Nurse Practioners the key to Quality and PDPM Success Presented By: Joni Paris, BSN, RN, MSN, AGPCNP Suzanne Nall, BSN, RN, LNHA, MBA Agenda Identify what NPs can do in Post-Acute Setting Discuss management of higher acuity patients or specialty program offerings with the use of NPs Discuss Benefits & Challenges of implementation of the different models of NP use Identify role of NPs in PDPM 1
Role of NPs in SNF What does an NP do in a SNF today? Initial visit for newly admitted SNF patient- making sure transition between hospital-snf is smooth prior to Attendings initial visit Treatment of episodic condition changes Specialized focused care wound care, psychiatry etc. Provide time with resident to communicate SNF POC that physicians often may not have Diagnose Prescribe medications and treatments orders https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNMattersArticles/downloads/MM4246.pdf https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNMattersArticles/Downloads/SE1308.pdf Benefits of NPs in SNF Identify undocumented needs ex: details the hospital forgot to share with us Emphasize why rehab setting is necessary Improved continuum of care post hospital transfer Med reconciliation Closely monitor a new admit that may still be unstable Respond to patient/family concerns related care needs 2
Benefits of NPs in SNF Reduce rehospitalization rates Quality of Care Reimbursement- hospital and nursing facility can be penalized for rehospitalization rates Rehospitalization Data 3
Benefits of NPs in SNF Specialized care which improves quality (ex: wound care, psychiatry, PTNM etc.) Creates specialty service lines Increase quality of care and QM management Can help mitigate liability with improved documentation Coverage for Attendings vacations. Only exception is that there needs to be attending coverage for any new admission Challenges Educating Physicians on the role of an NP Attendings are still responsible for initial H&P and oversight of medical care plan Specialty NPs are well educated on specific practice standards ex: wound care protocols Collaboration with Attending and NP regarding visit schedule NP s are there to augment care not replace physician visits/revenues Coordinate care between Physicians and the facility ex: formularies for drugs, wound care products etc. 4
Challenges Educating Facility Staff on NP role Ongoing monitoring of high acuity/high risk residents Orders post incident Change order for therapeutic substitutions Immediately address resident change in condition How does an NP benefit SNF staff? Compliance with most up to date standards of practice for specialty areas Facility employees an NP Use Geriatric Nurse Practitioners Association Partner with local hospital system providers NP-SNF Models Use of regional NP group ex: Optum Use of Independent practice group Use Geriatric Nurse Practitioners Association can help you locate these groups Attending physicians with NPs coming in Use of NP for specialized services 5
Reimbursement 85% of the Medicare physician fee schedule/visit Economics of employing an NP based on acuity, time and service type High acuity/high volume facilities have built in volume 50-60 visits/week will justify employing an NP needs to be a combination of SNF, Specialty & LTC visits What are you saving in lost revenue/staff time due to rehospitalization? The Village at Marymount Marymount Place 104 unit assisted living Villa St. Joseph 130 Skilled/Intermediate care beds 10 palliative care beds 12 memory care beds 12 Memory care assisted living beds 6
Program with the Cleveland Clinic System for a Doctor in the building around 3 days/week & then NP coverage 5 days/week Wound/Ostomy NP- weekly visits How The Village at Marymount Uses NPs Overactive Bladder Program- NP evaluates incontinence status for both AL & NF residents and orders percutaneous tibial neuromodulation (PTNM) Geripsych NP- monthly & episodic visits Cleveland Clinic Medical Care at Home- uses Doctors & NPs for assisted living home routine and episodic medical care visits NP coverage on weekends through an outside company Educating Providers on the NPs Role in PDPM DETERMINING PRIMARY REASON FOR SNF WILL BE THE MOST IMPORTANT FACTOR IN SETTING REIMBURSEMENT UNDER PDPM 7
The Key- Care Management MDS Nurses will be more like case managers under this system and communicating with NPs and Attending Physicians much more frequently Clinical Characteristics are important Important to Deliver Team Based Coordinated Care ICD-10 Coding Capture co-morbidities and are you coding them in the chart and on the MDS? Do you Look at all hospital transfer paperwork for clinical documentation to support diagnoses? Have access to partner hospital system medical record systems for residents you admit? 8
Use of NPs with PDPM Are NPs part of your Care Management Team? Focused and timely medical evaluation Rapid and Accurate Assessment, Diagnosis & MDS Coding Hospitalization/surgeries Comorbidities Chronic Illness - How well do you do with capturing these areas now? CMS PDPM Fact Sheet: NTA Comorbidity Score 9
- How well do you do with capturing these areas now? CMS PDPM Fact Sheet: NTA Comorbidity Score Where will your typical patients group? 10
NTA Coding Example Mr. Smith is a 79 year old morbidly obese patient who just had a joint revision. He is admitted on IV antibiotics for the next 3 weeks. He also has diabetes and COPD How many points can you capture? Let s Add Up the NTA points 12 Special Treatments/Programs: Intravenous Medication Post-admit Code Bone/Joint/Muscle Infections/Necrosis- Except Aseptic Necrosis of Bone Diabetes 2 5 2 COPD 2 Morbid Obesity 1 11
NTA Coding Example Mrs. Jones is an 88 year old that admits after being hospitalized for a fall at home. She is undergoing radiation for cancer, she has 1 stage IV pressure ulcer to her heel which is infected with MRSA and she is on IV antibiotics, a colostomy from the surgery to remove her cancer, C.Diff, she intermittent catheterizes herself post- surgery, weight loss and asthma. Within the 1 st 2 days of admission she has an outpatient appointment for a transfusion How many points can you capture? This Photo by Unknown Author is licensed under CC BY-SA Let s Add Up the NTA points Special Treatments/Programs: Intravenous Medication Postadmit Code Highest Stage of Unhealed Pressure Ulcer- Stage IV 5 1 14 Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code Special Treatments/Programs: Radiation Post-admit Code 1 1 Bladder & Bowel Appliances: Ostomy Bladder & Bowel Appliances- Intermittent Catherization Asthma 2 Special Treatments/Programs: Transfusion Post-Admit Code 1 1 2 12
Let s talk about what diagnoses MIGHT be missing The patient is noted to have weight loss in this scenario. There is not current malnutrition diagnoses but you suspect the patient is malnourished Can the NP look in the outpatient or hospital chart? Can the NP order lab work in the 1 st day or 2 of the stay to confirm the diagnosis? Could the cancer have caused any liver involvement? Is there an End Stage Liver Disease diagnosis or Cirrhosis? Use of NPs with PDPM Accurate reimbursement Improved compliance 13
Use of NPs with PDPM Optimizing LOS and Quality Outcomes Assist in the development of care paths for certain conditions Monitoring of resident outcomes related to expect recovery path Outcomes Increased resident/ family satisfaction Impact on reimbursementex: QM impact Impact on 5 Star Rating Participation in ACO & other postacute care contracts/ programs 14
What will Change? Greater importance of Resident s BIG picture. Need a Care Manager/Team Fewer assessments will be done What are your MDS Staffing needs? Critical Thinking & Care Management will be critical. MDS volume will shift to focused clinical documentation gathering & care management Payments will decline over course of stay. Need to capture all pertinent information for initial MDS NPs can be the link in identifying missing information Questions? 15