Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency
At Harmony Healthcare International (HHI), we are fielding massive amounts of questions on how and if the new PDPM reimbursement system will change the patient profile in a nursing home.
Some inquiries include:
- Does the advent of PDPM change the SNF admissions criterion for patient admission?
- Are there characteristics that define the ideal referral for skilled care in the Patient Driven Payment Model (PDPM)?
In the RUGs IV Prospective Payment System Model (PPS), the theoretical “ideal Medicare Part A skilled care candidate” participated in Physical (PT), Occupational (OT) and Speech Therapy (ST), was able to retain learning, and had a discharge disposition to home or another outpatient setting.
In the Patient Driven Payment Model (PDPM), reimbursement is linked to patient characteristics, specifically including acuity and Case Mix.
Admission liaisons will do well to consider the following elements when evaluating referrals for admission:
- Therapy Needs (PT, OT and ST):
Evaluation of Section GG (pre-therapy function) is essential for determining the facility niche for skilled care. Patients who require no assistance with bed mobility, transfers or ambulation (GG total functional score of 24), are essentially independent with these tasks. At first glance, these patients may be perceived to not benefit from rehabilitation therapy. However, this scoring system may not fully portray the functionality of a patient in the home setting.
Likewise, those who require total care (GG total functional score of 0) may be perceived as being too non-functional to receive therapeutic interventions. This too may be a misunderstanding of the value and services therapy provides in a Skilled Nursing Facility setting.
Review the pre-admission and acute care in Physical (PT), Occupational (OT) and Speech Therapy (ST)evaluations. Do the therapists recommend skilled therapeutic interventions?
- Acute Neurological Impairment:
An interdisciplinary review of the patient’s cognitive impairment, swallowing concerns, and acute neurological deficits should be completed. Patients who have a mild cognitive impairment (BIMS 10-12), and have swallowing disorders, or require a mechanically altered diet, will benefit from intervention.
Review pre-admission or acute care records indicating cognitive impairment, and neurological concerns. The patient may not require speech therapy yet may benefit from a short course of rehabilitation to reduce overall concerns with swallowing and other neurological deficits.
- Non-Therapy Ancillary Co-Morbidities:
There are 50 co-morbidities on the NTA list. Many of these are uncommon, and it makes sense to focus on the most frequently occurring co-morbidities.
The admission liaison will do well to focus on the following co-morbidities:
- Diabetes Mellitus (type one or two);
- COPD/asthma/chronic lung disease;
- Intravenous medication needs,
- feeding tubes,
- intermittent catheterization,
- ostomy needs.
- Nursing Care Needs:
Patients who have significant nursing level acuity do well in skilled care environments. In particular, those patients with high acuity who have the potential to progress to the next level of care will do well in the PDPM environment.
In general, the admission liaison should focus on reviewing patients with complex needs such as dialysis, chemotherapy, radiation, or those requiring isolation, intravenous medications, or with wound care treatments.
Strategy #1: Describe the Patient’s Situation
What happened to bring the patient to this point in their healthcare story? The medical and surgical history and physical can be most helpful in understanding the patient’s story.
Strategy #2: Identify the Key Reason for Admission
What is the reason that the patient needs skilled care? This may require the interdisciplinary team to single out the core reason for admission. That should lead to the ICD-10 Code that should be used as the Primary Diagnosis for admission.
Strategy #3: Never Short-Change the 5-Day Assessment
Since this is the assessment through which reimbursement will be determined, it is essential that the patient’s needs are carefully articulated and documented. As an example, Section GG is critical. The 10 areas included in Section GG for PDPM must be completed. Support for completion and for back-up to those completing it is recommended.
Above all else, the focus must be on the patient.
Providing an environment in which the patient can reach the highest practicable physical, mental and psychosocial well-being in order to progress to the next level of care, is a goal that will continue to meet regulatory requirements in addition to achieving optimal patient outcomes.
Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here. Looking to train your staff? Join us in person at one of our our upcoming Competency/Certification Courses. Click here to see the dates and locations.