Standardized Terminology and Language in Informatics
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Dear Professor and Class,
I chose to discuss Reimbursement from Centers for Medicare and Medicaid Services (CMS) Payment. I worked in a nursing home and every aspect of patient care resulted from CMS guidelines. Patients admitted on Medicare part A had to participate and show improvement for the services to be paid for. If a patient had refused therapy services repeatedly, they would be removed from therapy services and placed in our long-term care area. This had an impact on my practice as patients had to be educated in this and encouraged when they wanted to refuse their physical therapy. This could potentially cause money loss for the nursing home as they still had to pay for the services, but CMS would not reimburse them. There are specific medications that are not covered by Medicare or Medicaid. An alternative medication would have to be prescribed. After time, I would begin to know some of these medications and be able to give the prescribing provider this information. This was sometimes a great help as getting prescribers to change the scripts for an alternative saved the provider, pharmacist, and myself time. This was a benefit to the patient as they were able to receive their medications in a timely manner. The nursing home used the charting system called LG. LG was able to detect some of these medication coverages and only allowed approved medication orders to be placed. The LG system also had charting requirements to be filled out entirely before being able to submit to CMS. “The Centers for Medicare and Medicaid Services (CMS) developed core criteria that defined basic functions EHRs must demonstrate, including: basic entry of clinical information such as demographic data, vital signs, medications, and allergies; use of several software applications that begin to realize the true potential of EHRs to improve the safety, quality, and efficiency of the care through clinical decision support; and entry of clinical orders with safety measures within the software” (Hebda, 2018). This EHR program saved a lot of time for everyone that used it. Another thing CMS regulated was the staffing in the nursing home. There had to be a registered nurse in the building for eight hours each day. If compliance was not made, fines, star ratings, and monetary gains would be docked by CMS. Star ratings are a systematic way for CMS to determine the quality of care provided by each nursing home. These star ratings are available for the public to view. “The underlying motive behind public reporting is to foster an environment that improves quality by informing potential residents and their families about the quality of care within each nursing home thereby creating quality competition across the industry (Brunt, 2022). This could be a difficult thing to recover from as patient family member would look at these star ratings when determining placement for their loved one. In closing, CMS placed guidelines and requirements for reimbursement of services rendered for nursing home patients. These guidelines have made me tailor how I practice nursing in order to be compliant with CMS regulations.
( Melissa)
References:
Hebda, T., Hunter, K., & Czar, P. (2018). Handbook of Informatics for Nurses & Healthcare Professionals (6th ed.). Pearson Learning.
Brunt, Christopher. (2022). Assessing the impact of enforcement and compliance with minimum staffing standards on the quality of care in nursing homes: Evidence from the Centers for Medicare and Medicaid Services’ staff star rating downgrade policy.
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