doing the best they can normally there’s some when I’m, but yeah, get to know them, let them know you understand that they’re overworked and try to be a little bit of a link in communication for, the conditions that your loved one has, the needs that they have, that would be the best advice for families going into, putting someone in a nursing home.
Schenk:
Very very well said, Nicole, thank you again so much for coming on the show and sharing your knowledge with us.
Holloway:
This it’s been my pleasure, Rob. I’m so happy to do this. I’m happy that you do this because I think what we need to do is educate the public a lot about what goes on. And I think we could force them to improve, we did that. You and I will find somebody else to sue who won’t be.
Schenk:
That’s very true. Awesome. Thanks so much. Folks, I hope that you found this episode educational. I know that I did love Nicole. She’s fantastic, highly experienced, highly, nerds out on this stuff. So appreciate it whenever she can come onto the show.
If you have a suggestion for a guest that you want me to talk to, or a topic that you want to be. Yeah. On the show, that was awkward, a topic that you would like for us to cover on the show, then please reach out to us and let us know. New episodes of the nursing home abuse podcast come out every Monday on every single podcast platform, on YouTube, anywhere that you get your podcasts from.
And what was I going to say? I think that’s about it. Yeah. Okay. That’s it. With that folks, I’m sorry about that. We will see you. Next time.
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