It’s time to smash it up … again! I appreciate the positive responses to my March blog, where we learned about PDPM through various portmanteaus or “word smashes.” 

What I didn’t expect was a flood of suggestions (floogestions) for additional portmanteaus from many esteemed colleagues!

Through humor we directly confront Patient-Driven Payment Model myths and nonsense, as well as offer key “aha!” moments that ultimately lead to success under PDPM. Never wanting to hold back, or otherwise hold my tongue, I bring you “Portmanteau, a PDPM parody, part Deux!”

Lookriation (Lookback + Variation): Does this assessment item on the MDS have a three- , seven- or 14-day lookback? Do I include information from the hospital, home or not? Clearly, the answer to all these questions is “yes.”  

There is considerable variation in MDS item lookback periods. For example, Section GG asks about patient performance over the three-day period following a Medicare admission, but in the same section, it also asks about performance prior to current illness/injury or exacerbation. These lookback rules change, however, on an interim payment assessment (IPA), where you don’t go back to admission but rather to the previous three days. Don’t worry: The lookback period then changes again on the discharge assessment, where we assess the last three days of Medicare PPS stay. Good times, people!

The time frames associated with proper diagnoses for Section I is also a challenge. The RAI manual guides you to list those that have a “direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death.”  Use of the word “current” specifically means the previous seven days. You are directed to scour all available documentation from the last 60 days, regardless of source, and validate if the diagnosis is active or not. Examples of active diagnoses include things such as it requires treatment/medication or it impacts functional care. Here is the catch: Once you have evidence of an active diagnosis, you must ensure that it’s documented in your medical record by the physician or extender if your state’s practice laws allow. 

And, of course, friends, there are exceptions! You have to read it to believe it. (Please read it.)  

Lookriation examples go on and on, and this blog has a word limit! Hopefully you’ve got the point. What strikes me here is that MDS coordinators not only have to be clinically astute but must also be railroad engineers to keep everything moving.

Medinosis (Medications + Diagnosis): The process by which non-therapy ancillary (NTA) diagnoses are systematically identified during the required drug regimen review (DRR) completed upon admission. Every medication is given for a reason(s). DRR ensures that all medications are appropriate and are not causing adverse consequences (and it’s a QRP measure). This is a great example of making sure that the right hand knows what the left hand is doing, and engaging pharmacists and physicians in the care/PDPM process. 

Rushpiratory Therapy (Rush + Respiratory Therapy): Starting respiratory therapy the day of admission to ensure 7-day, 15-minute a day, minute capture required for Special Care High. Let’s make sure we say “hello” before the nebulizer therapy starts. In all seriousness, consider if you have access to qualified staff to deliver respiratory therapy 24/7. 

Cognicline (Cognitive + Decline): The sudden decline in cognition which begins on October 1, 2019. Cognitive impairment (CI) increases case mix index for (all of) the speech language pathology (SLP) groups and (some of) the nursing groups. The definitions of cognitive impairment vary for each component: For SLP it is a brief interview for mental status (BIMS) score of 12 or less or a cognitive performance scale (CPS) score greater than 0. For the nursing cognition component, it is a BIMS score of 9 or less or a CPS score of 3. 

Cognicline may seem overly harsh, even for a guy who reportedly moved part of his soul to make more room for sarcasm; but, I suspect rates of CI will increase. Not necessarily from over identification, but for the first time, accurate identification. 

Theractivity (Therapy + Activity):  Therapy developed specialized activity programs designed to augment more expensive formal therapy (a.k.a. gym class). We now have the greater flexibility to provide more appropriate and creative therapy intervention, let’s use it! The proposed rule indicates that group therapy can contain two to six (not four) people. Think Jack LaLanne, Jane Fonda and Richard Simmons all rolled into one … Actually, don’t!

Warnmit (Warning + Limit): A noun used to describe a facility that consistently violates the group/concurrent therapy 25% limit of total therapy minutes. CMS is watching, and in the future will consider a penalty for exceeding the limit. Keep those group and your concurrent treatment session under 25% of the total minutes provided by one or more disciplines.

Expensgement (Expenses + Management):  The extreme attention to expenses that a capitated rate inspires. Expensgement should be equal to but never greater than the efforts put forth to accurately capture data on the MDS and appropriately deliver and document care. Creative approaches to achieve excellent outcomes at lower costs to the front of the line please! 

Microsourcing (Micro + Outsourcing): In response to CMS payment, quality, and regulatory changes, new vendors with exciting value-propositions emerge. You can now outsource the assessment and treatment of your patient’s cognition, depression and swallowing disorders, to name a few. While that might be a perfect solution based upon market conditions, it runs the risk of siloed care. If you elect microsourcing, consider a contract that includes the development of your own staff. (Maybe now is the time to update your investment portfolio?)

Restorilema (Restorative + Dilemma): The uncertainty among care providers on what to do with restorative nursing. Most providers historically have considered restorative nursing programs only after a skilled therapy program concludes. Under PDPM, restorative nursing programs must begin early in the stay to meet the 6-day requirements on the first MDS. This is a great opportunity for nursing and therapy to coordinate and organize restorative programs and collaborate on resident centered goals upon admission. 

I-Puria (IPA + Ischuria): The complete inability to take a bathroom break on October 1 when you realize that all current Medicare Part A patients who already had a Medicare PPS MDS assessment in September need to immediately have an additional PDPM IPA completed (that is, only if you want to get paid for Medicare Part A days in October). If you were thinking about an October 1 vacation, don’t. If you were getting married then, elope. October 1 is a Tuesday — the good news is “hump day” is only one day away. 

My hope with this was to present some PDPM insights and a few laughs along the way. Many, many thanks to my colleagues, old and new, who answered the challenge and provided many of these portmanteaus: Pam Kaiser and Jen Gross of PointRight, Cheryl Field of Prime Care Technologies, Marc Zimmet and Don Lodwick of Zimmet Healthcare Services Group. You are all amazing!

I look forward to reviewing these and many more advanced PDPM insights in Atlantic City in August at “The Theory of Reimbursementivity.”

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group and chief clinical officer emeritus at PointRight Inc.