In less than 6 months, the long-awaited transition to the Patient Driven Payment Model (PDPM) will occur. By now you’ve probably participated in multiple webinars and on-site meetings regarding the shift to this new payment model. One of the most consistent themes in these trainings is the use of the interdisciplinary team to ensure accuracy with coding on the MDS. While it may be obvious why the therapy team needs to contribute information for the physical therapy, occupational therapy, and speech language pathology components of PDPM, it may be less obvious why their input is crucial to the nursing and non-therapy ancillary components.

The nursing component within PDPM employs the familiar hierarchical classification method for case mix qualification. The most significant change from RUG IV is the removal of Section G and the ADL score from the classification and the introduction of the Section GG function score. The nursing, PT and OT function scores factor in seven of the same GG late loss items. Unlike RUG IV, there is no direct correlation between the function score and the case mix index (CMI). Therefore, a lower function score does not necessarily mean a higher CMI. However, subtle changes in reimbursement for nursing services provided is reflected in PDPM as seen in the use of restorative programming, extensive services, present condition, and physical function.

The non-therapy ancillary component consists of fifty conditions, each assigned a weighted value of 1-8. The weighted value is in direct proportion to pharmaceutical costs associated with that condition. These point values are summed to determine the comorbidity score for the patient. The higher the comorbidity score, the higher the CMI and reimbursement. Additionally, PDPM accounts for higher pharmaceutical costs early in the stay by front loading this CMI at 300% for the first 3 days of the stay. A thorough review of the medical record, full body assessments, and reconciliation of prescriptions to conditions must be completed to ensure all possible comorbidities are captured on the MDS.

The rehabilitation team plays a critical role in identification and accurate coding of clinical characteristics for the resident in relation to the nursing and NTA components. By establishing a foundation of understanding in relation to therapy’s role for each component, as well as fostering clinical skills to conduct holistic, full system evaluations the therapy team will aid in ensuring comorbidities are accurately coded and help identify the appropriateness of restorative programming. The conversations occurring at the interdisciplinary table regarding each new resident will shift from the projected amount of therapy to review of clinical conditions and care to allow for appropriate resources for the projected needs of the resident.

PDPM is in many ways more of a prospective payment system than RUG-IV has ever been. Therefore, with the transition to PDPM, it is more important than ever for administration, nursing, MDS coordinators, and therapy to coordinate together for accurate coding on the MDS. If one piece of the interdisciplinary team is missing, important patient information may fall through the cracks.

While an interim payment assessment is always an option, capturing an accurate picture during the initial assessment ensures the full intention of the PDPM reimbursement methodology is captured for each component including the NTA’s variable per diem rate.

From an active diagnosis of endocarditis to an aphasia comorbidity, it is evident more than ever that physical therapists, occupational therapists, and speech language pathologists need to thoroughly review full body systems during evaluation for identification of the patient’s underlying conditions and comorbidities.

Under PDPM these holistic assessments extend beyond the impaired system and will allow the clinicians to bring relevant, meaningful clinical information to the interdisciplinary table. This information will contribute directly to the identification of SLP related comorbidities and the non-therapy ancillary comorbidity score to ensure the patient’s clinical classification is accurate and representative of the potential resource use needs during their stay.

A breakdown in this interdisciplinary collaboration may lead to missed opportunities for proper reimbursement. However, with extensive therapy evaluations and interdisciplinary collaboration, these opportunities won’t slip through the cracks.

Begin exploring how team conversations will change under PDPM and identify areas to improve interdisciplinary communication. Be on the lookout for Reliant resources relevant to interdisciplinary team success.

Earlier this month, Reliant hosted regional directors for its annual leadership conference in Plano, Tx. The first day, attendees were inspired by Roy Tuscany of the High Fives Foundation. He offered a patient’s perspective for clinicians and presented a call to shift from the “standard protocol” to the “patient protocol.”

Through his personal story and rehabilitation journey he detailed the importance of cultivating hope in our patients and a killer high five. He emphasized it’s not just the control, attitude, and effort of the patient that effects outcomes and recovery, but the clinician’s control, attitude, and effort that ignites success.

Day two opened with keynote Heath Slawner. Heath passionately detailed the importance of claiming and living out purpose. He led the audience through an exercise to evaluate personal reasoning for our daily choices, during which he stated “start with why.” What is your why? Recognizing and embracing the reason we set out to become a clinician, administrator, or other healthcare professional provides perspective. Knowing your company’s why allows for a common culture and approach to executing product delivery.

These speakers offered the perfect complement to the remainder of the conference which focused greatly on planning and preparing for PDPM. This is the sixth installment of the Reliant Reveal PDPM series. Previous articles have focused on the structural frame work of the model, details surrounding function score calculation, strategies for training, and coding success. Within each article, and the education we have created to date, a complementary theme is emerging: the importance of collaboration and communication.

Success under PDPM may be related to contract considerations, amassed resources, and field education; however, longitudinal success- the success that produces outcomes, will be directly impacted by each care professional’s ability to effectively collaborate and communicate for the patient’s care needs.

Facilities should begin moving from the standard protocol of care to an elevated, patient-driven protocol. This protocol will empower the evaluating therapist to collaborate with nursing to ensure comorbidities are accurately and timely identified. Therapists will bring to the table the clinical characteristics to be identified on the MDS, discharge planning notes, and knowledgeable discussions surrounding the clinical reason for admission.

The successful facility under PDPM will have a clearly defined “why” complemented by Reliant’s why: Care Matters. This is the heartbeat of our daily practice, service delivery, communication and collaborative approach to patient care.

CMS provides a Patient Driven Payment Model (PDPM) web page which houses a variety of resources (comorbidity mapping tools), fact sheets, and a training presentation.

During the open door forum, CMS announced updates to the materials found on the PDPM webpage in response to stakeholder feedback including:

• The training presentation has been replaced with the National Provider Call from December 2018,
• The classification walk-through document has been updated, and
• The FAQ document has been updated.