Over the last several months, Bill Goulding has crisscrossed the country, talking to providers who are trying to figure out how the new skilled nursing payment model may benefit them and what changes they should be making now.
Speech language therapy is getting a lot of early buzz, and it’s a service component that could be a “game changer,” according to Goulding, national director of outcomes and reimbursement for Aegis Therapies.
Currently, just 33 MDS items drive reimbursement for therapy and nursing services. Under the Patient-Driven Payment Model, however, that figure will grow substantially and leave providers with more ways to identify what services each unique resident actually requires for improved health and quality of life.
“Looking at it for the long end, the whole purpose of this payment method is to shift away from the volume base,” Goulding says. “There are well over 100 items they’re going to have to monitor. They’re working out a much more subtle way to see those patient characteristics.”
Under the currently used RUG system, PT, OT, and SLP minutes are combined for a total number of treatment minutes to set the overall treatment level.
When it goes into effect in October, PDPM will give speech language pathology equal footing alongside physical therapy, occupational therapy, nursing services, and non-therapy ancillary services.
Some therapy experts believe PDPM will give speech therapy a chance to come out of the shadows and prove what high-quality services can do for residents with identified needs. Still, most are taking a cautionary approach.
“There is either misconception or confusion or people don’t feel comfortable about the role of speech [in PDPM] yet,” says Elisa Bovee, an occupational therapist and vice president of clinical strategies for HealthPro Heritage. “Speech is one of the more involved algorithms. There are just so many pieces in the case-mix puzzle.”
Even at the highest case-mix possible, speech reimbursements will hit only $92 a day, less than half the maximum possible for physical therapy and occupational therapy services combined.
The Centers for Medicare & Medicaid Services has already warned providers that it will be on the lookout for sudden increases in the use of mechanically altered diets, Section O minutes that jump or drop off without explanation, early discharges, and overuse of high-impact ICD-10 codes.
So if services shouldn’t increase, why all the anxiety about access to speech language pathologists? Why so much excitement among some therapy companies about the potential of SLPs to increase revenue?
“I truly think the impact is going to be on a case-by-case basis,” says Liz Barlow, RN, senior director of quality for RehabCare. “I don’t think I can say we’re going to increase the speech workforce. But having the nurse in the building collaborate and discuss with our therapists is going to be vital.”
Trained SLPs will be key to helping spot swallowing problems defined in Section K and ensuring that they are observed and documented in the resident chart to back up case-mix calculations.
“I believe there is going to be a better focus on identifying those needs early in the stay,” says
Jessie McGill, curriculum development specialist for the American Association of Nurse Assessment Coordination. “[Under the current system] we might overlook some of the areas that speech therapy can be used successfully in improving resident outcomes.”
McGill says residents coming straight from a hospital stay or recovering from surgery often arrive with obvious physical symptoms — or referrals — that trigger PT and OT as part of the skilled nursing stay. But those referrals are less likely to include automatic calls for speech therapy evaluations. Using staff to spot those types of needs and get a speech screen started will require more focus under PDPM.
In some facilities, suggests Goulding, SLPs should be involved in determining the resident’s SLP group and his or her overall case-mix index, including playing a role in the identification of a specific swallowing disorder and use of the Brief Interview for Mental Status.
“In the current world, doing a prospective evaluation might be met by having a PT or OT jump in early, say, on a weekend,” Goulding says. “But that won’t work as well in the future … SLPs need to have their fingerprint on a much broader swath of the MDS.”
“Any provider who isn’t able to get a speech evaluation done earlier needs to take a look at PDPM and ask if they really understand the move that CMS is making,” he adds.
Yet for the majority of residents who require the help of an SLP, not much will change.
Bovee says the reimbursement bubble will burst for all but the most involved residents. Those who have a swallowing disorder but no neurological or cognitive impairment will net providers just $52.58 a day, based on available CMI calculators.
That’s not enough to make most providers hire a full-time SLP if they don’t already have one.
When PT and OT are docked a 2% penalty for stays beyond 20 days, each will lose about $2 per day. For most providers, those kinds of services won’t realistically lose their emphasis.
Special K, special hoops
Under PDPM, the speech case-mix index will be determined by a resident’s needs in four categories: presence of an acute neurological condition; cognitive impairment; a swallowing disorder as defined by Section K; or dependence on a mechanically altered diet.
Within Section K, residents may have needs dictated by loss of liquid or food from mouth when eating; pocketing residual food in mouth after meals; coughing when eating or taking medication; difficulty or pain with swallowing or “none of the above.”
A patient’s main ICD code also may carry with it one of 12 speech-related comorbidities, such as ALS, oral cancer or aphasia — all of which can drive the case-mix multiplier higher. But facilities will have to document at every step that services are truly indicated for a given resident.
Each resident’s needs are grouped together to create a category multiplier of up to 4.19.
“There are a lot of hoops to jump through to get the max speech CMI,” Bovee says. “We shouldn’t expect it.”
Speech services — even those provided to prevent a resident from backsliding — must require skilled care in order to trigger reimbursement.
Bovee warns that some equipment or services, such as augmented language devices, that help residents compensate for loss of ability will not be considered skilled interventions and should not be coded as such.
Likewise, Barlow says a pre-existing swallowing disorder with resolved symptoms should not factor into the SLP grouping. “‘A history of’ is not enough,” she explains.
Making sure those types of documentation errors don’t happen will be a true team effort that must go beyond MDS coordinators, experts say. Many organizations are providing online PDPM training such as American Association of Nursing Assessment Coordinators virtual workshops.
In a Netsmart webinar, BKD National Health Care Group Director John Harned reminds providers and operators that the majority of their employees have never worked under any system other than RUG. They will need strategies to help them adapt.
Deborah Lake, RN, senior consultant with BKD who has spent more than 30 years in long-term care, emphasizes teamwork will be essential. That may be most true in small or rural facilities whose SLPs are shared between sites.
“I think a lot of it’s just going to be an educational issue,” Lake says. “If your SLP is not in the building every day, the rest of your staff needs to know what issues actually need to be referred to them.”
Lake believes nurse aides should be retrained on visible eating or drinking issues like drooling or pocketing food.
“They may take some things for granted, like drooling is a part of old age,” Lake says. “But drooling can be a sign of some swallowing disorders.”
Also often overlooked: difficulty or pain with swallowing, especially in cognitively impaired patients. Employees should be taught to note grimaces or other non-verbal clues that a resident is in distress.
Reporting those observations up the chain and capturing them early and accurately in Section K will allow for the best interventions — a speech screen and possible evaluation — and the highest reimbursements if services are needed.
“Speech pathologists will be just as important tomorrow as they are today for our residents, but we’re going into a system that’s going to force us to be more proactive,” Bovee says.
“So think about those quality conversations we’re having about person-centered care,” she continues. “How are we most optimally assessing them and addressing all the issues that put residents at risk?”