Image of male nurse pushing senior woman in a wheelchair in nursing facility

The new Patient-Driven Payment Model, which is scheduled to start next October, could revolutionize the way therapy services are provided and paid for. Stakeholders have voiced various concerns, a major one being the plan’s variable per-diem rate. The new model also could lead to a more medically complex patient population and increase the need for prescription drugs and pharmacy services.

Experts explain how providers can best position themselves to be successful under this new system:

1. Brush up on core competencies.

“Providers need to understand how their current patient population will crosswalk from the RUGS to PDPM category and the resultant revenue implications,” observes Hilary Forman, PT, RAC-CT, chief clinical strategies officer for HealthPRO Heritage.

In order to optimize care management and assure appropriate clinical reimbursement for each patient mix, it is essential that providers “do exceedingly well” on things such as ICD-10 coding, MDS accuracy, ADL and functional scoring and overall care management processes, she adds.

2 PDPM will require deeper data dives and  broader record review of a resident’s episodic care, including visits to the

“A comprehensive review of the patient’s electronic health record  from both the acute-care hospital and the SNF to accurately capture and code MDS Section I, within the timeframe of the initial, five-day MDS, is imperative,” says Mike Capstick, executive vice president of Select Rehabilitation.

It also will require providers to code modified diets, cognition and Section GG in an accurate and timely way, he adds.

Laura Reuss, business development coordinator for Functional Pathways, says providers will need to ensure they have the tools in place to manage the mountain of additional data required to be compliant. This includes “instant data collection and reporting on outcomes to ensure they are safely transitioning patients to the next level at the appropriate time.”

According to a newly released white paper from Optima, therapy providers will need advanced business intelligence and data analysis tools to help predict their future needs and manage costs under PDPM. Other must-haves: tools for guiding treatment plans by resident classification.

3 PDPM will require  coordination to understand residents’ records.

Reuss says the interdisciplinary team must clearly identify all clinical needs and allocate resources to address those needs.

PDPM also will require “a team-oriented approach to ensure the medical record contains documentation to support the MDS, and the MDS contains everything that is documented in the medical record,” adds Capstick.

4 A thorough review of therapy contracts is essential.

This will confirm everyone is on the same page with PDPM.

“It will be critical to pursue continued partnerships with upstream and downstream providers to ensure longitudinal outcomes across the continuum that are aligned with reimbursement initiatives,” adds Reuss. “This also will go far in ensuring full transparency with outcome reporting.”

5 The sooner a facility gets a clear picture of resource utilization, the better.

This is particularly true with medications, says Chad Worz, PharmD, BCGP, CEO of the American Society of Consultant Pharmacists.

“PDPM offers opportunity and risk. The opportunity is in the recognition of higher cost medications that influence the short stay patient,” Worz asserts. “Providers are walking a tightrope of readmission penalty and the unknown of the new payment system. There are provisions for high-cost meds in the first three days of transition, but there is also management and risk of medication use that drives the successful discharge and safe transition to home.”

A deeper dialogue between the SNF provider and the pharmacy needs to occur, Worz adds.

6 Prepare to say goodbye to some practices.

SNFs can no longer rely on the therapy department to provide information to codes Section O and G without paying significant attention to the other pertinent sections of the MDS, says Capstick.

Another is the denial of admission based on high-cost medications, predicts Worz.

“Unfortunately, with the three-day adjustment and the lack of clear instructions on high-cost and speciality medications, this new payment rule will need continued revisions,” he adds.

In all, Reuss sees an end to providing “one-size-fits-all” care in silos, as well as rehabilitation programs that focus on therapy only.

7 Assume individual/concurrent therapy mixes will stay.

A popular notion right now is concurrent or group therapy may be encouraged more, as opposed to one-on-one therapy.

Capstick said he believes “quality rehab outcomes will continue to be a primary driver of SNF admissions. Any significant change in the quality or quantity of rehab provided will be poorly received by patients, family members and referral sources.”