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The transition to the patient driven payment model (PDPM) over the last two years has not been without its challenges. COVID-19 shifted SNFs’ priorities away from the PDPM transition during year one to an all-hands-on deck approach to prevent the spread of the virus.

Year two continued to bring fresh challenges, including the ongoing pandemic response and an administration change that impacted nursing facility operations and the way care is delivered.

What have we learned from the national data since the implementation of PDPM? What can we learn by looking back, and what do we need to be successful on the road ahead?

What do you know about PDPM so far?

  • Did you know the Patient-Driven Patient Model (PDPM) increased payments to SNF’s in Year 1 by $1.7 billion when it was expected to be budget neutral?
  • Do you know how CMS is monitoring the PDPM data?
  • Are you confident that your data tells CMS the right story about PDPM?

[psst! I’ll be answering these questions at the 2021 AHCA/NCAL Convention & Expo. Will I see you there? Learn more. ]

Transforming Tomorrow with the Right PDPM Tools

Since the beginning of PDPM in 2019, PDPM Insights has been used by 2000+ SNFs, including large, multi-state chains and smaller regional and local providers. Customers value the application for enabling accurate capture of PDPM reimbursement and limiting compliance risk.

[ psst! See the new PDPM enhancements in a live demo! ]

Discharge Destination PIe ChartPDPM Insights enables proactive management of PDPM reimbursement by resident, facility, and corporation, through up-to-date MDS analytics. SNFs can access case-mix, per diem, and revenue analytics for Medicare Part A and Medicare Advantage stays, before locking the MDS, so they can correct errors, ensure accurate reimbursement, and track projected revenue.

PointRight’s existing PDPM Insights product is being enhanced with a new Revenue Analysis tab to analyze total revenue trends, and additional analytics for length of stay (LOS) and discharge destination.

 

PDPM Revenue Analysis Highlights

 
Revenue analyses calculated daily with the most current MDS submissions

Enables proactive review of each MDS’ estimated revenue, payment days, and case mix drivers without having to wait for month end

Payment days and estimated total revenue by skilled resident, with flags for imputed stays:

Helps to identify missing MDSs potentially impacting LOS and revenue calculations

Length of stay metrics organized by discharge destination

 Supports operational performance analysis and business development.

PDPM Revenue Analysis Screenshot
Revenue Analysis tab of the PDPM Insights tool
[  Like what you see? Request a demo!  ]

Filed Under: Blog

Analytics for SNFs

We all want better outcomes for our patients accompanied by a lower cost of care. As healthcare becomes ever more complex, it is often difficult to tell where we need to focus our changes to achieve this desired outcome. This is especially true for Accountable Care Organizations (ACOs) that work to optimize value across a patient’s entire care journey, including in the post-acute care space.

Within this arena, patients’ needs are often more complex, as is the patchwork of Long-Term and Post-Acute Care (LTPAC) services, ranging from the care provided by specialty hospitals to that delivered by skilled nursing facilities (SNFs) and even community-based organizations.  But there is good news: ACOs that embrace post-acute analytics can learn how and where you need to make changes to improve care and earn more shared savings.

Types of Post-Acute Analytics

To start, it is helpful to have a quick refresher on the different types of analytics that exist. Prescriptive analytics give you data about what you should do, while predictive analytics can tell you what is likely to happen in the future. Descriptive analytics can give you a stronger understanding of what has happened in the past. Meanwhile, diagnostic analytics provide a more advanced drill down, perform data discovery, mine data, and find correlations to identify the root cause and answer why something happened.

Four Benefits of Using Post-Acute Analytics in ACOs

The strategies that lead to shared savings can be complex, but one simple component of successful ACOs is having the right post-acute data. The benefits of incorporating post-acute analytics into your ACO’s strategy look exactly like some of the goals that these organizations hope to achieve:

1.

Build and sustain high-performing SNF networks ​

2.

Prevent hospital readmissions and adverse events​

3.

Reduce total cost
of care​

4.

Earn more shared savings

Healthcare Organizations Achieving Results
with Analytics

Several healthcare organizations working in the post-acute care arena have a proven track record of using analytics to move them closer to the Quadruple Aim. For example, Boston-based health system Cambridge Health Alliance was able to gain confidence in their decision making and reduce their 30-day rehospitalizations by 25% in a year. Overall, PointRight’s post-acute analytics users in the ACO space have generated over $101 Million in Medicare savings to date.

Download CHA Case Study

Download Cambridge Health Alliance Case Study

Post-Acute Analytics Help You Earn Shared Savings

At the end of the day, the most important measures are improved care and better outcomes for patients. But increased shared savings is something no ACO wants to pass up either. In all, 67 percent of Shared Savings Program ACOs shared savings with CMS in PY 2020. Eighty-eight percent of two-sided model (potential for shared savings or losses) ACOs earned shared savings payments, and 55 percent of one-sided model (potential for shared savings only) ACOs earned shared savings payments. [ source: CMS.gov ]

ACOs are potentially leaving millions on the table in shared savings that could be earned by better managing their SNFs. The “formula” for getting there can be relatively simple with the right tools and support. When you can use analytics to assess the performance of your SNF Network, you can understand how your post-acute care (PAC) outcomes compare to others. Once you can understand and evaluate your readmission outcomes, you can then develop a roadmap to improve care for at-risk patients, preventing readmission through improved care management.

Filed Under: Blog

Providing patients or members with the highest-quality care while ensuring you have a handle on your high-cost drivers and liability risks is key to delivering the best in outcomes and realizing the benefits of value-based payment. To do this, Health Systems, ACOs, and REITs have the difficult task of collecting and interpreting the right data sets, and in the post-acute care (PAC) space, anecdotal or non-standardized data is common. It’s important to be aware of all the data available for designing a successful post-acute strategy.

Let’s look at two types of data available from skilled nursing facilities (SNFs), the pros and cons of the different data sets, and how to use each for maximum impact on care and cost.

Two Data Sets Tell Different Stories

There are two common data sources for SNF quality measures publicly available from the Centers for Medicare and Medicaid Services (CMS). The first is claims data. Coming from a Health System or ACO world, we might guess this data set comes from the SNFs billing claims as the name suggests. Rather, claims data refers to data used to measure SNFs’ performance in the quality measures for 30-day rehospitalization, emergency department visits, and successful discharge to the community. Claims data is hospital claims for those Medicare beneficiaries that receive PAC services following an inpatient stay.

Confusing? Yes, but this data can also be helpful because the claim follows the beneficiary. For example, for a patient discharged from a SNF who then promptly returns to the hospital, you can see the “bigger picture” care journey. Unfortunately, this data set is also limited as it only looks at Medicare Fee-for-Service claims submitted to CMS. If a SNF in your network has, for example, a high number of Medicare Advantage patients, you will be left with an incomplete picture.

The second data set is based on data from the Minimum Data Set (MDS), and it reflects the clinical outcomes that occurred during the patient’s SNF stay. The MDS is a standardized, structured assessment that is completed according to a mandated schedule for every patient/resident in a SNF, and it captures information on diagnoses, functional status, therapies, treatments, medications, cognition, mood, and behavior.

MDS data is essential to use because, among other reasons, it is part of public reporting; it drives the 23 MDS-based quality measures that are currently publicly available. It is also updated more frequently than the claims data set.

Defining Post Acute Analytics eBook cover

Download our guide to post-acute analytics for ACOs and Health Systems

While a limitation of this data set is that it doesn’t “follow the patient” between care settings, it does capture clinical outcomes that otherwise would not appear in a claim for Medicare FFS. For example, a SNF would bill Medicare for a PAC patient receiving skilled nursing and therapy under the Patient-Driven Payment Model (PDPM) classification, with the diagnoses on the claim to support that PDPM Clinical category classification. However, if the patient also has clinical issues such as pain or behavioral changes that do not impact PDPM classification, this would not appear on the claim, but it would appear on the MDS. Although PDPM is part of Medicare’s shift towards value-based models from the previous fee-for-service model, the existing claims-based quality measures lack the clinical richness of MDS-based measures.

Combined, Both Claims Data and the MDS Show the Full Story

Claims data can help you judge the effectiveness of care transitions, with MDS data filling in more detail about rehospitalization rates. Meanwhile, MDS data gives you greater insight into your areas of high cost and liability risk. For Health Systems and ACOs focused on value-based payment, the ideal plan is to rely on both data sets to understand the full story of post-acute and long-stay resident care.

Another way of stating it is that claims based data gives you a retrospective view – think of it as looking in the rearview mirror, it tells you what has happened.  MDS data provides you with a descriptive and prospective view – much like looking through your windshield, it tells you where you are going. 

By understanding these data sets and their capabilities in greater depth, you can improve your patient and caregiver experience, while containing costs. Contact PointRight to learn more about how to leverage PAC data to maximize your organization’s transition to value-based care.

Defining Post-Acute Data for Health Systems and ACOs [eBook]

Learn more about post-acute data sources to advance your post-acute care goals and strategies. 

Download eBook

Filed Under: Blog

Coming off the rollercoaster that has been the last 17 months, we are breathing a collective sigh of relief with most of our staff and patients vaccinated. And, while the pandemic isn’t entirely in the rearview mirror yet, taking that breath sure feels good. As we think about getting “back to business as usual,” it is time to gear up for CMS’ MDS Rule coming October 1, 2021. With a good understanding of the proposed rule and proposed updates to the Patient-Driven Payment Model (PDPM), a solid understanding of their implications, and some hints about where to focus to remain compliant, SNFs can be well-prepared. Jump to the Ten Tips…

Key changes to SNF Medicare Part A in the FY2022 Proposed Rule

As a reminder, the proposed rule issued last April indicates what CMS is planning, and the final rule is issued August/September to go into effect October 1, 2021. While nothing is certain yet, there is some good news. The Proposed Rule suggests an aggregate increase of $444 million or 1.3% of payment. (This does not include Value-Based Payment (VBP) reductions of $184.25 million and a $1.2 million decrease for new exclusion of blood clotting factors from your consolidated billing.)

We don’t see many changes to the PDPM (case-mix classification) apart from some ICD-10 mapping changes. Changes are intended to ensure codes are more appropriate and accurate. As usual, now is the time for all of us to get familiar with the proposed changes, so we’re ready to hit the ground running and code successfully come October 1.

The big change we do see is the parity adjustment. Last year, when CMS changed from RUG IV to PDPM, this change was supposed to be budget neutral. In reality, payments increased by 5%. To help solve this imbalance, CMS proposes to recalibrate case-mix indices (CMIs) across all PDPM components to reduce spend by – you guessed it – 5%.

Within the proposed rule, CMS gave us a few options for how they might accomplish this: a delayed implementation of blanket cuts or a phased implementation with smaller reductions per year. Most providers commented they would prefer a mix of both. We’ll stay tuned for the final rule.

PDPM Rate-Driver eBook

Download our  PDPM Rate Driver Benchmarks – how do your rates compare? 

Prepare for Oct. 1 now to ensure compliance and proper reimbursement

If we take a closer look at where that 5% spending increase came from, we can essentially create a crystal ball and see areas CMS will be focusing on for compliance monitoring in the months ahead. In short, spending increases occurred in Speech-Language Pathology (SLP), nursing, and non-therapy ancillary (NTA) services. These three areas are heavily influenced by how SNFs capture both diagnosis and co-morbidities. The coding of the MDS itself will be key to getting appropriate reimbursement.

Digging into our MDS dataset at PointRight, examining data from Q3/Q4 2019 until Q1 2021, we’ve identified some trends, and this gives us a sense of where auditors might take a closer look in the future. Not surprisingly, most of these trends are related to COVID-19.

Here is a summary and ten quick tips to help stay compliant when October 1, 2021 arrives.

Ten Tips for your MDS Team to Get Ready for October 1

  1. Depression severity score has risen rather dramatically. CMS will be taking a closer look, so the right documentation for a depression diagnosis is key to your success.
  2. Use of Extensive Services has risen as well. Correct documentation in care plans will be critical (see Tip #3 below).
  3. Rates of COVID-19 and isolation have, of course, increased throughout 2020 and early 2021 (though thankfully they are finally declining). For a COVID-19 diagnosis, SNFs should ensure they only code confirmed cases documented by the provider and review related codes (e.g., suspected exposure). When coding for isolation, remember to review to ensure you meet all four criteria. (see: RAI v. 3.0 Manual p. 0-5 for further detail).
  4. The SLP case-mix drivers have had several changes. Well-documented resident interviews are critical for a cognitive impairment diagnosis. SNFs residents will be well-served when they are closely observed eating to determine a swallowing disorder. SNFs should then review any resident with swallowing disorder for documentation of Speech Therapy evaluation and/or treatment as this has caught the attention of CMS.
  5. For depression and cognitive impairment, remember that interviews still must be attempted if the resident is at least sometimes understood. If an interpreter is needed but not available, answer “no” to the gateway question. If the interview was not attempted but should have been, code the gateway question “yes” and dash the interview items, but don’t complete the staff assessment. Always follow the RAI Manual instructions, and be sure to note the reason no assessment was done in the record.
  6. CMS will likely be looking at NTA as it has increased. SNFs will be well-served to closely document any NTA.
  7. As a reminder, code active diagnosis on MDS and redouble your efforts to follow the rules and capture all other diagnoses.
  8. For skilling in place (the three-day waiver), SNFs should ensure appropriate documentation, including a physician’s documentation of medical necessity and certification.
  9. Therapy delivery does not impact PDPM, but CMS is watching this area closely too. Keep your eyes open for inconsistencies between ADL coding and therapy documentation and potential inaccuracies in reporting functional outcomes (e.g., ADL functional score).
  10. Documentation for daily skilled services has not changed, but again, increase your efforts to make sure your documentation is air-tight. Interdisciplinary input ensures that no skilled needs are missed, and your patients are best served.

Measure correctly: proposed changes to the
SNF Quality Reporting Program (QRP)

There are two proposed new measures in the SNF QRP and one proposed change to an existing measure. Proposed new measures include SNF Healthcare-Associated Infections Requiring Hospitalization (SNF HAI) and COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP). The first is a claims-based measure that has several exclusions and includes risk adjustment. As of April 2022, this is publicly reported. However, in another COVID-related complication, the initial reporting period for this measure has actually passed. But to be ready for the future, now is the time for SNFs to re-examine and shore up infection prevention and control policies and address any issues.

To be ready for the HCP measure, SNFs will want to look at which groups of employees are covered under the measure (including volunteers, students, and trainees) and the reporting time frame. As a reminder, reporting is now mandatory and subject to a fine for those who do not comply.

Claims versus MDS Insights thumbnail

What are the differences between MDS-based and Claims-based insights?
Download eBook

With the existing measure, Transfer of Health (TOH) Information to the Patient—Post-Acute Care (PAC), the denominator changed to exclude patients discharged home with Home Health or Hospice services. (As a reminder, TOH Information measure reporting is on hold until at least two fiscal years after the end of the COVID-19 Public Health Emergency).

Due to the Public Health Emergency (PHE), the Skilled Nursing Facility 30-Day All Cause Readmission Measure (SNFRM) will be suppressed for the FY 2022 program year. All participating SNFs will receive a performance score of zero and will receive a 1.2% back from the 2% program withhold (SNFs subject to the Low-Volume Adjustment would receive the full 2%). Data will be reported with the notation that the measure was suppressed due to the PHE.

And CMS isn’t done yet. They are looking for input on future quality measures, and they can add up to nine new VBP measures. We will keep our eyes and ears open so we can weigh in and report back.

At the end of the day, comply, comply, comply

As always, compliance is key and annual updates to the Proposed Rule do not change the Requirements of Participation. Understanding the proposed changes above, now is the time for all SNFs to ensure consistency in compliance programs and that infection prevention and control are top-notch. Having these in order ensures your SNF is only compliant but also realizing your mission: providing the highest quality care to all residents.

Filed Under: Blog

Back in 2019, the Centers for Medicare & Medicaid Services (CMS) rolled out the Patient Driven Payment Model (PDPM) with the goal of better aligning payment rates with the costs of care by taking a value-based approach to reimbursement.1 And since reimbursement is now primarily based on the medical complexity of the patient, it’s imperative to get MDS assessments right to correctly capture compensation.

While many SNFs and healthcare organizations planned to use 2020 to get a good grip on PDPM training and value-based care, the COVID-19 pandemic had other plans, postponing a lot of that work. But as we start to come out the other side of the pandemic and transition out of reactionary postures to proactive ones, it’s time to get back on track.

In this article, we’re going to look at three great strategies for mastering the MDS assessment to offer the highest level of care management to patients and to ensure proper reimbursement.

1. Align Timing of an MDS Assessment to Ensure Reimbursement

Analytics for SNFsUnder PDPM, the non-therapy ancillary (NTA) component of reimbursement is tripled during the patient’s first three days.2 NTAs are conditions or comorbidities that add to a patient’s medical complexity, including things like opportunistic infections, HIV, and morbid obesity.

And with patients being the sickest when they’re first discharged from the hospital, the timing of the MDS assessment becomes critical to capture these additional conditions or comorbidities. If the assessment is delayed, conditions you treated may no longer be evident or the assessment may get rushed leading to missed opportunities.

Have a plan in place to logistically handle the MDS assessment in a timely manner.

For more information on PDPM, consider reading our free e-book—PDPM Rate Driver Data Shows How SNFs Performed in 2020

2. Upgrade from an MDS Scrubber to a Data Integrity Audit (DIA) Tool

SNF software and healthcare analytics tools can do quite a bit to have a team’s back. One of the more commonly utilized tools is an MDS scrubber that checks MDS assessments prior to submission to CMS for errors, missed conditions, or any other inconsistencies that could affect reimbursement.

But a step higher in the technology support hierarchy to consider is a Data Integrity Audit (DIA) solution. Not only do these tools handle everything you get with an MDS scrubber, but they go further to offer data-driven feedback from clinical, regulatory, financial, and risk management perspectives. It’s a fantastic next step for an organization looking to better its care management operations across the board.

For more information on this, consider reading—Rub-a-dub-dub – More than a Scrub! Mastering the MDS for SNFs.

3. Have a Plan to Mitigate Adverse Events

One of the most impactful factors on treatment costs and patient success is adverse events. When patients fall, develop pressure ulcers, face rehospitalization, or have any other unexpected negative event, it’s never a good thing.

But thanks to the growth of predictive analytics in healthcare, these “unexpected” events don’t have to be so unexpected. Existing MDS systems are already collecting data that can be used to identify higher-risk patients. Once identified, care management teams can develop plans of action to mitigate risk and to get friends and family on the same page of what to expect and how they can help.

Actionable steps for harnessing the power of MDS-based insights.

If you’d like to learn more about how to use MDS assessments to improve patient care and strengthen the bottom line, we’d encourage you to check out our free e-book—The Power of Leveraging MDS-Based Analytics to Improve Patient Care.

Download eBook on MDS-based Analytics

 

  1. Centers for Medicare & Medicaid Services (CMS), https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM, June 14, 2021.
  2. Centers for Medicare & Medicaid Services (CMS), https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MLN_CalL_PDPM_Presentation_508.pdf, June 14, 2021.

Filed Under: Blog

No matter what a SNF’s goals are, data has the potential to help them meet and exceed those goals. However, the operative word here is ‘potential.’ Many SNFs are fully aware they need to collect and leverage targeted data to drive decision making. But when it comes to executing on that, there may be issues they’re unaware of.

We can see the real-world implications of all of this from a recent case study conducted on Cambridge Health Alliance, a SNF and hospital network based out of Boston, Massachusetts.

Some of the Issues Cambridge Health Alliance Faced

Like many SNF networks, Cambridge Health Alliance knew there were opportunities to leverage data to make impactful changes and drive meaningful gains. However, the company faced many of the same issues other SNFs deal with when broaching this topic.

download Cambridge Health Alliance case study PointRightHere’s a cursory snapshot of some of those issues:

  • Having to rely on anecdotal experiences to make clinical decisions
  • Not being able to accurately measure nursing home KPIs
  • Lack of benchmark data to compare and contrast performance among nursing homes
  • Insufficient metrics to enable management of at-risk populations

How Cambridge Health Alliance Met the Challenge

Thankfully, the remedy for these challenges proved to be fairly straightforward for Cambridge Health Alliance. The spoiler of the story is that through strong leadership and a great partnership, Cambridge was able to realize the full potential that data brings to the table. Some of the benefits the team experienced include:

  • Cambridge Health Alliance QuoteIncreased synergy and information sharing between facilities
  • Reduction in readmission rates
  • Identification of successes and areas to improve
  • The ability to benchmark the effectiveness of changes

The story is compelling, inspiring, and surprisingly simple. If you’d like to learn more about how Cambridge Health Alliance took control of data and the exact steps the team utilized to get there, we’d encourage you to read the full Cambridge Health Alliance case study now.

Filed Under: Blog

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