CEO of a skilled nursing facility staring at his laptop with his glasses in hand

Journey to PDPM, Stage 1: Conceptualize

The Conceptualize phase in your journey is all about the plan. The plan you develop in this stage is the roadmap that will guide you throughout this journey. The changes you need to make along the way will be built on your gap analysis — from the review of all the changes to your current state using the RUGS approach to reimbursement, to the end state of mastering PDPM, all these changes will need to be planned and executed accordingly.

It is important to remember that PDPM is not just a payment shift, it requires a cultural change in care delivery, care delivery models, and a clear understanding of how your technology will support your PDPM journey. Change management will be the key to success and you need to focus on:

  • Optimizing reimbursement
  • Addressing their facility’s changing resident populations
  • Preparing for the impact of the change

To determine what your comprehensive plan should include, you should be reviewing the potential impact of PDPM, determining and examining workflows, finding what needs to change, getting an understanding of what education and advanced skills staff may need in order to get you to your end state, and obtaining an understanding of how referral partners and vendors will support you in this transition. 

This is also a great opportunity to align QAPI requirements under the ROP to your PDPM activities. Your journey is a Quality Assurance and Improvement Plan — it follows the basics of QIPS; conceptualize what you need to do (Plan), standardize and Implement the things you need to do (Do), analyze the data to confirm progress (Check), optimize processes by closing any further gaps, make improvements and update resources, operationalize those resources across the organization, and scale the changes needed (Act).

Though this isn’t intended to be a comprehensive list, every home has its own unique processes and will have its own objectives to achieve in the journey, here are some areas you should be considering in developing your plan.

1.Understand the Impact PDPM will have on business and operations

The current RUGS payment model incentivizes the volume of therapy minutes provided. PDPM is intended to appropriately and holistically reimburse providers for treating the patient’s specific needs. Understanding the impact of this change on care and billing processes is the key to a successful journey through PDPM.

There are many sources of information out there to help with this part of your planning and you should use whatever data you have available. EHR vendors will have tools to help you understand where you may need to make changes and improvements. They should have tools that help you understand your current case mix and data that allows projections. These tools can be used to determine acuity mix to understand resources and project needs moving through PDPM.

For further information on understanding your impact, check out these resources:

  • CMS: has provided a tool that takes your 2017 MDS data and coverts it to PDPM case mix called the SNF PDPM Specific Provider Impact Analysis.
  • CASPAR: reports can give you trends over time that help you look for areas for improvement.

2. Audit ICD-10 codes for accurate and comprehensive diagnosis coding to ensure adequate resourcing

In PDPM, the ICD-10 code selected will drive reimbursement in OT/PT/NTA and SLP Case Mix Groups. Comprehensive diagnosis coding and ensuring those codes are on the MDS is something that facilities can change now.

Focusing on how to select the most appropriate ICD-10 Primary diagnosis by clinical category is key. Diagnoses affect all case mix groups for all disciplines in one way or another — for reimbursement and for documentation. Non-therapy ancillary capture will be extremely important to revenue and getting the information as soon as possible to capture it on the 5-day will be paramount.  This will also mean looking at data sources and the timing of capturing that data to ensure appropriate reimbursement for resources used is captured. This is an entire interdisciplinary team process — and doctors, therapists, mental health teams as well as facility staff should be included in the conversation.

3. Audit Records and Referrals

There is only one chance to get the 5-day payment assessment right. You will need to understand what information is needed on admission — and what can be collected before admission — to comprehensively code that payment assessment and expedite the process on admission. This will not only improve data capture for diagnoses but also ensure that the required supportive documentation is in the chart. Your resident records are great sources of information. Compare current 5-day assessments to 14-day assessments to look for missing data points and figure out what there is to change. Note that you won’t have that 14-day assessment moving forward, so timing of data collection must be examined. Do some chart reviews and look for missed diagnoses such as information captured in the record but not on the MDS. Records analysis under the lens of PDPM will provide a lot of information on areas to improve.

4. Determine staff learning needs to be PDPM competent

Staff will need to understand what is changing and why in order to understand why processes are changing in the home. The focus moving forward is on the clinical characteristics of the resident. The answer to the question, “Why are they here?” should never be “they needed rehab”. Focussing on clinical characteristics of the resident may require a renewed focus on physical assessment and documentation skills.  If your strategy is to go after the medically complex residents to optimize case mix, then your clinical content and technology strategy to support knowledge and learning should also be examined. This is also a cultural shift — the patient isn’t only the focus of our care — they are driving it. Soft skills to support better care such as empathy and communication will also help your staff in this journey.

This is the most important step in getting through PDPM and shouldn’t be taken lightly. The only way you can determine that you have met your goals and successfully managed change is if you have truly done a suitable current and end state evaluation that documents all of your gaps and milestones to be achieved.

Want to learn more about Stage 1? Check out our recorded webinar “Your Journey Through PDPM”.

March 15, 2019