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With Phase 3 of the Requirements of Participation (RoPs) going into effect on Nov. 28—just as providers are gearing up for the Patient-Driven Payment Model (PDPM)—it may seem like it’s raining cats and dogs. While they can’t stop the barrage of change, they can create an umbrella strong enough to weather the storm.

“It feels like Phase 1 was so long ago,” says April Diaz, vice president of clinical services at Marquis Cos. in Milwaukie, Ore. “Phase 3 builds on the foundation built by Phases 1 and 2. While some facilities may already have some of the requirements in place—the new Phase 3 requirements, such as the formal role of an infection preventionist and corporate compliance officer, will likely present some challenges and struggles for providers trying to balance it with implementing the new PDPM payment model.”

Sara Rudow, director of regulatory services at the American Health Care Association (AHCA), says, “Phase 3 has some big-ticket items that tie everything together.” (Brief overview of Phase 3’s elements).

Compliance with Phases 1 and 2 placed heavy burdens on providers, but most succeeded by taking the requirements one piece at a time. “As a large organization, we were fortunate to be able to slow it down and step into it,” says Diaz of Phase 1. “We broke it down, went through all 700 pages, and aligned everything to current policies and procedures. We then developed an action list. We outlined what we needed to do for each phase and what staff needed to know.”

Phase 2 was challenging, Diaz says, partly because while facilities were struggling with issues such as how to do a facility-based assessment, they also had a new survey process and a new emergency preparedness survey to deal with. “All of that hit at once. We had the bandwidth to manage it all, but that is a lot of change to handle all at one time,” Diaz says. “The facility-based assessment component of Phase 2 was most burdensome for facilities to complete, but now we have [done it], we’re not sure how surveyors will address these assessments. It will be up to the surveyors’ interpretation to determine if you did an effective job of gap analysis, for example,” she notes, adding, “Going into Phase 3, providers can only work based on what the rule says, but they won’t know how surveyors will address it until the Interpretive Guidelines come out later this year.”

“The Nov. 28 implementation date is not the date you start preparing,” says Amy Lee, RN, MSN, CRRN, QCP, president and chief executive officer of Coretactics Healthcare Consulting in Albany, N.Y. “When I conduct training courses, I ask, ‘How many are done with Phases 1 and 2? You’d be surprised how few hands go up. Now Phase 3 is rapidly approaching. If you’re not ready, you need to start preparing now.”

The trauma-informed care (TIC) requirements of Phase 3 are causing anxiety for some providers. “It’s a stumbling block for some because for many it’s a new program that needs to be developed,” Lee says. However, she notes that most facilities are already providing TIC to some degree, and it may just require formalizing the program through the development of policy and assessment and following it up with staff training.

“It starts with identifying those who have a history of trauma during the initial assessment and carrying that diagnosis into a person-centered care plan to meet their assessed needs. The primary goal is to develop a treatment plan that eliminates or mitigates triggers that may cause re-traumatization,” Lee says.

On the plus side, if done right, TIC can increase residents’ comfort and save staff time and work down the road. As Lee says, “If we can identify trauma factors up front, we can be proactive and avoid triggers and prevent behavioral issues. Think about the angst—however unintended—we cause if we don’t identify individual triggers.”

In some ways, Phase 3 may put more stress on facility finances than staff. For instance, many already have someone working as an infection preventionist in some capacity, and they understand ethics and compliance. But costs such as paying the salary for a compliance officer and various required training efforts could be burdensome.

There are some free and local training materials and programs out there—through AHCA and the National Center for Assisted Living (NCAL) state chapters and quality improvement organizations, for example—and these can help fill training needs without breaking the bank.

Providers also can seek community and other partnerships to share resources and tap into area experts. For instance, they can invite local trauma experts in to train staff on assessing for post-traumatic stress syndrome or other aspects of TIC, or they can reach out to staff and family members for valuable background information.

Don’t undervalue the resources the facility’s own clinical leaders bring to the table. “The medical director as clinical leader has access to a wide array of evidence-based webinars, programs, articles, and other resources,” says Michael Wasserman, MD, CMD, a California-based geriatrician and president of the California Association of Long Term Care Medicine. “This is their wheelhouse, and they can help identify the best resources and use their clinical acumen to customize them for your organization’s need.”

Partnering with local educational institutions is another option. Lina Dureza, RN, LNHA, MSM, administrator at Hughes Health and Rehabilitation in West Hartford, Conn., and her team partnered with Yale University on infection-related studies and the University of Massachusetts on dementia research programs. As a result, they received free educational materials and information and established a connection with experts they hadn’t had access to previously.

Whatever sources the facility uses for training, “You need to create a dynamic training program for Phase 3,” says Paige Hector, LMSW, an Arizona-based clinical educator and consultant. “You need to stop, step back, and look critically at what you do. Some inservice programs work, but we need to recognize that adult learning principles are key. Adults can be ornery learners. People need to know why the instruction is important to them and their role in the facility.” Using adult learning principles such as role playing and interactive activities are most effective at promoting sustainable change, Hector says. She also stresses the value of coaches and mentors.

“Let’s say you want to learn a new cooking skill. You could take a class, but it isn’t enough. You need to practice, but it also helps to have someone—a coach—to come and cook with you. We often are missing the coaching piece in long term care, especially when it comes to applying new knowledge.”

Some basic, easy, and often overlooked sources of information are the RoPs themselves. “I will go into a facility and ask staff if they have the most recent copy of the regulations. They often don’t have them or can’t find them,” Hector says. “How can they comply with the RoPs if they don’t know what’s in them?” She suggests sitting down with staff and the RoPs and going through key points together.

The RoPs have created several new and revised definitions. Communicating these to staff and others is not that difficult. However, ensuring that everyone absorbs the new definitions is more challenging. “Our team struggled with the revised definitions for facility- and patient-initiated transfers. We ultimately changed the verbiage in our EHRs [electronic health records] to match the revised definitions,” says Diaz.

“It’s important to make sure new or revised language, definitions, and other changes are implemented throughout the entire system. And it’s also essential to have leaders and trainers use these words and definitions consistently, so when someone talks about abuse definitions, for example, everyone has the same understanding of what’s being discussed.”

Sustainability is a component of the process improvement cycle, Lee notes, and often providers stop before they get to this part. They make the change and think they are done, Lee says. However, to look for sustainability or opportunities to promote it, she says, “Your No. 1 mechanism for identifying opportunities is walking rounds and monitoring processes.”

Lee offers an example: “When making your rounds, you see residents with their heels buried in the bed and not elevated as they should be. You ask staff why this is happening, and they say that we’re out of pillows. So, you go and tell your supply manager to order 200 pillows. Problem solved, right?” Wrong, she says. “If you stop there, you’ve only temporarily solved the problem and jeopardize sustainable improvement. Instead, work with the supply manager to order 200 pillows every six months on a continuous basis. That is the final step in process improvement that will ensure sustainable change.”

Those organizations that have yet to embrace technology may be incentivized by the RoPs to take the plunge. “We went paperless in 2010, and the technology enabled us to change titles, language, etc., throughout the system to coincide with the information in the regulations,” says Diaz. For instance, the right technology can enable a change from “responsible party” to the new term, “resident representative,” with one click. This way, Diaz says, “Everyone is automatically updated. Otherwise, it becomes labor-intensive, and the ability to remain compliant is reduced.”

If a company is still using a paper-based system, it’s challenging to flip back and forth between pages. And it’s harder to ensure that the facility has changed definitions and terms and related guidance as necessary throughout all of its records. Software that includes a dashboard that offers real-time access to data and a look at what is happening in the facility any time day or night is ideal. However, Lee notes, “Software doesn’t think; it only knows what you put into it. You can’t trust electronic data until you pull it apart, understand it, and make sure it’s accurate.”

When facilities are dealing with wave after wave of change, it takes a toll on staff. “We continue to hear that making so many changes all at once is challenging,” Rudow says. “The change feels rapid fire, and that puts a lot of strain and demand on staff. It can be fatiguing.” However, she adds, frontline staff in particular are often the first to identify problems, adverse events, and acute changes.

“We need to train, orient, and onboard new staff. This constant need to train new staff is amplified when there is new leadership—such as an administrator or director of nursing,” she says.

It’s essential to keep an eye on how staff are dealing with change. Are they embracing it, resisting it, or just barely staying afloat? This means watching for signs of stress, anxiety, frustration, and depression. Watch the data, and not just turnover.

Red flags may include upticks in sick or personal days, higher utilization of mental health benefits, lower attendance at staff parties and other events, and more complaints from residents about small things, such as cold food, lost laundry, or unanswered call buttons. This is another area where walking around can tell managers a great deal. For instance, are staff smiling and cheerful, or do they look anxious and tired?

It’s important to encourage staff to come forward with questions and concerns, Diaz says. This is an area where a strong culture of trust and mutual respect can make a difference. “When you have an open,

nonpunitive culture, staff self-report problems and mistakes and ask for help to get on track,” she says.

Gaps in training or knowledge can be addressed when management is aware of them. However, in a culture where people are afraid or ashamed to come forward, that’s when errors are more likely.

In a Docebo survey of 2,400 respondents 18 and older in the United States and Great Britain, nearly 30 percent say that they have made a bad decision or turned in poor work because they were afraid to admit that they lacked the skills or knowledge to complete a task.

This openness and trust must be embedded in the organization’s culture, Lee says. “Over the years, it’s been common for people to be afraid to speak up when they make a mistake. However, most frequently when something happens, it has great potential to be a systems or process issue. And even when people are doing their best, mistakes and accidents sometimes happen. They need to feel comfortable admitting their mistake and working with others to prevent it from happening again—the worst mistake is the one we don’t learn from.”

“It comes down to starting with who your residents are and what care needs they have,” Rudow says. “You need to talk to your residents and staff. The facilities that are successful are the ones that get that feedback.” It is best to start with the issues that will have the greatest impact on resident outcomes. This is the best way to focus the team’s actions and enable everyone to make the journey one step at a time, she says.

Staff often look to leaders for cues about how to react to change. “While employees generally appreciate the value of a healthy culture that promotes teamwork, they don’t always think that leaders communicate or model this culture well,” says Wasserman.

“Leadership needs to affect change in a way that is inclusive of staff, their ideas, and opinions,” Hector says. “We’re asking staff to do so much already, and when change is necessary, leaders need to support

staff and help them prioritize responsibilities.”

This starts at the top. For instance, Hector says, “If I went into a facility and wanted a sense of the culture, I would observe leaders. How, and when, do they interact with staff and residents? Are information and power shared? Are staff engaged in the life of the facility, including policies, practices, and decision making? Does leadership welcome active participation?”

Clinical leaders also need to be actively involved in promoting RoP compliance. “Clinical leadership matters because today’s nursing homes are yesterday’s hospitals. It is essential to understand the critical nature of the clinical approach in day-to-day operations,” says Wasserman. However, he stresses, “Of course, you don’t want that person running everything alone. It takes everyone’s expertise to ensure appropriate and effective delivery of care.”

Hector agrees, adding, “Facilities need to have a strong medical director, administrator, and director of nursing, but it really comes down to people working together as a group. No one person knows it all.”

While the RoPs have created burdens, challenges, and headaches for facilities and staff, they have encouraged and enabled some positive changes. “RoPs have moved the conversation on issues such as antibiotic stewardship. They allowed us as providers to have a little more of a voice,” says Diaz. For example, they required antibiotics-related education for patients and families. As a result, they are less likely to expect or demand antibiotics when these medications aren’t necessary or appropriate. “That is very positive,” she says.

The RoPs also were holistically framed in terms of patient-centered care where it is appropriate. “Putting it in a solid context for providers was key. It focused on ensuring that we understand patients’ goals of care and discharge goals. This is a positive focus,” says Diaz. “It has really helped some providers who have been struggling with getting the resident’s voice heard through the care continuum.”

Lee shares a RoP success story. “A facility found through its facility assessment that it was a pretty good plain vanilla home.” The organization was doing okay, but just okay, and leadership wanted to do better. 

“Using the facility assessment as a tool in strategic planning, we discovered that there was a nearby hospital challenged with timely discharge of its telemetry patients, so the facility did their research and developed a telemetry unit. It’s been a very big success,” Lee says. This was win-win in that it filled the hospital’s needs for a facility where it could send telemetry patients, and it helped fill the facility’s beds by establishing a niche.

“Sometimes if you look for the forest through the trees, you can see opportunities and really excel.”