​

Resource Utilization Groups are out, and the Patient-Driven Payment Model (PDPM) is in. While providers have been preparing for months, the transition could prove less than smooth. Key to navigating the challenges are strong clinical leaders who can help steer the team into compliance and ensure accurate, adequate reimbursement while providing quality care.

“There is no question that PDPM is a clinical program, and it is important to put a focus on that aspect of it.You need a level of clinical expertise to identify nuances and complexities of diagnoses,” says Michael Wasserman, MD, CMD, president of the California Association of Long-Term Care Medicine. A high level of clinical expertise is critical for both appropriate diagnoses and quality outcomes, he says. “If you don’t have this, you risk seeing more readmissions, fewer referrals, or even lawsuits.”

Rajeev Kumar, MD, FACP, CMD, chief medical officer of Symbria in Illinois, adds, “In my ideal PDPM world, while this must be a group effort, a clinical leader would take ownership of the program. There must be someone capable of handling this and juggling all of the responsibilities involved, while tracking all the necessary information.” The more comprehensive and timely the initial assessment is, he says, the more likely the facility will be successful in PDPM.

“We need to prepare our clinical staff for this major change while enabling them to maintain their focus on day-to-day patient care,” says Sarah Ragone, MS, PT, RAC-CT, QCP, vice president of reimbursement and education for Coretactics Healthcare Consulting in Albany, N.Y.

“We can’t operate with existing processes,” says Steven Buslovich, MD, MSHCPM, a geriatrician and president and chief executive officer of Patient Pattern. “There is a new emphasis on diagnoses to drive reimbursement, and our teams need to recognize that medical complexity is tied to payment.”

No matter how much training clinicians have received on PDPM, it’s difficult to change thinking long term. At the same time, some persistent misconceptions will need to be addressed. For instance, “The biggest misconception is that this is not a change in how care is delivered, but a change in how [skilled nursing facilities] are paid for that care,” Ragone says. However, with therapy minutes no longer driving reimbursement, there will be a strengthened focus on individual care needs and goals of the resident, she says.

Peggy Connorton, national director of skilled nursing facility operations for Covenant Living Communities and Services in Illinois, says, “It’s about changing staff’s mindset about care from rehab-driven to holistic. We want staff to communicate and care plan as a team, not work in siloes. In the first few months, we will be changing these old habits and reminding teams to follow this new way of thinking and working.”

Another misconception is that therapy is going to be a nonentity. “This couldn’t be further from the truth,” Kumar says. “The entire onus will no longer be on therapy, but it will still be important.”

At the same time, he says, some patients won’t benefit from therapy, and there will be no need to put them through it. This new paradigm presents an opportunity for therapists to use the full extent of their scope of practice to help determine the intensity and duration of services needed for patients based on medical necessity. “There is more opportunity to customize therapy services for each resident,” he says.

PDPM involves six buckets that will drive reimbursement: physical therapy, occupational therapy, speech-language pathology services, nursing and social services, nontherapy ancillary services, and non-nursing case-mix index. These will all need some degree of clinical leadership.

“Facility staff will need to understand how to do the long math on each of the case-mix-weighted components for PDPM,” Ragone says. “We cannot afford to rely solely on our electronic medical record. Staff will need to understand the components of each of the PDPM buckets.”

Management will need to ensure that staff have expertise in diagnosis coding and are using the tools from the Centers for Medicare & Medicaid Services to map those diagnoses to clinical categories appropriate for PDPM, she says. “Interdisciplinary teams will need to communicate with one another on these diagnoses as early as possible, ideally before a new admission comes through the door.”

Ragone says that nursing documentation will go a long way in supporting the diagnoses Minimum Data Set (MDS) coordinators will be coding to support PDPM. “As an industry, we have long focused on improving documentation from therapy,” she says. “Often, facilities have specialized electronic software for rehab documentation. We have not necessarily done the same for nurses.”

Consideration should be given, she says, to “how we can use our electronic medical records more efficiently to support nursing documentation.” Building in templates and structure to note-writing for nurses, based on a resident’s clinical presentation or reasons for skilled coverage, will support PDPM coding.

The nontherapy ancillaries in the first three days are a big driver for reimbursement, but it’s also new and, therefore, challenging. “There needs to be an awareness among clinical staff that they need to identify [nontherapy ancillaries] and capture them in the initial MDS assessment,” says Kumar. More expensive treatment may be necessary with time, such as wound care or antibiotics, with a change in condition,” he says. “If you add more expensive treatments, this needs to be captured as early as possible with an Interim Payment Assessment [IPA].”

The IPA presents another opportunity to capture reimbursement, and this requires constant vigilance by all collaborators. The IPA should be completed when providers determine that the patient has undergone a significant change justifying a new assessment. “Someone needs to own that job and skill set,” Kumar says.

More than ever, all clinical staff, including therapists, will need to observe for condition changes. “Functional scores will change over time, and payment projections will track with the scores. If a patient improves a little and can perform a few more ADLs [activities of daily living], he or she might benefit from more intensive therapy, and there might be an opportunity to receive additional reimbursement to cover it,” Kumar says.

At the same time, therapists and MDS coordinators need to track cognitive deficits, swallowing, diet modifications, and neurological diagnoses, as reimbursement can go up or down with changes in these areas.

Prompt identification and management of acute condition changes is critical. As Wasserman says, “A change in condition will trigger an opportunity for a new assessment. If you fail to identify these changes quickly, the result is a lose-lose situation. The patient can have poorer outcomes and possibly be subject to an avoidable emergency department visit, and the facility loses out on opportunities to bill for new and necessary interventions.”

For all buckets, communication skills will be key. People need to be able to work together, Connorton says. “We need to make sure people know how to chart correctly, and we need to review charting daily to make sure everyone has the skills and competencies to be effective.” She suggests conducting some self-audits.

“This can help you identify those who are having difficulties so that they can get additional training promptly. If you conduct audits and monitor what people are doing, you can catch gaps in knowledge before they become long-term habits that can likely cause problems in the future.”

Timeliness of assessments and documentation take on a new urgency under PDPM, and clinical leaders can help drive these efforts. Ideally, assessments should start before the patient even sets foot in the facility.

“The admissions process is probably the weakest link in that most facilities don’t currently have strong assessments before patients come into the building, and this will be necessary under PDPM,” Buslovich says.

“The process starts pre-admission to help optimize and generate the most appropriate clinical assessments from the start.”

The facility team needs to know they have the resources and staffing to care for each patient in a cost-effective manner, and this requires information beyond the hospital discharge summary. It also calls for the engagement of the clinical leaders, including the medical director, Buslovich says.

Wasserman agrees, noting, “You need an engaged medical director who can spend a fair amount of time helping to evaluate patients’ complexity and needs.” This clinical leader also needs to be involved in areas such as behavioral management, treatment of wounds, appropriate medication use, and infection control. To not have a strong, engaged clinical leader at the top is “penny-wise and pound-foolish,” he says.

The medical director should be encouraged to lead a “deeper dive” in the admissions process, Buslovich says. “There is a misconception that we can just use the hospital diagnosis under PDPM, but diagnosis information on the hospital discharge summary lacks depth and contains only a small fraction of information about the patient’s medical issues and history,” he says, “If we count solely on this information, we miss opportunities for reimbursement.”

It is key to create a process that reallocates staffing and resources from therapy services to the admissions process. This doesn’t necessarily mean new hires, Buslovich says, but “repurposing” existing staff to do more thorough record reviews and clinical assessments.

MDS documentation needs to have a focus as well, Kumar says. “It’s all about the timeliness and accuracy of the data, and we need to track revenue and expenses per diem, per service-line [bucket] for each patient. If you can identify discrepancies or deviations, you can hone in on problem areas.” 

Clinical leaders have not always been heavily involved in the utilization review process. However, under PDPM, this must change. “We will need to work closely with practitioners to prioritize clinical conditions and code them accurately in the medical record,” Ragone says.

“The pharmacist will need to be involved and engaged with the medical staff on medication reconciliation, especially regarding stop dates for certain medications that are expensive and possibly unnecessary,” Kumar adds.

“We need to use ICD-10 mapping tools to track data such as return-to-provider status to see if we’re going down the right path with diagnosis coding,” says Ragone. “We need to look at data on functional status and watch lengths of stay.”

“I can’t stress enough how important it is to educate the interdisciplinary team. This will be an all-hands-on-deck endeavor,” says Ragone. “Clinical leaders need to stay in touch with their teams and make sure they are comfortable asking any questions they have.”

It also will be important for clinical leaders to ensure their staff are hearing a consistent message—both with the big picture and the small details. For instance, use of the ICD-10 code for a diagnosis of morbid obesity, rather than relying on weight entered on the MDS or an ICD-10 code for obesity, will help ensure the facility is coding appropriately for accurate reimbursement. “Everyone has to own a piece of this,” says Ragone.

Leaders need to bring the interdisciplinary team together and make sure everyone knows each other, knows their roles and responsibilities, has necessary tools and resources, and is able and willing to collaborate, Kumar says. They need to know every professional involved in every bucket and be in constant communication. Leaders in the building need to work “as a unit and jointly own the process,” he says.

Not every team member has to be tech savvy, but clinical leaders can help ensure that everyone knows what information they need for their part of the PDPM process, how to secure it, and how and where to document it.

“We started to have change management meetings months ago. We rolled out a new documentation system and asked team leaders to review it every day and become familiar and comfortable with it,” Connorton says. 

“We worked with them to help ensure that everyone understands why we need to do things differently. We gave MDS coordinators the ability to take charge of meetings and get used to holding people accountable for their roles in assessments, data collection, and documentation,” she says. “We worked to help them feel more comfortable having difficult conversations.”

Training can’t stop just because PDPM is here. “We need to make our centers places where people can ask questions,” says Connorton. She suggests shoring up clinical competencies to address issues and challenges that are new and unusual under PDPM.

“We have to make sure that we have the right staff involved. If someone doesn’t want to or can’t do this, we need to evaluate the staff member’s capabilities and discuss where he or she will feel more comfortable working, such as the long-term unit, another level of care, or a different shift.”

While ongoing training and education are key, Wasserman stresses the need to ensure that staff don’t get so caught up in the minutia of PDPM that it takes their focus from their day-to-day patient care responsibilities.

“We need to let people do their jobs and not pull them in different directions. Limit training to what people need, and provide these basics in an ongoing fashion,” he says. “Provide them with the resources and support they need, but also make sure they know that leadership is there for them.”

PDPM is complex, but clinical leaders can help the team focus on key points and not get overwhelmed. At the same time, they can prevent people from oversimplifying their approach to the new system.

“We know that reporting will be complex. We know that therapy will be diminished somewhat and will be more customized. However, just addressing these two issues won’t be enough,” Kumar says. This is all about customizing care delivery to individual resident needs; leaders need to focus on what is medically necessary and doing what is right for each patient, he says.

Everyone is talking about the revenue side of PDPM, Buslovich notes, but few are talking about the costs associated with managing more medically complex patients. “There may be a temptation to admit more complex patients to maximize reimbursement potential, but if you don’t adequately assess clinical risk, those patients could end up costing more and experiencing poor outcomes such as readmissions,” he says. “You need to make sure you have the clinical leadership, staffing, and resources to manage any patients you admit.” 

Buslovich suggests working with clinical leaders to develop a strategy regarding the type of patients the facility can manage safely and effectively, as well as “how you will measure this in a meaningful way.”

“Clinical leaders set the mood and culture in the facility,” Ragone says. “Staying engaged and excited over new processes is key. Empowering our staff with the knowledge and resources they need to be successful will help them rise to new levels.”

Clinical leaders play a key role in keeping up people’s morale and helping them find the good in their day-to-day work, Buslovich says. Otherwise, there is a higher likelihood of burnout and people “losing their drive and the passion that brought them to this work in the first place.”

Wasserman suggests that leaders help keep their teams focused on the common passion of providing quality care for their residents.

Kumar has the perfect positive message for team members: “There is no reason to panic. PDPM is here to stay, but there has been enough education all around and numerous articles and in-service presentations. Everyone has heard about it and is prepared,” he says.

“There will be hiccups initially, but if you make a mistake, fix it and learn from it. It shouldn’t be a cause for alarm. We’ve been through changes before, and, in many ways, this is no different,” he says. “On the other hand, it is a huge opportunity to receive credit for everything we do for our patients.”