Skilled nursing facilities are about to go through major changes. The Centers for Medicare & Medicaid Services call it “transformation.”  These changes will affect operations, the way facilities staff, what skill sets are needed, and how patient care is managed.

There are a host of consultants, therapy companies and the American Health Care Association where experts are offering to help you prepare for the logistics of the Patient-Driven Payment Model. However, if you want to see what cultural and conceptual changes may be necessary under PDPM (and ultimately under the Improving Medicare Post-Acute Care Transformation) Act, there may be lessons to be learned from inpatient rehabilitation facilities.

IRFs weathered the transition to a prospective payment system. The changes they implemented allowed them to survive and even flourish. IRF providers may have déjà vu as remember how they adjusted from reasonable cost reimbursement to a prospective payment system based on CMGs (Case Mix Groups) in 2002. That system better measured care and value (a function of cost and quality). Success required improved outcomes, coordination of care with other providers, enhanced discharge planning and shorter lengths of stay. 

This should sound familiar to SNF providers preparing for PDPM!

PDPM will measure care differently and reward value. What IRFs have learned, I believe, will be very similar to what will be required for skilled nursing facilities to be successful. Below are some success factors I believe SNFs may need to enhance and develop. 

  1. Patient selection – ensuring your facility admits patients that you can clinically document their needs and can provide the care needed.

  2. Efficiencies – delivering the right care, based on an accurate clinical assessment, at the right time.

  3. Communication – ensuring the multidisciplinary team is communicating the needs of the patient, including social determinants and factoring these into the discharge plan.

  4. Prevention – falls, medication errors, wounds are preventable variances and negatively affect outcomes and increase cost.

  5. Partnering – appropriately managing care across the continuum becomes more critical. Hospitals will be looking for preferred partners who can demonstrate value and patient satisfaction. Post-acute providers may need to communicate and ensuring care is occurring in the right setting.

The following chart demonstrates how prepared I believe SNFs are for the changes we face compared to IRFs. These are not comments regarding the skills of clinicians but more the focus of care. 

IRFs have fared better simply because they have already experienced some of the changes SNFs now face. All post-acute providers, including LTACs and home health agencies need to appreciate where the IMPACT Act is taking us. As a reminder, the stated goals include promoting effective communication among post-acute providers, promote effective prevention, promote best practices, make care affordable, make care safer by reducing harm, decrease cost of delivering care and strengthen person and family engagement.Therapy – SNFs may need to enhance therapy skills, as they must now move from a focus on minutes to specific skills that address a safe functional discharge and coordination of care with other disciplines. 

Team Communication – The team at a SNF may communicate but the communication may need to change in its focus to address transition needs, family dynamics and discussions with other post-acute providers. 

Cost Effective – Although SNFs are viewed as cost effective compared to IRFs, especially by the payers, because CMS will now be able to compare outcomes across the post-acute continuum SNFs will now need to validate their value.

Outcomes – SNFs will need to confirm their outcomes with the quality measures and be able to solidify their unique role in the post-acute continuum.

Medical Acuity – SNFs have focused on rehab RUGs. Under PDPM, the focus shifts to medical acuity and SNFs may have to assess the skills needed to identify these on the MDS and then be able to provide the appropriate care. 

Nursing – The skill mix needed may change, the ability to identify and care for a more medically complex patient is a key component to how SNFs will be successful under PDPM and how they fit into the post-acute continuum. 

Understanding Partners – How well do I understand my partners’ capabilities? How we work together will be essential; IMPACT will facilitate healthcare providers to work together for lower cost outcomes. 

Discharge Planning – Efficient discharge planning becomes a pillar for success. 

PDPM presents several challenges one must consider. Obviously, providers will have to keep their eye on their profitability, and that will start with the patient selection process. 

As you begin here are some questions you may want to ask yourself: 

Will we need the same level of physical and occupational therapy?

Are we equipped to identify and care for patients with a higher acuity with cognitive, behavioral, nutritional or depression issues?

Are we prepared to streamline care coordination and the discharge processes?

CMS is looking to save money and maybe move away from per diem payments to SNFs. It is moving post-acute towards value-based purchasing. Officials will be watching to see how clinical assessments and the provision of therapy change. If CMS’ costs increase to this population to I suspect, we may see them implement a “behavioral offset.” These are negative adjustments applied to your payment formulas to maintain budget neutral payments. This occurred when IRFs implemented their CMGs. 

IRFs survived the last CMS payment changes.  The amazing thing is IRFs watched value AND outcomes improve!

What might SNFs learn from IRFs? Clinical assessments and discharge planning start during the patient selection process. Robust clinical evaluations and updates must be communicated to the team and be used to formulate the discharge plan. Families and the patients’ support system are important to the team process. 

We may need to begin thinking outside our industry’s silo and discuss what is the best setting for the patient. This makes us all better partners.

Andy Whitener has worked as a physical therapist, nursing home administrator, executive director of post-acute services and CEO of an inpatient rehab hospital. He is currently employed by an acute care hospital and works on various projects. He is also the owner and founder of Post-Acute Care Expertise (P.A.C.E.), a consulting entity and leads strategic planning discussions with providers.