Part I PDPM OBJECTIVES

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1 1

2 Presenter 2

3 Part I PDPM OBJECTIVES 3

4 How Did We Get Here? 4

5 History of Medicare Payment for SNFs 5

6 Case-Mix Adjusted Payment 6

7 What s Wrong with Current Model? THERAPY 7

8 How Was PDPM Created? 8

9 What is Patient Driven Payment Model? 9

10 Patient Driven Payment Model Payment 10

11 PDPM Summary Component Patient Characteristics For CMI Payment Structure # of Different Case Mix Categories Physical Therapy Primary reason for SNF care: (ICD-10) Functional Status: Section GG Cognitive Status Payment decreases after Day Occupational Therapy Primary reason for SNF care: (ICD-10) Functional Status: Section GG Cognitive Status Payment decreases after Day Speech Therapy Primary reason for SNF care: (ICD-10) Cognitive Status Swallowing Disorder/other comorbidity Average Daily Payment 12 Nursing Clinical Status/Extensive Services Functional Status: Section GG Depression Restorative Nursing Average Daily Payment 25 Non-Therapy Ancillary Clinical Status/Extensive Services Co-morbidities Payment decreases after Day

12 Dangers of PDPM 12

13 Danger #1: Chasing Clinical Complexity for Reimbursement 13

14 Danger #2: Fewer MDS Assessments Means Fewer MDS Coordinators 14

15 Danger #3: If ICD-10 Coding Drives Reimbursement, MDS Coordinators and Therapist Can Become ICD-10 Coders 15

16 Danger #4: If Therapy No Longer Drives Reimbursement, Decrease Therapy 16

17 Danger #5: If Therapy and NTA Reimbursement Decreases Over Time Then Decrease Length of Stay 17

18 Danger #6: How Accurate Are PDPM s Assumptions? 18

19 What Impact Does PDPM Have on Hospitals/Insurance Companies? Hospitals Home Care Insurance Doctors 19

20 October 1, 2019 PDPM Begins 20

21 Next Steps Billing & Accounts Receivable Social Work & Discharge Planning PATIENT MDS Coordinators Patient Screening/Admissions MDS Audits/Assessments Discharge Planning Patient Screening & Admission Nursing PT, OT, SLP Where Are the Physicians and Medical Providers? 21

22 Presenter 22

23 Part II Frailty OBJECTIVES 23

24 Not just another day under PDPM How will you determine clinical complexity? How can you predict nursing needs? Will a diagnosis be enough? Will the ICD-10 be accurate? 24

25 RECAP: PDPM payment is based primarily on medical complexity & nursing needs This determination starts with an ICD-10 Code + ICD-10-PCS ICD-10 Code clinical complexity ICD-10 Code nursing care needs 25

26 Which resident is clinically complex? Which has high nursing needs? 26

27 Where are you on the continuum? I do not exercise every day or or even a few times a week. I lost 10 lbs in the past 6 months without dieting. I fell 1 time or more during the past 6 months. I have physical pain every day. I have difficulty often finding a word or completing a sentence. True or False 27

28 What is Frailty? A frail elderly person represents a complex system at the edge of failure (Rockwood, 2009) 28

29 The evidence merits consideration How to measure FRAILTY H 29

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32 Residents with complications in MS-DRG Residents who have several comorbidities Residents who receive extensive services (e.g., trach, ventilator) Residents who use IV medication Residents with acute infections Residents recovering from non-orthopedic surgery Vulnerable subpopulations: residents with addictions, bleeding disorders, behavioral issues, chronic neurological conditions, and bariatric care Clinically Complexity = PDPM $$ 32

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34 FACTS: Increased reimbursement is available Identifying the vulnerable residents is key Intentional change in focus is required 34

35 1. MDS completion will need to be accurate and complete 2. Comprehensive patient characteristics must be documented 3. Nursing assessments for MDS completion are imperative 35

36 Part III The Medical Staff OBJECTIVES 36

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38 Data Used By Hospitals and Insurers

39 Practice Groups and Practice Providers Operate With No Data Available

40 Drivers of Utilization Severity of Illness Frailty Expectations 40

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47 Drivers of PDPM Nursing Diagnosis Frailty 47

48 Primary Diagnosis 48

49 Accurate Primary Diagnosis Critical for PDPM Payment Category Hospital Discharge Summary Hospital H & P Let SNF medical records staff assign MDS coordinator assigns Hire coders to help Attending physician 49

50 Who can assign a diagnosis? Statutorily: only a State licensed medical practitioner Pitfalls to be aware of: Let MDS Coordinators be MDS coordinators, not coders Let nurses be nurses Let medical records collect accurate records Don t hire coders to become diagnosers 50

51 Key to assigning a primary diagnosis Most accurate source will be the treating medical practitioner Challenge Trained on assigning ICD-10 codes, with variability Not trained in assigning primary diagnosis codes in the context of PDPM 51

52 Engage Your Medical Staff 52

53 Partnering with Medical Directors Few Medical Directors are aware of PDPM, even fewer practitioners Assigning a primary diagnosis in the context of PDPM impacts reimbursement for the building, not the practitioner Facility EHRs lack physician billing visibility Educate and engage your medical directors and practitioners now to prepare for October 1st, How...? 53

54 Available Solutions Free solution Provides practitioner - SNF communication bridge Access to practitioner ICD-10 codes including primary diagnosis Secure messaging with practitioner for facility and patient needs reduces noise Align ICD-10 coding 54

55 New Emphasis: Cognition & Depression 55

56 Cognitive dysfunction, including memory impairment is a leading cause of functional impairment worldwide 1 Terrando N, Brzezinksi M, Degos V, et al. Perioperative cognitive decline in the aging population. Mayo Clin Proc. 2011; 68(9):

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58 Cognitive Changes: Normal Aging? Dementia is NOT part of normal aging Pseudo-dementia = depression. Presents atypically in older adults. May be misinterpreted as dementia. Resolves with treatment of underlying depression Cognitive changes impact medical, legal and financial decision making now it impacts your PDPM reimbursement 58

59 Depressed? Depression is often under diagnosed by nursing, social work and medical professionals. Requires formal evaluation and testing Many facilities with falsely low depression rates Important variable for nursing case-mix Why? 59

60 Depression Geriatric depression preferentially afflicts patients with chronic medical illnesses Physical disability originating from medical illness and exacerbated by depression is a barrier to treatment adherence MacArthur study: Symptomatology represents a substantial risk for disability in ADLs (even those highly-functional at baseline) 1 Other studies: 25% of persons with COPD have depressive disorders 60

61 Cognitive (dys)function 61

62 Significance Delirium and Depression can impact Length of stay and likelihood for institutionalization Medication adherence Linked to hospitalization and re-hospitalization risk Studies suggest that executive cognitive dysfunction can more reliably predict loss of autonomy than memory impairment Identification of subtle cognitive deficits in the least suspecting patients may impact their risk for physical, psychologic and cognitive decline 62

63 Value of Therapy in a Post-RUG World 63

64 Approach to Therapy under PDPM Therapy minutes outcomes Facility still accountable for patient outcomes Acute hospital stay will continue to lack in adequate therapy provisions Patients typically come to SNF for complex needs and therapy Patients can benefit from group therapy when appropriately utilized need to assess for cognitive impairment specialized therapy, i.e. stroke, joint replacement Consider recreational therapy as valuable therapeutic activity lack of social engagement and boredom often leads to isolation, depression, loss of hope decline poor outcomes 64

65 Medical Director PDPM Resources patientpattern.com/pdpm AMDA Annual Conference 65

66 Summary 6 dangers of PDPM Educating & engaging medical directors and clinicians is key Those with early, accurate primary diagnosis will see increased reimbursement Those with more frail residents will see increased complexity of care and nursing needs Depression and Dementia require full assessment & impact reimbursement 66

67 Questions? 67