By Maria Arellano, MS, RN
Over the last 12 months, skilled nursing facility (SNF) providers spent considerable time and resources preparing interdisciplinary teams for the anxiously awaited Patient Driven Payment Model (PDPM). PDPM is the most dramatic change to hit skilled nursing facilities in two decades and shifts payment for caring for Medicare beneficiaries from a therapy services-based method to one based on the patient’s clinical characteristics. Not only does this change require a shift in mindset, but it forced SNFs to look deeply at their internal roles and processes and consider adjustments to support PDPM.
Now comes the hard part: executing the plan. In the final days approaching the October 1, 2019 implementation date, final preparations and practice runs should be happening now. One last item to put in your plan: a method to evaluate your efforts along the way.
Does your PDPM strategy include steps to monitor your progress? Just as the SNF nurse evaluates the effectiveness of a patient’s care plan throughout the stay, SNF leadership must periodically evaluate how their PDPM plan is working and make necessary adjustments.
But how do you evaluate success in PDPM? What metrics will tell you that you are on the right track?
One important concept to understand is that reimbursement isn’t the only measure of success, so even if your claims are paid, it doesn’t mean you’ve provided the level of quality care CMS is expecting. In CMS’ August Quality Reporting Program (QRP) training, it was made clear that CMS is watching your outcomes closely, so you should be, too! Knowing what CMS and auditors are focusing on will help focus your evaluation.
Key Metrics to Watch during Your PDPM Transition
Rehospitalization – Did this indicator rise post October 1? Why? What practices changed that may impact care? At what point in their stay did they return to the hospital? [Learn more about managing rehospitalization.]
Length of Stay (LOS) – While LOS doesn’t tell the whole story, it can provide patterns and in conjunction with other quality measures such as rehospitalization, can help identify root cause. Are you discharging folks quicker to avoid the variable payment reductions only to have them return to the hospital from home a week later? Are you accepting certain types of residents that you are not equipped to care for effectively simply because they bring a higher per diem?
Therapy utilization: Therapy minutes – CMS has clearly stated that they are watching therapy minutes closely. You will still report minutes in Section O so CMS expects that your therapy minutes post 10/1 should be similar to therapy minutes pre 10/1. Watch for inadvertent changes in therapy practices.
Therapy type: Group/concurrent minutes – Along with PDPM, CMS added the 25% limit on the use of group and concurrent treatments. Are you monitoring your therapy levels during the stay or relying on your therapy vendor? Are you monitoring each discharge assessment to identify possible red flags? While there may be a resident who appropriately exceeds the 25% limit, it shouldn’t be the norm. Documentation in that resident’s record should support the need.
Changes in Resident Characteristics – Has there been a sudden increase in swallowing disorders, use of mechanical soft diets, cognitive deficits and depression? Is there a valid explanation for this that is documented in each residents’ record or could it be viewed as padding the per diem?
MDS Coding Trends – Watch your coding trends to ensure key MDS items that may impact your reimbursement aren’t missed. Coding inconsistencies and errors are common. For example, is Section G walking in corridor coded as Partial Assist but GG Walking 50 is not attempted? Is Major Joint Replacement Surgery checked, but Surgical Wound is not. PDPM success begins one MDS at a time so a thorough review of each MDS prior to submission will be critical. [Related Blog: Is Your Documentation PDPM Ready?]
Quality Measures – Keep a close eye on your outcomes because CMS is! For example, did your Improvement in Function Quality Measure decline? If so, is it possibly due to a decrease in therapy services provided? Having access to real-time updates on your quality measures will allow you to monitor this and other measures. Waiting for CMS to post is too late.
Key Steps to Monitor Your PDPM Progress
- Revisit team expectations so all are clear on their new responsibilities.
- Set team and individual team member goals weekly for the first 30-60 days. You can shift to monthly and quarterly if all is going well.
- Hold each other accountable. PDPM is a team sport!
- Use existing meetings such as daily stand up or weekly Medicare review to ensure good communication and get progress updates using a PDPM checklist to ensure new processes are occurring consistently.
- Schedule additional check points as needed to address deviations quickly. You may need to adjust your plan along the way. Be open to the need for plan changes.
- Evaluate the tools available to you to help you monitor your progress.
These and other measures can provide great insight into your PDPM progress and identify potential problems before it’s too late. Regular checkpoints with the team and holding each other accountable are important steps that should be in every PDPM plan. Remember, you can have the best strategy in the world, but effective execution of the plan is what will drive your PDPM success.
Maria Arellano, MS, RN
Senior Healthcare Specialist, PointRight
Maria has over 35 years’ experience as a registered nurse in the post-acute industry. Maria has served in a variety of roles directly in or supporting the long-term post-acute care sector including staff development, director of nursing and corporate consultant where she demonstrated regulatory excellence and exemplary quality outcomes. Previously she was a nursing home quality specialist with a quality improvement organization (QIO) and worked to enhance the quality of care for residents. Maria participated on CMS Technical Expert Panels as well as various committees and advisory boards throughout her career. She is focused on quality improvement, which fuels her passion for transforming data into knowledge and actionable insights.