How to Prepare for the Patient-Driven Payment Model (PDPM)

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PDPM is a big buzz right now. What is the 30,000 foot view of what operators can expect?

PDPM is the most significant change in payment in skilled nursing since PPS was initiated, which was 1998. PDPM is a shift from utilization payment to value-based and patient-specific, diagnostic view. Most of the industry is welcoming this change. It has always been a challenge when one component of the patient’s care heavily drives the overall reimbursement. It’s important that the other sectors of care are also recognized.

PDPM takes the emphasis on therapy and puts it into the context of the overall needs of the patient. There is real value in having the patient’s diagnostic categories driving care. Further, this new payment structure is in-line with other payments forms in post-acute care. From hospitals to home health, it’s all episodic and diagnostic-based.

We know that PDPM is separating therapy minutes from reimbursement. How will this regulatory change impact care delivery?

The rehabilitation and the therapy that is provided today in our skilled nursing centers is extremely valuable and provides patients the ability to improve their function and return to the lowest level of care, most importantly home. The danger when you shift from a driver and bring it back to the overall picture of care is that you run the risk of compromising the patient’s access to therapy.

Stewards of healthcare need to understand that the ability of the patient to improve cannot change. The way in which that is done, the way in which skilled nursing centers are paid for that, certainly has a different focus with PDPM.

Group and concurrent therapy are very valuable in care delivery and now there will be measures under Section GG that will determine the patient outcome. The utilization has always been there, but the quantification of that utilization to drive an outcome has not been measured. It’s important to be sensitive and recognize that the cost of therapy may diminish if you provide less care. But, that can’t be done without a realization that patients are coming to us for therapy to go home. Therefore, protocols need to be put in place to make sure that happens. If therapy isn’t enough to keep patients active during the day, patients will turn to home to receive that therapy. But, there is a huge value-add to the intensity in a skilled nursing center.

How does PDPM impact SNF’s and the residents they receive?

Skilled nursing centers are going to receive higher acuity patients. The more complex patients are leaving the hospital sooner and they are going to locations with the competencies to manage them. The nursing shortages and the complexity of our patients are all adding to one of the main challenges of our industry – access to strong nursing.

The Importance of Nursing Competency

With PDPM, nursing is going to be challenged with competency. Today, we have a very well-educated and competent workforce in therapy. How do you take different components like wound care, dementia and coding to support the nursing centers? These components can be well-partnered with nursing to increase competency. Also, we can look at competency for cardiopulmonary and vent patients.

Ultimately, we are looking at complex medical patients. With those complexities comes risk of care. This shifts the focus to nursing competency and documentation. Under PDPM, the documentation from therapy will need to support nursing documentation. This is different from the current system of utilization driven therapy, where nursing drives therapy. To determine if the right setting and care was provided, the heavy focus is going to be on nursing.

With this heavy focus on nursing, there is an assumption that a lot less therapists will be needed. But, I think it’s wise to look at the skills we already have in the organization. We have more complex patients and we are challenged by workforce. We have access to strong clinicians in therapy. The partnership between nursing and therapy, in my opinion, becomes even more important.

How can you prepare for PDPM?

First, you have to start now. October 2019 will be here before we know it.

It starts with the information you are receiving from the referral source. You need to know the complexities of that patient immediately when you bring them in to the nursing center. That information is going to drive the kinds of care, as well as the payment for that care, as you start to build out the PDPM classifications. So, building referral relationships to access information quickly and accurately is critical to help put the right patient with the right caregiver.

Second, the knowledge of coding is important and complex. Payment in PDPM is going to be based off the ability to capture that information from a medical record that is challenged. You need expertise in coding.

Third, you need to understand your capabilities with high-risk rehospitalizations. Why are your patients returning to the hospital today? Is it a gap in skill? Is it a gap in physician communication? What you identify as a problem today will be the very same thing(s) that will keep you from being the best provider and receiving the right payment for the care.

Lastly, it’s important to have a strong blend of RN’s and LPN’s. This goes back to workforce. If the nursing isn’t strong, the patient will return to the hospital or go to home health. So, you need to do a deep dive into the skill set you have, and the skill set you need, to identify any gaps and resolve them by reengineering your workforce.

PDPM is an opportunity to look at the care that you provide in a new way. The nursing centers that can adapt will survive and thrive.

About the Author
Mary Van de Kamp, MS/CCC-SLP, is the Chief Clinical Officer for Kindred Rehabilitation Services (KRS). Her responsibilities include overseeing quality initiatives and measurement across all aspects and business lines of the rehabilitation division of Kindred Healthcare. Ms. Van de Kamp has served in leadership positions with Kindred since 1995, in both clinical and operational capacities, with the primary focus of attaining clinical excellence. Formerly the Senior Vice President of Quality for KRS for four years, she excelled in providing innovative clinical leadership to internal and external customers, and helped assess, monitor, and improve quality and clinical goals and outcomes.

Mary has also established process oversight and reporting in collaboration with compliance and legal departments. She has served as a technical expert for many organizations, including the American Health Care Association, the American Speech-Language-Hearing Association, the National Association for the Support of Long-Term Care, and the Centers for Medicare and Medicaid Services, supporting appropriate quality and reimbursement in post-acute rehabilitation services. Prior to joining Kindred, Ms. Van de Kamp provided Speech-Language Pathology services across the spectrum of care in all rehabilitation settings.