Webinar: The Patient Driven Payment Model (PDPM): 131 Days to Implementation—Are You Ready?

Disclaimer: This transcript is intended to provide an overview of the main topics discussed in the original version of this webinar. Because it has been auto-generated, it might contain errors (including to proper names, industry terminology, numbers, and punctuation) that result in altered meaning. To hear the webinar in full, please listen to the archived recording.

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And welcome everybody today, whether you’re on the east coast or the west coast, we are going to focus today on the proposed rule and then look at how the resources kind of pan out and what kind of things need to be considered in care planning. So I have the objectives here and I will let you read them. Hopefully we will. We got a lot of information to get through today, so we’re going to go ahead and jump into it. I have provided some abbreviations here, so we use a lot of abbreviations in this in this webinar. And I want you to have it for future reference to refer back to now, before we get started, I’d like to do a few poll questions. It will hopefully spawn some thinking of transition ideas, as well as give you an idea of what others are doing to prepare for PDPM.

So the first thing is for me to get a better idea about the audience. What role do you have in PDPM if you’ll take a minute and just answer this question, whether you’re an administrator, an MBS or assessment quarter coordinator, we are a part of physical therapy department, occupational therapy, speech therapy, or nursing. So let’s go ahead and do that. I also included social worker and biller or other. So if you don’t mind, just take a few minutes and let’s see what people are saying here. Give us an idea of who’s in the audience today.

We’ll wait for at least about 60% of people to respond to hope and we’ll get a few more in nobody be shy. Okay. So we have about three quarters of our audience audiences responding and and the results are here. Ah, there we go. Here we go. Okay. So about 17% of people, the, and assessment coordinators, a third of people are physical therapy and then the rest are kind of scattered all throughout. So that’s good to know. All right, so let’s move into chapter one. And this first chapter, we’re going to look at the CMS proposed rule and understand how some of the proposals in it may affect PDPM P PDPM. So many of you may be like me and literally counting down the days until PDPM. So as of today, as Ashley said, we have 131 days or approximately 3,132 hours until PDPM is upon us. Hopefully that number doesn’t impart fear or anguish and too many of you that’s let’s take the next question here on a scale of one to 10 with one being, I don’t feel prepared at all to 10 being I’m fully prepared. Now, how many of you feel ready for PDPM?

Hopefully many of you are feeling pretty prepared. This is this is kind of a scale for you to think about for yourself as far as how ready you feel. Let’s jump into the proposed rule. The fiscal year 2020 skilled nursing facilities, prospective payment system proposed rule was released a little over a month ago. Comments can be submitted by anyone. All right, I’m going to move on ahead. And we’re going to get into the meat of things, the pole, the pole, it wasn’t quite working on that one. Like we hoped. So the fiscal year 2020 skilled nursing facility, prospective payment system rule was released a little over a month ago. Comments can be submitted by anyone, but they must be submitted by 5:00 PM Eastern time on June 18th, 2019. So there is the link there for the final rule or the proposed rule and the con the address to which you can send comments.

So I want to encourage anyone to to do that if you feel inclined to do so. There are six major provisions of the what was proposed in the, in the rule, and I’m going to cover each one. So the payment update re provisions the level of care, administrative presumption, consolidated billing, and of course, updates to the PDPM. We’ve got the Smith quality reporting program and the value-based purchasing program. As a reminder, this rule applies to the all Medicare certified skilled nursing facilities. And that means the PDPM model does also apply to all Medicare certified skilled nursing facilities. This includes swing bed units, enrolled hospitals, but does not include swing beds in critical access. Hospitals, CMS has said, they’re going to continue to be paid on a cost based payment system. The PDPM model also does not apply to any patients receiving skilled nursing facility care under a managed care Medicare program or patients in or patients in Medicaid only stays.

So a common question that arises is whether these managed care programs or state Medicaid programs will change. Now that remains to be seen each managed care program, determines their own methods of paying providers. And because SNFs enter into agreements with them, which can vary across the nation. Then this means that skilled nursing facility providers are going to have to have discussions with their managed care companies, who they are in contract with to determine if payment will change. The same thing is true for state Medicaid. If your state is currently a case-mix state, then the state will have to determine how that will change in the future. Medicare did change course in April and say that they will continue to support the software for the rug system indefinitely, but to find out whether your state or managed care program is going to change, you will need to contact them because Medicare has no jurisdiction over that decision.

This slide serves as a reminder of how the payment under PDPM works. There are six components with a federal base payment rate, five are adjusted by case mix index three are adjusted again by a variable per diem adjustment, and each component is calculated separately. And then all six are added together to determine the total daily rate. The only caveat to this is that if a facility admits patients with an HIV or aids diagnosis, that information is going to be taken from the claim and the adjustment will be added to the nursing case mix component. Only Medicare said, they’re going to maintain that adjustment, but instead of it being 128%, like it is today, it’s going to be reduced to 118%. Now, if you have not yet viewed the med bridge PDPM webinar that was recorded last August, I invite you to do so. It was a deeper dive into each component of the PDPM system.

But today I’m proceeding under the assumption that everyone has a basic knowledge of the PDPM system. So CMS projects that total payments to skilled nursing facilities are going to increase by $887 million next fiscal year, compared to this one that represents approximately a 2.5% increase. Keep in mind that that could change in the final rule. But right now, Medicare estimates, a 3% increase to the market basket with a 0.5% reduction for the multi-factor productivity adjustment. There are also other adjusters that can impact a skilled nursing facility payment. And that includes the quality reporting program and the value-based purchasing program, unsuccessful reporting. And the QRP could result in a 2% payment penalty and a poor performance in the value based purchasing program could mean that a facility does not earn back the 2% removed for the program under PDPM. There is still an administrative presumption for those patients whose resource need is in one of the heaviest for each category. The administrative presumption only exists on the initial or five day MDs. And these are all the PDPM categories under each component that would carry an administrative presumption.

There are no proposed changes to the consolidated billing rules. In other words, the same services, drugs tests, and devices that follow consolidate billing rules today would remain the same under PDPM Medicare is inviting, however, for any additional items that should be added in these four categories every year, the proposed rule updates, the base rates through which skilled nursing facilities get paid under the rug system. We’ve been used to these four components, the nursing therapy therapy, non case mix, and the non case mix rates as we expected CMS is providing updated amounts for the PDPM components. You may recall that last year they published what the PDPM base rates would have been. If PDPM were implemented last October one, they did this. So providers could begin to model what the impact might be on their operations. Last year, they published what the PDPM rights were and this year they are proposed.

These rates they’ve updated them for fiscal year 2020. These are taken from table two, three, sorry, three and four in the SNF proposed rule, and keep in mind that they could be updated again. And the final rule, if Medicare makes additional adjustments to the data under PDPM, we are going to have new billing hits codes. And the proposed rule provided us with additional clarification of how each of these components would be recognized on a claim, gets Medicare information on the patient characteristics and the time point for which we are billing today, the HIPPS code consists of five characters. The first three relate to the rug level. And in this example, I’m showing a realtor high with the AE, representing the ADL split for the functional level. The last two characters represent the assessment type. The code represents. So in this coat, in this example, and oh, one means this is the five day assessment under PDPM.

We’re still going to have five characters, but they’ll represent different things. The first represents PT and OT. The second speech therapy, the third skilled nursing, the fourth, the NTA component, and the fifth will represent the assessment type. This shows all the possible hips codes for each of the PT, OT S T and MTA groups. You could make some logic out of it by using the second letter of each of the groups case mix group. So in other words, a payment group of TJ for PT and OT is going to be represented on the claim with a J in the first spot payment group of insi for the NTA will be represented on the claim with a C in the fourth spot of the code. This slide shows the nursing groups and what hips characters they translate to. It’s a little bit harder to easily identify which payment group the hips characters associated with for nursing.

And this shows the hips character for the assessment types. There are only three that’s because Medicare has significantly reduced the, of required assessments under the PDPM. One thing billers may be wondering is, well, what is the default code? The default code is used when a provider must bill for days associated with light assessments or missed assessments. CMS has given us a code of zzz Z five DS. And I have heard CMS say in a presentation a few months ago that this is on purpose, because if you end up having to build a default code, then you must’ve fallen asleep. So I found that kind of humorous, even for Medicare. Another important point for billing is that interrupted stays will be indicated on the claim in the same way. A leave of absence is today a big surprise for therapy was that Medicare is proposing to revise the group therapy definition effective October 1st, 2019.

Currently the group therapy is defined as the practice of one therapist or therapy assistant treating four patients at the same time while patients are performing either the same or similar activities in this role, CMS is proposing to define group therapy in the Smith party setting as qualified rehabilitation therapist or therapist assistant treating two to six patients at the same time who are performing the same or similar activities. Medicare explained their decision to do this as an effort to support their cross setting initiatives under the impact act. So they’re looking for ways to align the definition of group therapy used under the SNF PBS more closely with the definition you used within the outpatient setting covered under part B and with the inpatient rehab facility setting, they also mentioned that they think it would be best for the decision to reflect the clinical judgment of the therapist, which of course, I’m sure all the therapists on this call agree with. So today there must be four persons in a group therapy session for the time to be counted on the MDs as group therapy. However, under PDPM, the clinician will choose how many people would be in a group. So it could be two people or three people or four people, five people or six. So my next poll question is how many of you plan on using group therapy and what is the percentage of group therapy or concurrent therapy that you do intend to use?

Go ahead and take a chance, take a minute and submit your thoughts on that one. Here we go. We’ve got lots of people responding on here. It’d be interesting to see what the results are. We still waiting on a few, got a few more responses. Be great to see what people are saying. Anybody else want to submit real quick four, we move on to the answers. Great. All right. So let’s see what the group is responding. Let me go back here. And there we go. Alright. So we have about a third of people saying they’re still planning on and using less than 5% of group for concurrent. And the rest of the group is kind of split between six and 10, 10 and 15, 16 and 20 and 21 to 25. So Medicare did say in the proposed rule that it continues to believe that individual therapy is the preferred mode and that it offers the most tailored service for patients, but they also maintain that when group therapy is used in a skilled nursing facility, therapist must explicitly document it’s used to demonstrate or justify why it is the most appropriate mode of therapy for the patients receiving it.

They have said the description should include at a minimum, the specific benefits to that particular patient of including the documented type and amount of group therapy. That is how the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals. However, they did not change the upper limit of group plus concurrent that should be provided the 25% limit by therapy. Discipline remained as finalized last year. Also, you want to note that the minutes that are coded on the MDs are unadjusted or an allocated minutes, meaning the minutes are coded on the MDs as the full time spent in therapy. If a provider exceeds the 25%, they will receive a non-fatal warning edit when the MDs is submitted.

Another proposed thing in the, in the rule was that beginning with updates for fiscal year 2020, they are going to include non-substantive changes to the ICD 10 codes through sub-regulatory process. And any substantive revisions would be proposed and finalized who noticing comments. But what they mean by this, if is a nonstop, tan of change would be those that are necessary to maintain consistency with ICD 10 medical code dataset that’s updated every October, but a sustained change would be defined simply as any change. That is not a part of the normal coding update. The skilled nursing facility proposed rule also addresses the SNF quality reporting program annually. This slide shows the current quality reporting measures that affect payment for the fiscal year 2020 year. That is October one at 19 through October one of 20. So there are 12 measures. Keep in mind that these are the, these are only the measures that are included in the skilled nursing facility, quality reporting program that was driven by the impact act of 2014.

There are a lot of other measures. However that nursing homes watch and are concerned with like the nursing home compare and five star. These measures are only monitored on part, a fee for service. Short-Stay skilled patients now, beginning of fiscal year 21, which is October one of 20 through September 30th, 2021, the new or worsened pressure ulcer measure will be retired. And that’s because it has been replaced with the changes in skin integrity. As for fiscal year 22, Medicare has proposed two new measures for skilled nursing facility. These are the same two measures that were also included in the proposed ELPAC and inpatient rehab rehabilitation facility rules that were also put out in April. These two new measures have to do with the transfer of health information. And while testing of this measure involves a lot of different pieces of health information that are commonly transferred from one setting to the other.

This measure right now is only going to include medication. The proposed measure denominator is the total number of skilled nursing facility, residents days ending and discharged to a subsequent provider, which they defined as a short-term general acute care hospital. Another skilled nursing facility, an intermediate care provider home under care of an organized home health agency or a hospice or hospice and an institutional facility, an inpatient rehab facility, a long-term care hospital, a Medicaid nursing facility, an inpatient psychiatric facility, or a critical access hospital. You can see a lot of different providers are included in that definition. Now for the denominator of the transfer of health information to the patient, that’s looking at the total number of SNF residents days ending and discharged to a private home or apartment a board and care home and assisted living a group home, the transitional living or home under the care of an organized home health service organization or a hospice.

You can see there is a little bit of overlap there, but the idea here is that both the patient and the next provider get the relevant information. This is an example of what the question might look like on the MDs. You can see that the first question is at the time of discharge, did the facility provide the patient’s current reconciled medication list to the subsequent provider? And then you would answer yes or no. And then you indicate the route. In other words, how did you, did you transfer it, knit it, did you do it through electronic health record or verbally paper or other methods there’s no pros and cons or, or points taken away for any one of these, it’s just that they’re gathering information on how you do it. And then the second question would be, did you provide it to the patient family or caregiver?

Now, why is Medicare focused on this? Because failed or ineffective patient handoffs are estimated to play a role in 20% of serious preventable adverse events. Another change that was made to the quality reporting program was the discharge to community measure. Currently, all patients discharged from the medic stay are included in the measure, even if they were discharged back to the skilled nursing facility, which may have been their regional home. Medicare in this case heard our feedback, that residents whose home is in the nursing home should not be counted in this measure because it could falsely reduce the measure for those providers who don’t admit a lot of new residents, baseline nursing facility residents are defined as SNF residents who had a long-term nursing facility stay in the 100 days preceding their hospitalization and a SNF stay with no intervening community discharged between that day and the hospitalization.

So that should help with some providers feeling like perhaps they are discharged to community measure was lower just because they didn’t get a lot of new patients from the community. Now let’s go back to this slide that shows all 12 of the measures. I realized the little blue stars are hard to see, but there are six with the blue stars. And that means that these are currently displayed on nursing home. Compare the ones with the red stars. Here are the ones that Medicare is proposing to begin displaying in calendar year 2020, or quote, as soon as feasible thereafter, unclothed outcomes from facilities with less than 20 part a PBS day though will not be reported.

And the proposed rule, Medicare also included a discussion on the standardized patient assessment data elements also called spades. They they’re items that would be identical across all four of the post-acute care settings, meaning that the inpatient rehab facility, the long-term care hospitals, skilled nursing facilities and home health agencies would collect same item with the same definition with the same response items is will enable Medicare and providers to monitor a patient across the continuum and recognize important changes or trends that should be addressed. In of course, it’s also going to facilitate CMS and the development of a unified post-acute care payment model. They have been testing this model for several years, as you can see from the slide, it started with information gathering and continued with the first round of testing the national beta test from November of 17 through summer of 2018 collected data from over 3000 patients and residents across 143 L techs, nips herbs, and home health agencies.

And they wanted to evaluate how these item elements performed across the settings. It also gathered feedback on from the staff who did, who administered these tests protocols to figure out exactly what the usability and the workflow of these elements were. So you may recall that in the fiscal year of 2018 SNF proposed rule CMS did propose adopting a wide variety of the, but they ultimately only finalized two of the six categories. So, and this rule, they are proposing several categories of new items and requesting feedback. Furthermore, Medicare is proposing that SNFs submit the hearing and vision ones and race and ethnicity ones only on admission because they feel like they will not have changed between admission and discharge. So I’ve listed some of the categories here and some of the elements that they are proposing to include, you can see that many of them have to do with special services, treatments, and interventions. These are the kinds of things that may drive up cost or further delineate. What types of patients are best served in each of the different settings that helpfully will help them pay for them more appropriately. Social determinants of health is an interesting one. We, we know that Medicare and all payers are really interested in understanding the effects that various social determinants of health like race and ethnicity, language, health, literacy, and transportation can have on a person’s health outcomes.

The last proposal to the quality reporting program is the data collection piece. Currently the quality measure information is only required on Medicare part, a fee for service residents and Medicare only only measures it for part, a fee for service residents. But in this proposal, Medicare is proposing to collect it on all patients who are there for short-stay regardless of. So that means that it would be collected on part a patients, Medicare advantage patients and Medicaid patients. Now, as a reminder, the new items transfer an of health information. Those two new items, if finalized would be collected between October one of 20 and December 31st, 2020. And if providers correctly coded these on at least 80% of all NDSS, then they would not be penalized for the QRP in fiscal year 22, which starts paying on October 1 21. This is in line with how they introduced other quality measures too.

So facility facilities should be pretty familiar with it. Medicare is also requesting information from stakeholders on these areas of consideration. They want input on how we feel or what importance we feel. These have the relevance, the appropriateness, and the applicability of each of these areas on future standardized patient assessment, data elements, or consideration for the quality reporting program. And the last major part of the proposed rule is the SNF value-based purchasing program. And the fiscal year, 20,017 final rule Medicare adopted in all condition risk adjusted, potentially preventable hospital readmission measure per SNFs. This year, they are proposing to replace it with the skilled nursing facility, potentially preventable readmission measure. But since there is also another different potentially preventable readmission measure in the QRP, they’re going to change the name of this one. So it’s more clear how this one differs from the one in the quality reporting program.

The one in the quality reporting program measures any readmissions after skilled nursing facility discharge. So therefore this one is going to be renamed the SNF propo proofs, potentially preventable readmission after hospital discharge measure this baseline period for they are also issuing their proposed achievement and benchmark threshold for the FYI 2022 performance standards. And here they are achievement being 20.5 to 4% and benchmark meaning 16.788, which means that they expect skilled nursing facilities to have a rehab utilization measure of no more than 20.5 to 4%. And if you are between 16.78, eight, and around that level, then you are really doing well.

So here is the baseline period. They’re going to be starting to measure our performance against this 20.5 to four effective October one. And they will also measure our improvement from two years prior, which is October 1st, 2017. So it’s interesting to see how the achievement and benchmark numbers have changed since implementation of the program. Cobar one, 2018 was the first year that SNFs were either penalized or received an incentive payment based on their performance just a few short months ago. So it is it has changed CMS updates, these achievement and benchmark threshold every year, based on the median performance of all nursing homes across the country. So you can see that the benchmark and achievement level for this coming year is slightly higher than what it is currently now. So let’s move on to chapter two. We know that the PDPM model is quite complex.

There are a lot of dials and levers that drive this payment model. Their providers really do need to have a handle on a number of clinical and operational processes to be successful financially, but also to ensure that their clinical care doesn’t suffer PDPM is moving us away from a system that rewarded types of service and amounts of service to one that is wholly based on patient characteristics. Now, what I tried to do here was illustrate what the rug rights would have been in fiscal year 20 using the market basket update, not an official number. It’s a projection. You can see that the total federal unadjusted rights are slightly lower, but that doesn’t mean that all skilled nursing facilities will get a payment reduction under PDPM. Medicare has said they want the system to be budget neutral, which means they don’t plan to spend more in fiscal year 20, 20 than they could have, or they would have under the rug system.

If it was back in place, keep in mind. There are a lot more variables that go into determining how much that undigested rate goes up and down. It’s going to be determined by the patient characteristics. So let’s take a look at this in the context of a patient. Let’s talk about Joe Joseph’s 75 year old male admitted after two week hospital stay or ascending aortic aneurysm repair, and aortic valve replacement. He comes in with comorbidities of insulin dependent, diabetes mellitus with peripheral neuropathy and requires daily insulin. He also has hypertension, COPD and a history of cabbage three years ago. Other past medical history includes the OPD and the hypertension, which I just realized is repeated there. So you get it twice. Then we also have his prior level of function, which he lived at home with. His spouse was independent and all IDLs IDLs and he walked without a device.

Now on its SNF admission, we have we have some some tests and measures there that were that were I gathered on the patient admission. So let’s take a look at some of those. We have the bands, we have the PHQ nine that indicates some depression. We have no complaints of swallowing problems. His self-care GG scores are there. His mobility, GG scores are there. Now I realized that that, you know, you would be gathering more than this and that the section GG is not representative of all the items, but for the sake of time and space on the slide we’re including those things that would be necessary in order to calculate a PDPM. PDPM right. So let’s look at the PT and OT the PT and OT case mix, which first is determined by the primary reason for the skilled nursing facility stay.

So as the therapist evaluating this patient, you might be asked, what is the primary medical condition for this patient? And you would need to understand what the primary medical condition would be. If you said the primary reason that I’m having the patient, seeing the patient, or they came to the nursing home is muscle weakness or gait abnormality then, and you tried to use that. And I 20 B of the MDs, what you would find is that those do not result in a category. It doesn’t result in one of these four that’s because these are symptom codes and not medical condition codes. So as therapists, we need to begin thinking about what is the underlying condition that is causing the muscle weakness or gait abnormality today. You may think of that as the medical diagnosis, but in a lot of facilities, PTs and OTs and SLPs, don’t participate in that process.

We wait for the facility to tell us what it is, why is that we all have evaluation skills, and we need to provide that input to the interdisciplinary team. Since that is important to determining what the primary medical condition is. The REI manual suggests that the primary medical condition is in in the it or that section. I is intended to code diseases that have a direct relationship to the residents, current functional status, cognitive status, mood, or behavior status, medical care, medical treatments, nursing monitoring, or risk of death. So who better to indicate the medical condition, that’s having a direct relationship to the resident’s current functional status then therapy. Now the answer here may be that you need more information to determine why the patient had a repair and an aortic valve replacement. The physician may be involved in determining which one of these two conditions is different are the primary.

So we’re going to proceed and say, it’s likely that if he had an aneurysm of the aorta, whether it was a dissecting or a dissecting aneurysm or with, or without rupture, it would classify in the cardiovascular and coagulation category, which would then be categorized into the medical management category. So this patient is going to fall into med management for PT and OT. Next, we turn to his JAG scores. His self-care DG scores were four on eating two on toileting hygiene, four on oral hygiene, which gives us three points for toileting. Or it gives us three points, three points for toileting. Sorry. no, I’m getting myself confused. Eating gives us three points. Toileting gives us one in oral hygiene equals three. So what I did there was I took a self care. GG scores, converted them to the points. According to CMS is point system.

And we have a total of seven points for these three self care items. Then we turn our attention to mobility. It’s aligning was a three line to sitting on the side of the bed was a three that to stand, was it to cheer? Banditry air transfer was it to oil. It transfers to two persons. Therefore it’s a one and walk 10 feet, but substantial max assist is to give this a tube. So for purposes of being able to look at the scores, I’m going to flip back here. So then we convert these scores to point that, to align, get this two points as deadline to sitting on the side of the bed. After you remember from our first webinar, these have to be averaged. So we get a bed mobility score of a two, two plus two divided by two is a two. Next we average the transfer scores, sit to stay and give this one point care to bed to chair, get this one.

And since toilet transfers were dependent, we have a zero. So we have a total of two points divided by three, which is 0.6, six, six, and the walking items were both eight eight. So that gives us a score zero. So if we add up the total mobility score, it gives us two in bed mobility 0.6, six, six in transfers, zero for walking. So we have a 2.66. So we go back over here and we add seven plus 2.66, which gives us 9.66. And we up we rounded up at this point to get a 10. Now I understand that your software is going to help you add all this up, but please understand it’s important that we all understand how the system works and how scores are going to affect your overall function score and your PDPM category. Next, we move to the SOP component.

Since the patient is a med management category, we know he will be a non neuro patient for speech therapy. There was nothing in the information we had indicated he had a swallowing problem, and there was no indication in his past medical history that he would qualify for an SOP co-morbidity his Ben score, however, did trigger as a mild cognitive impairment. So that’s noted in the SOP co-morbidity and in that, and it would be noted there in that category. So now we move to nursing. Since the patient has both diabetes and surgical wounds that needed daily treatments, he would be in either a special care high or a clinically complex category. And we know that the system defaults to the higher pain category. So in this case, he’s going to be put into the special care high category. Now we move to the non therapy, ancillary fees.

How many did Joe have? Well, he had he had two for diabetes mellitus. He had to for CLPD in lying flat, and the patient had a documented diagnosis of diabetic retinopathy, which is one envision would be important to his functional recovery. So that gives us a score of a five total of five points, which puts him into an indie category. So now we go to to calculating our rates. PT is a TK, which translates to 92 point 96 under the new rates. OT is a TK 86, 7 67. Then we have SLP, which translates to $33 and 33 cents. And nursing is an HBC two because of his depression score, which translates to $238 97 cents. NTA is an MD translates to $107. And the non case mix rate is set at 95, 48. Now these are all of the federal on adjusted, right? So keep that in mind, we have the PDPM table, which is quite busy, what this shows is the different components for payment across this day.

So in days one to three, the empty rate is tripled. Then after day 20, the BPDA or the variable per diem adjustment goes down for PT and OT and begins to set in. So by day eight, the PT and OT rights are 96% of what they were on day 20. And on day 49 to 55, they’re 90% of what they were on day one, the two red lines show the PDPM right in comparison to what the rug rights would be if the patient were in an AR UC or an RVC category today. So again, you can see in the first three days, the facility is getting paid much more than they do under rugs, but then after that, the values even out, please keep in mind again, that these dollar amounts do not reflect real dollars. They’re not wage adjusted for any particular city or state.

That would be a different step. Many cities and counties have wage indexes less than a 1.0, so that would bring these dollars amount, even lower in re in real world. It’s. This is meant to be an illustration of how CMS has reorganized the resources under PDPM. So now we take our code and put it into a PDPM HIPPS code, and this is what it would look like with all of our different categories. And this is how it would be represented on the claim. You can see it’s much different, and it’s hard to really pick out just by looking at it, what exactly it is. Now let’s begin to look at how we are going to treat this patient. So a question for the group here is will your admission and evaluation process change under PDPM everybody take a minute. And let’s look at that.

If we can get as many participants as possible federal, if he more, hopefully everybody’s thought about that. Anybody else want to participate? All right, so we’ve got a little over half everyone. So let’s go ahead and take a look at what people are saying. Most people are saying yes, that your, that admission evaluation process will change under PDPM. And I think that’s a, that’s relatively relatively common. We, this, this fundamental change, we do need to think about what we’re doing. So how we respond to these changes are going to be critical to a skilled nursing facility, success as therapists, we have to embrace our role, strengthen our clinical skills. And I think the same thing goes for whether you’re an MDs coordinator or nurse, anyone in the, that works in this setting, Miniclip therapy have provided a kind of crutch for nurses and therapists and MDs for 20 years, there was a tendency to just say, this patient’s in our you, or this patient’s in RV, rather than thinking about the patient from the standpoint of both their clinical characteristics and their functional needs.

Now, since there are no longer minutes to rely on, we, as therapists will need to understand our patients and their individual needs as well as nurses. That means digging into the chart, asking questions, collaborating with each other, as well as the physicians, the dieticians, and all the other therapists involved. We need to be able to translate patient characteristics into appropriate and effective treatment strategies. At admission. We need to understand the type of patient that’s in front of us. This means gathering as much information as we can at the outset, even pre-admission if we can, it means that PTs and OTs and SLPs must have strong evaluation skills. So the first thing I would challenge us all to think about is how long do you typically spend in evaluation? If we go pull all of the grids across the country and look at how many minutes are allocated to evaluation codes, I bet you that number would be somewhere between 15 and 25.

And we have to ask ourselves is that enough time to evaluate a patient in this setting? And in this context, we have to have good interview skills. We have to understand that an examination is more than completing boxes in a form. It means understanding the difference between natural decline and the decline that occurs related to underlying injury condition or pathology once we’ve completed our examination. The next step is to synthesize the information. And again, the most important piece in this step, in my opinion, is the ability to think beyond the dip dip, the typical plan of care, which is five times a four or six times, eight weeks per therapeutic exercise, gait training, self-care cognitive retraining, whatever CPT codes are chosen with the payment redistribution. We really need to understand how to individually apply doses of intensity and in duration. So do your therapist understand how to write a specific exercise prescription or a specific specific prescription for realistic cognitive training?

For example, rather than just saying therapeutic exercise should be done five times a week, what exactly do you mean? What muscles, what level of resistance, what oral motor exercises should be specifically addressed and in what order should they be addressed? So, and the last step is the biggest one. It’s it’s about management of the plan. It’s understanding how to measure and assess whether the patient is responding. As you thought they would. It’s understanding the patient’s deficits require a therapist or therapist assistant to achieve the goals. You have enough staff, will there be artificial time points of reassessment that are present management means partnering effectively with other members of the IDT as well, such as restorative activities and dietary. It means understanding their transitional needs, having effective methods of identifying those as early as possible therapist can also assist the facility with followup. After the patient’s left, the building, focusing on these processes will improve a facilities, outcomes, and all those areas of the QRP and BBP that we’ve talked about.

So a tool I’d like to offer my idea for the therapist’s writing this tool began almost two years ago with, I read the advanced notice of proposed rule making, which discussed the RCS one model. You may remember that I knew then that CMS was finally beginning to land on a model that would shift us away from minutes. So the idea came more, became more crystallized when the proposed rule for fiscal year 19 was released. So this tool was designed by rehabilitation therapists with both therapists and therapy therapist assistants in mind by company, as well as the academy of geriatric physical therapy, the American healthcare association and occupational and speech therapist gave feedback and helped refine these tools. So this is a screenshot of the PT readiness tool. Each one is two pages. It could have been much longer than that, but with feedback from other therapists, we determined that trying to limit it to two pages would be more practical and feasible for implementation.

So my hope is that it will generate additional discussion among therapists and between therapists and supervisors. This tool is free. It can be used by individuals or team leaders to assess their own or their team’s strength, weaknesses, and areas of potential growth. Each of the ones for PT, OT, and speech had disciplined specific measurements because each therapy discipline is unique and offers unique contributions to a patient’s recovery. So we need to be sure that we are taking advantage of that uniqueness and be an effective team. And in addressing a patient’s needs blind courage you to download that from the med bridge website or contact me offline when you use this tool, I encourage everyone. To be honest, there is no right or wrong answer. This is not going to affect badly on your performance. We all need to understand how we need to what areas we need to improve on and how we can be an effective team member under PDPM.

So you answer for if you’re very confident that your practice currently reflects what’s on there. Three is somewhat confident. Two is slightly, and one is not confident at all. Since we’re suggesting that anything with a three or less, that you out tools and resources, either from med bridge, from your professional association, from your company, your clinical supervisor, lots of opportunities out there. And lastly, we’re going to just touch on some of the compliance issues that are present under PDPM. So I want to ask everyone what issues keep you up at night when you’re thinking about the transition to PDPM everybody take just a few minutes and answer that question.

Hopefully this one will generate a lot of interest. Anybody else have any thoughts on this? Anybody who is still, still hanging on with us, we’d be interested to hear your thoughts at about a third of people responding. Let’s get just a few more. All right. We’re getting close to that, mark. All right. Let’s go ahead and put these out there and see what people are saying. All right. Well, we got 6% of people who are feeling really good about PDPM. So that’s reassuring. Rest of us are most worried about the MDs and about how much therapy to provide. So certainly that that those are viable and, and certainly understandable concerns. So it is something that we all of course want to be sure of is that our patients get the right care at the right time and that our facilities get paid the right amount.

So these are all areas that we know are going to be looked at by CMS and others, as far as how to be compliant. I also think they’re very good for us to look at ourselves. So we, we know that section, I is going to be scrutinized at the kind kinds of diagnoses that we have, but more importantly, do we have the documentation to support the code that we chose? We know section GG is going to be is going to be scrutinized. We’ve been collecting GG for almost three years. Now, are our scores going to change now that they are affected by payment? That will be something that Medicare is watching. They also want to be sure that there aren’t a whole lot of patients that end up on mechanically altered diets, just because it gets just because it gets, you know, the more points there.

It also will be related to daily skills. So, you know, what daily skill do we have going on? Is it, is it covered, is there five to seven days a week of therapy or is there a seven days a week of nursing? There were some interesting comments in the recent draft REI manual that came out about how the patients refused to participate in therapy. It might trigger an interrupted stay. So we certainly want to make sure that we have daily skilled documented, and it’s supported. We also want to make sure that that by you know, re-engineering our care, we don’t inadvertently cause more readmissions, which would increase the number of interrupted stays that we have interrupted stays will certainly hurt our outcomes. And we want to be aware of that. We also need to make sure that we’re, that we’re coding depression correctly.

Depression can increase a nursing case mix. And today, you know, there aren’t a lot of patients that end up in that category. And so there’ll be watching to see if more patients are identified with depression and if the documentation supports that. And then lastly, section O section, oh, and the minutes of therapy, we know that they will be monitoring to make sure that there isn’t too much therapy reduced under the new system. We want to make sure that our patients and we must be advocates to make sure that our patients are getting adequate amounts of therapy doesn’t mean that we can’t look at what we’re doing and make sure we’re doing the right amount, but we certainly don’t want to err on the side of providing too little just in the face of trying to maintain current payment levels. So at this point I want to turn it over and begin to look at some of the questions in our remaining minutes. So I’m looking here in my folder to see if there are any questions in this box.

Okay. One question was, can assistance PTA or OTAs contribute to section GG the eye, not on manual defines a qualified clinician as the healthcare profession professionals practicing within their scope of practice. And a, and that is accurate is that they, the section GG is considered an assessment. So the best way that I try to explain this is that is that the person who decides what the scores are that go into the MDs should be a person who has assessments in their scope of practice. So typically we think of this as nurses, PTs, OTs, and SOP. However, I, as a PT need to use the input of assistance to help me in determining what I might recommend to put into GG. So it’s not that they can’t contribute to it. It is just that the decision about what goes into the MDs and gets transmitted as the final score needs to be done by one of those qualified healthcare professionals.

Another question is, can you please explain the non therapy ancillary base rate for urban areas? 84, 80 45. So for resident has five NTA points. Does that mean the Syria will be $80 and 45 cents times five? No, that’s not exactly what it means. If you go back to the slide that shows the NTA, there are six levels and those levels are defined by points. So it’s the number of points that you have. We’ll put you into level 1, 2, 3, 4, 5, or six. Each of those six levels is associated with a specific case mix. And so depending on what the case mix is, it will be multiplied by that number. So for instance, a a, someone with five points might have a case mix of a 1.12, which means you’re $80 and 45 cents would be multiplied by 1.12. So you want to look back at that table and the slide presentation to be able to get those numbers.

Another question is, I assume they retained the rule that requires therapy minutes and visits still be reported at discharge. That is correct. And the second part of that question was, does this include all minutes of visits provided during this day? And that answer is yes, even if the patient had an interrupted stay. So if the patient went out to the hospital for two days and came back, then you would not do a PPS discharge assessment, which means that when the patient did finally get discharged from part a, you would include all the minutes and all the days from their original admission date. And then the last part of the question was, do you foresee them requiring additional reporting? If therapy is drastically reduced? I don’t know what they would require Jeff, but they definitely will re to be doing something. If they see therapy is drastically reduced and there is a change in the therapy outcomes.

There’s no doubt that they will follow up with some kind of a new with a new rule or a new choir mint of some kind. Another question was, does the 25% group time per discipline refer to minutes provided, or number of sessions provided good question, 25% group of minutes. So, and again, keep in mind that it’s not just group, it’s 20, you have a limit of 25% of your total minutes that can be provided in group and or concurrent therapy, the 25% limit, but those things combined, and it is it is be by discipline. So 25 of all speech minutes could be delivered in group or concurrent 25% of all PT minutes and 25% of all OT minutes. Another question is, will the group therapy minutes still be divided by four? Like currently? No, they will not good questions. So if I have four patients in a group on October one, each of those patients will have 60 minutes counted towards their 25% allocation.

It will not be it will not be you know, broken down. And another question was, have you seen in documentation that sets parameters on time for groups? I’m not sure if that’s referring to the start and stop time of group or whether a group has to be no more than 60 minutes. So either way, whichever whichever way the question was, I have not seen anything anything like that. So I think I’ll take two more questions. One is that you mentioned that the rule does not apply to critical access hospitals. So is there anything that we need to do as a critical access hospital in order to be prepared for October one? I would say, you know, not necessarily, but just kind of watch of course, and and be aware. I think it’s a good idea to be aware of what these changes are cause you never know when they may come to your setting or how they might affect your payment or even the flow of patients to and from your facility.

So I think that I think it’s just always a good idea to kind of, kind of keep an, keep an eye on that. And the last question was, can you review again the documentation requirements for group therapy and I’d love for everyone to look at the resident assessment instrument manual as well, but I will go ahead and read again what the proposed rule said about documentation. It said therapists, miss explicitly document its use to demonstrate or justify why it meaning group is the most appropriate mode of therapy for the patient receiving it. The description should include at a minimum, the specific benefits to that particular patient of including the documented type and amount of group therapy. That is how the prescribed type and amount of group therapy will meet the patient’s needs and assist the patient in reaching the documented goals. So in essence, there’s not, you know, there may be some semantics there, but I don’t read it to be that different than what we are required to do today if we use group. But I understand that a lot of people do not currently use group. So I realized that we have gone over our time limit. I appreciate everybody who hung in there with us. So a lot of information to cover and I thank you for your attention.