Renee Kinder

We are in the midst of conference season.

That brings a lot of good …

Time for collaboration across the industry.

Seeing your friends and partners that you haven’t seen since last fall.

And this year specifically all the conversation is circulating around one question:

What are you going to do to be successful under PDPM?

Many providers are heading in the right direction, with a focus on increased collaboration with their rehab providers on interdisciplinary coding of the Minimum Data Set, encouraging all team members to practice at the top of their license and implement a greater level of evidence-based practice, and a stronger focus on safe, effective, person centered and fluid discharge planning that begins day one of the day.

For those of you having these conversations. KUDOS! Keep up the good work.

I have, however, also heard some off-track conversations about the “goals” and “outcomes” of what the proposed Patient Driven Payment Model will do to the industry. To say I have been shocked, appalled and troubled by some of these statements is an understatement.

As we often say in the South when someone pushes the parameters between what is right and what is wrong a little too far… It’s time for a “Come-to-Jesus.”

1. I have heard over, and over, and over again the statement that PDPM will cause therapy to be a cost-center, like the DRG models that the acute care hospitals use.

Wrong. Therapy will NOT be your cost center.

Remember: The definition for accessing a continued level of skilled care following the acute-care stay under the Medicare Part A benefit will not change under PDPM.

If you have an individual coming to your community for skilled care and therapy is the skilled need, then therapy must and should be delivered.

As a reminder, the requirements for accessing the Medicare Part A benefit are below.

Care in a SNF is covered if all the following four factors are met:

  • The patient requires skilled nursing services or skilled rehabilitation services, i.e. services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 – 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;
  • The patient requires these skilled services on a daily basis (see §30.6); and
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e. are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

2. The second comment that I am hearing more frequently is that there is a sense that CMS is asking us to do more with less under the PDPM model.

Again, not true. Remember that PDPM is a budget-neutral model.

What CMS is asking us to do is to put on our clinical hats, remember why we all decided to work as caregivers in the first place and de-program ourselves from the current volume-based model into a clinical and quality-based model.

PDPM is also being implemented during a time where we see an overall industry push for improved quality from QRP, VBP and the new state survey process and implementation of the critical element pathways.

We now have an opportunity from day one of the stay to speak clinically about the individuals we are serving. We have the chance to now speak across the entire IDT about functional levels tied to data analyzed portions of the MDS (thanks, Acumen) for which historical claims show significant trending for certain clinical categories that are specific to disciplines. These areas, of course, include from a therapy perspective: Sections GG, B, C, K and I.

3. The third set of comments that I am hearing are related to what are being called “approaches” providers will use to be “successful” under PDPM. These include, among others: an increase in restorative-based care in conjunction with a reduction in skilled therapy, and clinical pathways that set volume-based requirements on skilled therapy.


For starters, restorative programming can and does provide benefits to the individuals we care for when used as an extension of skilled therapy, but not as a replacement.

We have to go back to our regulatory roots on this one, and remember that therapy is a skilled service for a reason and placing a skilled level of care on an unskilled discipline is not an effective approach.

Skilled therapists are required to provide care that is evidenced-based, is complex and sophisticated, that does not use medical diagnosis as a primary determinant, and that is provided at the appropriate frequency and duration.

Restorative, earlier in the stay, as an extension of and as prescribed by therapy, yes.

Restorative, to replace or reduce therapy. Not a good plan. Also, if this approach is used, what is your skilled need? Are you meeting the regulatory requirements to even access the benefit appropriately?

The clinical pathway conversation is also an interesting topic. Mostly when I hear how groups intend to implement them.

Clinical pathways, when person-centered, evidenced-based, and interprofessional while not being overly prescriptive, are amazing tools, not just for the individuals we serve but for the entire clinical team to have a foundation road map to guide assessment, treatment and milestones aimed at functional progress.

Clinical pathways that are geared at limiting therapy treatment time based on clinical categories. Not a good plan.

I have even heard misinformation to the level that CMS has time parameters tied to the clinical categories for how much therapy should be delivered. Again, not true.

In closing, I hope everyone who has been in the midst of conference season over the past week arrives home safe and sound and will have the right tools and information in hand to fully understand the intent and purpose of the PDPM model.

Looking forward to an exciting year ahead, and to us all collectively spreading the right messages moving forward.

 Renee Kinder, MS, CCC-SLP, RAC-CT, is Director of Clinical Education for Encore Rehabilitation and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs 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).