PDPM will require teamwork


Skilled nursing facilities must focus on care coordination in preparation for new payment model

The quality of a skilled nursing facility’s care coordination efforts will be one of the determining factors in how well it adapts to a new Medicare payment model taking effect Oct. 1.


The new Patient-Driven Payment Model (PDPM) which the Centers for Medicare and Medicaid Services (CMS) will implement in FY2020 uses a case-mix methodology largely based on individual patient characteristics to determine payment.

“Communication, coordination and collaboration will be integral to accuracy under this new payment model,” said J’non Griffin, owner and president of Home Health Solutions, a nationwide consulting and outsourcing firm which has served the home health and hospice industries since 2012.

Her Alabama-based company has launched a new long-term care solutions division known as LTC Solutions in anticipation of a PDPM-inspired need among skilled nursing facilities for training, consulting and outsourcing.

“CMS is putting into place a framework which will require greater care coordination throughout the post-acute care industry, moving it away from traditional therapy-driven reimbursement to new payment models that focus in great detail on individual patient characteristics.” J’non said. “This is true of both the PDPM which will be implemented for skilled nursing facilities in October and the Patient-Driven Groupings Model (PDGM) which will be implemented for home health agencies in January.”


Both new payment models base reimbursement on a complex system of variables classifying patients by diagnosis, co-morbidities and level of functional impairment.

Accuracy in collecting all individual patient or resident data and conducting careful assessments will be key factors, according to J’non.

Areas for team work

At skilled nursing facilities, PDPM will require thorough and skilled initial assessment in collaboration with interdisciplinary team members, with a focus on acquiring and sharing all pertinent information, J’non said.

She describes the initial assessment as one of the foundational pillars for an effective care coordination program.

Pre-admission documentation will play a significant role in determining the resident’s co-morbidities, which are an important determinant under the new case-mix methodology.

“Care transitions are critically important for effective collection of information, and collaboration ensures that important details aren’t missed,” J’non said. “Since these details determine the care and services to be provided, be sure to bring in interdisciplinary team members and make them part of the assessment process.”

Therapists may identify specific deficits and needs which should be addressed through services, and may be a valuable part of setting practical, resident -centered goals as well. Social workers may identify psychosocial determinants which could impact patient outcomes and the ability to achieve goals. Social workers will be able to provide valuable insight and input on length of stay as well as resident-centered goals.

Follow-up and documentation

Follow-up and effective documentation will be two additional pillars of care coordination efforts.

“Right now, management at skilled nursing facilities should be evaluating and putting into place plans for how the care team will work together under PDGM to collect patient information,” J’non said. “Whose responsibility is it to make certain all members of the interdisciplinary team contribute to that all-important initial assessment? Who is following up to make certain the skilled care and services delivered align with the goals and care plan? Who is reviewing documentation to make certain all these important elements are being captured?”

Mapping out these responsibilities prior to the launch of PDPM will help skilled nursing facilities sidestep issues later, she said. With therapy minutes no longer driving reimbursement, it is more important than ever to adequately document the resident’s needs and align therapy services provided to risks and needs specifically identified by the initial assessment.

“The need for therapy services isn’t disappearing just because the payment model is changing,” J’non said. “Residents are going to need therapy just as much under a value-based system as they did under a volume-based system. The difference is that it will be up to skilled nursing facilities to establish the value of therapy provided to residents. And documentation is the way they are going to have to do that.”

Resident and family input

Resident and family concerns are the heart of care coordination efforts, according to J’non. Effective communication must take place between the facility, residents and families regarding care goals, care decisions, all changes and developments.

“All of this is going to take strong clinical and organization support under PDPM. Skilled nursing facilities need to be working now on shoring up their efforts in these areas in order to meet the demands of the new payment system,” J’non said.

The result will be a smoother transition to a complex payment model honing in on the individual needs, risks and characteristics of patients – and more effective, efficient and beneficial provision of care to those patients.

We can help

Need help preparing for PDPM? Would you like to discuss how using coding and review services from HHS can improve your facility’s bottom line? Contact us today!


710 Langston Rd. 

Carbon Hill, AL 35549 

888-418-6970

services@homehealthsolutionsllc.com

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