Steven Littlehale

The word “portmanteau” means either a large trunk or suitcase, or a “word smash” that takes the meanings and sounds of two distinct words and combines them into one. Common examples of the second definition are: smog — which blends smoke and fog; motel — which combines motor and hotel, and the currently popular infomercial — which is, of course, information presented as a commercial.

I’ve found that humor is an effective tool for learning, although it runs the risk of putting some people off. My goal is the former. Please know the spirit in which the following portmanteaus — created to provide some Patient-Driven Payment Model insights — are intended: to directly confront PDPM myths and nonsense, as well as suggest some authentic opportunities to provide and document better care.

Therasplaining (therapy + explaining): The sustained effort by contract therapy companies to explain how many ways they now support nursing services under PDPM. In actuality, when a therapist (PT, OT or SLP) are in the skilled nursing facility, they are often the most educated person on the care team.

They are essential contributors, not only in the assessment of the patient’s function and potential, but also in cognitive and wound assessment and intervention, as well as and significant contributors to pain management and hospitalization reduction. In truth, it was our response to our current reimbursement system (RUG) that confined them into the box of therapy minutes. Now is our opportunity to perfect “therasplaining” and bring therapy more fully to the table.

Mechanistand (mechanically altered diet + standing orders): The inclusion of mechanically altered diets into standing admission orders. In 2018, the national average for mechanically altered diets was 24% (as reported on the MDS). These types of special diets indicate a greater acuity in the patient and trigger higher reimbursement under PDPM. I suspect this number will increase after PDPM simply by improving the accuracy of MDS (not by actually increasing these diets within the facility). Why am I so convinced? Read on!

Swallidemic (swallowing difficulties + epidemic): The sudden rash of swallowing disorders soon to emerge in U.S. nursing homes. A patient with K0100A, K0100B, K0100C or K0100D checked on the MDS qualifies for a swallowing disorder under PDPM. Careful assessment of swallowing ability is essential for proper care for a host of reasons, ranging from proper nutrition/hydration to self-esteem. We’ve studied the various payment drivers of PDPM to support our clients’ transition to this new reimbursement system and establish their compliance programs.

In a 2018 analysis we examined 246,000 MDS assessments and identified a surprisingly low prevalence of swallowing difficulties (3.7%). However, when you turn to the professional literature, several studies cite much higher rates of dysphagia (40% to 68%).

Nurspeech (nursing + speech): The emerging alliance between nursing and speech and language pathology. Much of the SLP case-mix indices comes from functional areas often assessed by nursing, such as cognitive impairments and mechanically altered diets or swallowing disorders. While it’s often the nursing staff who complete these assessments on the MDS, it’s not always in concert with SLP. This likely contributes to the low rate of swallowing disorders found on the MDS. The elusive SLP is the nurse’s new best friend!

Depresinami (depression + tsunami): The sudden increase in depression identified in nursing homes. In 2018, 4.9% of patients were moderately depressed according to their 5-day MDS assessments. In actuality, this is low and a dramatic underreporting of a condition that has serious consequences. Some studies suggest that depression in institutionalized elders is as high as 42%! More conservative studies report moderate depression at rates ranging from 15% to 25%. Depression rates likely will increase to the lower end of 15% post PDPM.

PHQEnvy (PHQ-9 + envy): When nine just isn’t enough. This is linked with Depresinami and indicates the threshold (10) on the PHQ-9 that is required for the resident to be considered moderately depressed. Depression less than 10 should still be addressed on the care plan. I can already see the PDPM PEPPER reports benchmarking the rate of PHQ 10 against 9.

CoderQueen (coder + queen) or the more gender neutral Coderoyalty (qualified coders + royalty): The new status given to qualified ICD-10 coders. When is good, good enough? In PDPM, patients are first classified into a clinical category based on the primary diagnosis that justifies their stay in a SNF, not their reason for initially going to the hospital.

ICD-10-CM codes indicated on the MDS in Item I0020B are mapped to a PDPM clinical category. Clinical classification may be adjusted by a surgical procedure that occurred during the prior inpatient stay, as coded in Section J of the MDS. Debate exists between “perfection” in ICD-10 coding and “good enough to get you into the right clinical category.” Where does your staff fall in the ICD-10 accuracy continuum? While I understand that good enough and perfect coding will land you the same reimbursement as long as you’re in the right clinical category, I believe that good enough will come back and haunt our profession. The data we submit will be analyzed for patterns and trends and ultimately drive policy.

As we work our way to payment site-neutrality, we must insist that our data be accurate. Data inaccuracies will lead to inaccurate perceptions about who we care for, how we care for them, the outcomes we achieve, and the cost effectiveness we truly offer.

IdonotC-10 (ICD-10 + 68,000+): The sinking feeling you get when you realize that the “10” in ICD-10 doesn’t refer to the number of diagnoses you must consider, or the emotion experienced when wrestling with CMS ICD-10 crosswalk.

Prescribtrophy (prescribe + atrophy): The specific 20-year under-utilized muscle in a therapist’s brain that assesses patient functional potential and prescribes an intervention. Customizing actual therapy needs is a long-ago forgotten skill set if you look at patterns of care delivery within each iteration of the RUG system. PDPM payment has no linkage to the amount of therapy minutes provided, but still providing proper therapy is required. CMS does require that you report on therapy minutes in the discharge assessment. We should see variation in therapy minutes provided, most likely best explained by patient comorbidities.

Bulltral (bull__ + neutral): The belief that PDPM will be budget neutral. There is simply no way. All projections were based upon the presumption that behavior, patients, technology, etcetera haven’t changed since 2017 and won’t change moving forward. But they will. The challenge for us all will be defending what appears to be “upcoding” motivated by PDPM when, in fact, changes result from more accurate assessment. We have a legacy of mediocre MDS data integrity; good care is provided but nevertheless poorly documented on MDS. Always code accurately, document appropriately, and provide excellent care. You’ll be a winner! CMS will recalibrate rates as needed to ensure budget neutrality (Budtrality).

Again, my hope was to present some PDPM insights, and a few laughs along the way. Having lived through the transition from cost-based reimbursement to PPS, a few more laughs and a lot more insights would have helped. You tell me: What is your favorite portmanteaus? I bet you can come up with a few more!

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.