Renee Kinder

This week has been, well, eye-opening. 

I have shifted from policy enthusiast, someone who has praised the Centers for Medicare & Medicaid Services for the move to a clinical model, someone who was involved in technical expert panels for the creation of PDPM and, therefore, assumed I had considered the full implementation impact on beneficiaries. 

I shifted into a new role this week.

Granddaughter of Mrs. Brown. 

My grandmother, my last living grandparent, was admitted to a SNF for “rehab” following a qualifying hospital stay. 

I wrote about her in a 2018 Rehab Realities blog, Grandmother-level quality.

She is the reason I clean under, behind and outside every surface in my house.

She is the reason I have a traditional view of the need to dress in your best for travel, flights, and shopping.

She was living at home, alone with help from family, prior to her recent decline. 

And she is the reason my natural start to the weekend involves cooking for the family. 

Friday February 7, 2020 7:12 pm EST

Incoming text from my father: 

She did not get admitted till 3:00. So, no therapy today. This place is spotless clean. Mom is happy, the PA checked mom out and is encouraging. She may start therapy Saturday. I will let you know.

Outgoing text from me: 

When therapy evaluates tomorrow, ask them for their scores in Self-Care and Mobility. And ask them how much time she will get with rehab. FYI – Since her last stay the Medicare model has changed.

Saturday February 8, 2020  11:46 am

I fire up the gas stove, turn on some music and begin the typical Saturday afternoon routine in our home. Cooking to ensure a weekend stash of meals and snacks for the family. 

First on the menu, homemade potato salad, my grandmother’s recipe. 

I boil eggs, five pounds of potatoes, and Isaac (age 7) preps the relish, mayo, salt and pepper. Emmy (age 5) roller blades in and out of the kitchen. “Born in the USA” plays in the background. 

Honestly, is there a better tune to play while making potato salad? I think not. 

Next in the YouTube automated play list is a duo, Sting and Springsteen, “Every Breath You Take.”

Don’t you just love it when the perfect song comes on next in the play list? 

My mind wanders, thinking, exactly, right now is a time to focus on every breath, every move, every mobility step. Grandmother, we will all be watching you. 

In the background my phone dings … messages from my father with updates.

Pictures of the spacious and spotless room, Grandmother, laying in bed.

Saturday February 8, 2020 12:29 pm

Incoming message: 

PT 5 days a week, 45 mins each, she needs at least 75% help. Mobility score 22/100. The look on the PTs face was awesome when I asked for those numbers. 



Did they give you all an update and time for her first Care Plan meeting?




Ok. I am going to send you a list of questions to ask them. 

Also, need you to download an app on your phone.

The PDPM Navigator App, once we get more info I will have you drop some scores in.



This is when it hit me … Overwhelmed? 

I have never seen my father stressed. Outside of coaching me in soccer, I have never ever seen him raise his voice.


We are just getting started here, Dad. You must be an advocate for Grandmother. That requires you to be armed with an understanding of the model and how care should be delivered. 

We don’t have time for overwhelmed. 

I then considered what other families are experiencing, what they do not know, what they fail to ask.

Monday February 10, 2020 8:27 pm

Incoming message:

Planning meeting will be Tuesday. Mom doing better. Big change from last night/this  morning.

I started drafting a list of comments and questions for my family to use during her initial care care plan meeting. 

Dad, the care plan meeting is intended to be a time during which the nursing and therapy team will explain to you all the findings of their clinical review of Grandmother. The new reimbursement model is based on some key assessment areas of her function, which is why I asked you to get the scores from therapy. Also, during the care plan meeting Grandmother should be prepared to tell them what her goals are for her rehab stay.

These are some initial questions you will want to ask the team:

  • What are you using for her primary dx in I0020B? This will be a diagnosis related to her hospital stay and the reason she is receiving care. She has quite a few, so I am curious as to what they are using for primary. 
  • What is her “usual performance” as documented for MDS Section GG Self Care and Mobility? The scores you gave me before were standardized tests. Ask for the GG.
  • What is the overall HIPPS Code for PDPM?
  • How did therapy determine the volume (amount/time) of care she will receive? 
  • As her POA you would like to request a copy of her therapy evaluations. 

An additional question I should have had Dad ask prior to the meeting:

  • Who attends the care plan meeting? 

Tuesday February 11th, 2020 11:58 pm

Incoming message:

Meeting is at 1. The Social Worker said you could participate in the meeting if you want by phone.

Outgoing message:

Perfect. Call me then.

Tuesday February 11th, 2020 1:01 pm, incoming call the Care Plan meeting

I hear voices in the room, everyone settling into place and then I hear a kind voice giving an overview of the meeting.

Mrs. Brown, we are here today to talk about what you need, to answer any questions you have, and make sure you are getting the best care

I think, great, the tone here at least is off to the right start.

Next, I hear my Dad interject, I have Mrs. Brown’s granddaughter on the line, she is a therapist and may have questions. 

The kind voice speaks-up, Great, but therapy doesn’t attend these meetings, we can reach out to them with any questions you have. 

Honestly, I kind of checked out. How is therapy not here? Surely, they sent some notes. I will ask at the end.

Lesson learned for me, and lesson for any families reading this on that list of questions I gave my dad.  I should have told him to share those to the nursing and therapy teams PRIOR to the care plan meeting. 

Then, I listen to the nurses review care, ADLs, meals, preferences, all of the essentials. They did a great job covering immediate care needs and then moved into what goals my grandmother needed to meet to go home. 

What do you need to be able to do to go home? Have you had home health in the past?

At the close of the meeting, I spoke up, using somewhat of a script families are free to save and use during meeting with their loved ones.

Thank you for allowing me to call in, I started.

Sounds as if you have the care areas covered and appreciate you asking about her goals for returning home. 

As we all know here, there is a new reimbursement model effective October 1 of last year, with the move from RUGs to PDPM. That is why I wanted to call in. Can you tell me what you have for her anticipated HIPPS codes. I’m also curious as to what the group, including rehab, has for her self-care and mobility scores. Also, what about NTA? I reviewed her discharge summary and it appears there are some complexities to be captured. As her family, we just want to make sure she continues to receive what she needs.

We understand, a voice spoke up, and, yes, we are all adjusting to the change. 

Today, 9:58 am

Incoming message:

Mom is having one of her best mornings in two weeks. Glad to see.

Best message ever. Progress is in store. 

As I said in opening, I thought I had an adequate understanding of how PDPM would impact beneficiary/person access and care. I was wrong. 

The complexity of the model, with its clinical specificity, is beneficial for care teams. It is driving increased conversations in the right areas. 

However, if we are being honest, we have all also heard and read stories of how PDPM is shifting models in the directions that may not be the most clinically focused.

I wish I could say to all readers, my hope for you is that you can understand the impacts of PDPM as if your loved one were receiving care in a SNF. We say these things daily. We provide care as if our patients are our family. 

I have also learned, however, that it is close to impossible to understand until you are on the other side of the table. 

Hoping at a minimum that I have been able to provide some increased perspective, given you some considerations on how we communicate and pro-actively message content to patients’ loved ones, and raised some awareness of what it means to sit on the family side of the table. 

Remember: Every step you take as a caregiver families are watching you. Let’s make sure they also understand you. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).