With the Patient-Driven Payment Model (PDPM) set to take effect this October, skilled nursing facilities must change care delivery systems to maximize efficiencies and reimbursement. However, they must not compromise on patient outcomes.

Creating a true value-based care program means putting equal stock in efficiency and quality, requires a top-down adoption plan, and underscores commitment to value.

The finalized version of PDPM is a long overdue step toward bringing the SNF industry closer to a payment system based upon the needs of the patient. It’s a welcome change from the therapy-minute driven payment system of the Resource Utilization Group, Version IV (RUG IV), where quantity versus quality of service drove care decisions and profitability. This payment reform model required SNFs to capture the unique clinical characteristics of a patient, not only for reimbursement, but to ensure the provision of comprehensive clinical care. Where PDPM falls a bit short, however, is not explicitly tying quality outcomes to the measurement of the provider’s success.

To be successful under PDPM or any other iteration of this proposal, buy-in from C-suite executives, administrators, and clinicians is a core requirement. A significant amount of change management and care redesign is in our future.

The process will take time to develop and fully integrate, but with CMS official announcement finalizing the program, here are four ways SNFs can redesign care now in advance of the October 1 go-live date.

  • Maximize efficiencies of care delivery: Work smarter, not harder.
    Nursing and rehab therapies need to make care delivery more efficient and focus on tasks and treatments which contribute to a safe discharge.
    True interdisciplinary care must be the core of interdisciplinary team meetings: Talk barriers, not status.
    Focus on creative problem solving versus repetitive services to overcome challenges. Nursing, therapy, and discharge planning can no longer ask the question, “What will skill the patient (so that he/she will stay longer)?” but must ask the question, “What are the skilled needs required now to progress this patient safely to the next level of care?” Restructuring meetings from a status update to instead addressing barriers to discharge will have a quick and significant effect on overall efficiencies.Nursing must reinforce therapy goals and vice versa: Repetition accelerates learning.

    Consistency and repetition are key to behavioral changes, but we must recognize repetition is not necessarily a skilled service, and all caregivers associated with the patient’s recovery are responsible for carryover and generalization of skills learned.

    If the patient’s goal is for a higher level of independence with transfers, every transfer in the therapy gym and on the nursing floor must be executed with the same level of assistance and instruction. If a patient’s cognitive goal includes memory, sequencing, and problem solving, then speech and occupational therapy may incorporate a nursing goal (such as using a glucose monitor) as a part of treatment strategies.

    Focusing on common goals and consistency between disciplines will help the patient learn faster and better. Both nursing and therapy goals and treatments must be functionally focused, specific to patient’s barriers to discharge, and uniformly and consistently addressed.

  • Think like managed care: Establish goals that are consistent with next site of care. In today’s fee-for-service world, the more care a patient receives within a single care setting, the more revenue is generated. In a value-based environment, maximizing the full care continuum is key to better patient outcomes and better reimbursements. Prior Level of Function (PLOF), if reasonable, is the goal of the full rehab journey which most times extends to home health and outpatient services.

    Establish team goals consistent with the next — and safest — discharge site. Therapists and nurses can no longer set PLOF as the SNF goals. Goals should incorporate, consider, and reflect available caregivers at the next site, environmental changes (ramps, etc.), and possible need for alternate living sites, like with a family member.

  • Remember the family: Like nursing and therapy, patient and family goals must be realistic and achievable.   If, collectively, the care team recognizes a return to a prior setting is unlikely and an alternate discharge plan must be considered, this information must be brought to the attention of the patient and family. Collaboration allows everyone involved to work toward attainable goals.

    Discharge planners must talk with the patient and family frequently about alternate options where medical and therapy services can continue to be delivered after SNF discharge, and develop a “Discharge Plan B” within days of SNF admission, which can be quickly executed should functional and medical gains not be met.

    While this is no easy task, when done right, patients and families are thankful they were well informed and had plenty of time to prepare.

  • Use data to support your clinical decision making Whether data is provided through decision support tools, internally from organizational leadership, or through third-party outcome reports, the information is critical to analyze and inform care plans. Typically interventions based on research, tested treatment protocols, and reduced practice variation produce the best outcomes. Using data to provide a better patient experience and to highlight the quality a facility brings to the marketplace serves organizations well.

    PDPM may incentivize lower intensity of rehab therapy delivery, but a word of caution: don’t fall into this trap. As the recent announcement proves, CMS will enforce quality outcomes for both functional gains and readmission prevention through quality measures, so these parameters can’t be compromised. Patients will continue to require skilled therapy, which must be delivered more efficiently, with better coordination with interdisciplinary team members, and with more emphasis on function.

    With PDPM, CMS has taken a big step away from paying for quantity of care and has simultaneously begun tracking, measuring, and rewarding quality outcomes. PDPM must not become a game of coding, but rather a collective strategy for patient success, ensuring the right care is provided for the right clinical complexities of the patient. With the guidance from CMS, SNF teams should begin preparing for the changes now by evaluating their current care delivery and strategizing their redesign, all while keeping the patient’s needs — not the facilities resources — top of mind.

Colleen O’Rourke is the Senior Vice President of Network and Clinical Solutions at naviHealth. 


Amy Leibensberger is Senior Director of Outcomes Integrity at naviHealth.