PDPM ACADEMY – Business Solutions for Better Patient Care...Single and batch MDS data AHCA PDPM...

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PDPM ACADEMY –Business Solutions for Better Patient Care

2/8/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 1

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AHCA Board: What are CMS’ Issues with RUGs?

Interviewed Members: What Do You Think About PDPM?

To Dos: What Did Interviewed Members Think SNFs Should Do?

PDPM Preparations Are Member Driven

IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 3

… Which Drive Our Goals Today and Our Designed Outcome

• Establish Understanding of SNF

Operational Changes;

• Learn About Patient Classification &

How it Drives Payment; and

• Gain Insights on How to Think

Creatively About PDPM


PDPM Transition Plan

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Orientation to the Workshop

2/8/2019 IMPROVING LIVES by DELIVERING SOLUTIONS for QUALITY CARE 5

Workshop Day is Experiential and Hands-On Rather Than a PDPM Overview

• Workshop Day Will Focus on How to Use AHCA/NCAL Designed PDPM Tools

• PDPM Basics Are Addressed in Pre-Recorded Webinars


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Workshop Overview


More Resources Will Be Available – Workshop is Just the Start

Mon

thly

Web

inar

s • Q&As • Updates on CMS

Activities • FAQs from Each

AH

CA

Em

ail • [email protected]

• Responses drafted by AHCA staff or fielded with CMS as needed

• Answers synthesized into FAQs Weekly A

dditi

onal

Too

ls • Regular Release of Additional Tools

• Updates to Existing Tools as CMS Releases Information


PDPM Academy Focused on Supporting Members for Transition –Reboot in Fall 2019 for Operations

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Module 1: Re-Thinking SNF Operations for PDPM Transition


Module 1 Materials

Document (Follows Binder Materials Order) Purpose

Coversheet Orientation to the Module Activities

Core Competencies Summary SlidesFollow Along During Presentation & Group Exercise

SNF Case Examples & Worksheets Group Exercise

LTC TeamSTEPPS Overview Document Reference-Only & Take Home

CMS PDPM Webpage – Will All be at ahcancalED Reference-Only & Take Home


As we progress through the binder, trainers will note which page and document to reference as needed

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Why is Assessing SNF Building Operations Important?


Resource Utilization Group IV Patient-Driven Payment Model

Basis for Payment Fundamentally Changes

Key Competencies and Activities

Driven by Therapy Minutes

• Based on Clinical Characteristics

• ICD-10 Diagnosis and 188 MDS Items

Multiple, Regularly Scheduled Assessments

Driving Per Diem Payment

• Single Rapid Patient Assessment – 8 Days

• Variable Per Diem

Therapy Frames Care in Most Instances

• CMS Expectation for Holistic Care

• Coordinated, Team-Based Care

Understanding CMS’ Framework for PDPM is Key


CMS Framework Element PDPM SNF Operational Implications

Remain within Existing Statutory Authority

• Sum of Per Diem Rates (PT, OT, SLP, Nursing, NTA, Non-Case Mix)• Accurate Assignment to Five Component Case Mix Groups (CMG)

Use Existing Data • PDPM Simulated Revenue and All Other Modeling Are Estimates • Assess Ability to Classify into PDPM CMGs • Develop capacity to collect supporting documentation

Develop a Readily Implementable System –October 1, 2019

• Hard Stop – No transition period• Do Not Wait to Start Transition Planning • Develop a Work Plan (Module 1)

Shifts Away from Therapy Minutes as Basis for Payment

• Payment Based on Patient Characteristics • Minutes only Counted at Discharge & Must Match Claims

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What Can Go Wrong If You Are Not Prepared for PDPM?


Four Core Competencies for Successful Transition


1

2

3

4

Understand New Payment Driver’s Impacts

Accurate Collection of Clinical Information

Strengthen Care Delivery Process

Optimize Resources to Support PDPM

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Core Competency #1 – Understand New Payment Driver’s Impact


Understand PDPM payment drivers and expected facility adjustment if no changes to patient mix

Identify organizational gaps that will affect implementation and subsequent payment under PDPM

Make changes in organizational culture to support PDPM

Ensure operational staff understand overall model goals and individual components relevant to role on team

Build ICD-10 coding capacity to ensure payment

Option 1: Estimated Revenue Impacts on Your Building(s)


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Open the CMS Workbook


Scroll Down to Provider-

Specific Impact

Double Click to Open the Impact

Analysis File

Quick Overview Demo on How to Find Your Revenue Data


CMS Simulated Payment Data

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Option 2: AHCA PDPM Academy Resources

AHCA PDPM Resident Classification Toolkit◦ Includes today’s resources & more

AHCA PDPM Case-Mix Grouper Simulator Toolkit (early 2019)◦ Excel workbook◦ Variable per-diem impact estimator◦ Single and batch MDS data

AHCA PDPM ICD-10-CM Toolkit◦ 16 hour online certification program for coders &

clinicians◦ 4 hour online ICD-10 CE program for

administrators & non-coders


Be sure to download and use the AHCA PDPM Academy Toolkits and Instructional Webinars

Core Competency #2 – Accurate Collection of Clinical Information


Understand importance of clinical documentation

Ability to quickly capture admission information

Capacity to be proficient when determining ARD & initial coding

Ability to capture functional status correctly—Section GG

Develop process in to determine when an Interim Payment Assessment is needed

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Patient Characteristics Represented by MDS Items Drive Payment


Five independently determined PDPM component rates set during 5-Day assessment window using 188 MDS item fields

PT: 37 OT: 37 SLP: 66 Nursing: 132 NTAS: 34

… Shifting Away from Therapy Minutes as Basis for Payment

Rehab RUG rates Determined by 20 MDS Item Fields

Over 90% of resident days reported via Rehab RUGs

168 Additional Auditable MDS Item Fields Apply to ALL Stays/Days

Compliance Policy & Medical Documentation Will Need to be More Robust in PDPM


High Risk Behavior Examples

Motivation Implications

Upcoding Revenue Maximization CMS will have a direct line of sight via ICD-10 and other MDS document

Downsizing Therapy Overhead Reduction CMS is clear the SNF benefit and cover requirements remain the same and will be monitoring for outcomes (e.g., QRPs)

Over-Use of Interrupted Stay

Restart Variable Per Diem

Risk of losing VBP bonus or increasing penalty up to 2% for all SNF stays & risk of being placed under “heighten scrutiny”

Vague IPA Trigger Definition

Room to Argue +/- in CMGs and Rates

SNFs should follow clear internal IPA policies and demonstrate adherence

Download AHCA/NCAL Compliance Policy Checklist based on CMS priorities in FY19 Final Rule from ahcancalED.

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Compliance Policies Checklist Version 1.0 – for Reference-Only in Your Binder


Compliance Checklist

Document is located between the Core Competencies Checklist and the Group Exercise materials.

Core Competency #3 – Strengthen Care Delivery Process


Evaluate care planning team and processes

Assess communication between nursing and therapist staffs

Define how therapy practices may change to ensure best outcomes

Ensure ability to deliver exceptional restorative nursing

Ability to support complex patients

Evaluate and consider development of specialized clinical programs (e.g., cardiac, respiratory) and transitions program

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CMS Care Plan Expectations in PDPM and Requirements for Participation


Sources: CMS PDPM Webinar (12/11); Final Rule, Page 39189

To develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident’s goals, preferences, and services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.

Sources: Section 483.21, Final Rule Page 652

PDPM Drives “Holistic” Patient Assessment

Comprehensive Person-Centered Care Planning Baseline Care Plan Audit Checklist

RoP-Required Comprehensive Person-Centered Care Planning

Available at ahcancalED

Utilizing Evidence-Based Tools for Redesigning Care Team Coordination


Download TeamSTEPPs Long-Term Care Version 2.0 from ahcancalED and review care team assessment sheet in binder for reference purposes.

Knowledge◦ Shared Mental Model

Attitudes◦ Mutual Trust◦ Team Orientation

Performance◦ Adaptability◦ Accuracy◦ Productivity◦ Efficiency◦ Safety

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Teams That Perform Well …


• Hold shared mental models• Have clear roles and responsibilities• Have clear, valued, and shared vision• Optimize resources• Have strong team leadership• Engage in a regular discipline of feedback• Develop a strong sense of collective trust and confidence • Create mechanisms to cooperate and coordinate• Manage and optimize performance outcomes

Core Competency #4 – Optimize Resources To Support Implementation


Assess MDS coordinators’ abilities and growth potential

Identify the need for / investment in additional clinical staff (e.g., NPs)

Assess therapy contracts

Determine need for additional training to improve coding accuracy

Evaluate current business office capabilities

Discuss internal / vendor software readiness and schedule beta testing to ensure accuracy

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Resources Should be Assessed in Tandem to Ensure Optimal Outcomes


View PDPM Impacts on SNF Benefit, QRP, and VBP Webinar ahcancalED PDPDM Academy page. ICD-10 training platform also is available at ahcancalED.

Assess PDPM Impacts on Quality Reporting Program

and SNF VBP Program

Assess Information Technology Needs

Using Specifications

Review Therapy Staffing/Contracting

Options Tool

Utilize AHCA/NCAL ICD-10 Virtual

Training Programs

Coordinated Resource Re-Alignment

MDS Coding Impacts QRP Outcome Measures and PDPM Classification

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PD

PM

Obs

erva

tions

• CMS and OIG will Track and Flag Declines in Patient Outcomes

• Pressure Ulcer Worsening or Appearing During a Stay often Indicative of Broad Problems with Care

• Importance of Restorative Nursing in These Outcomes

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Claims-Based Measures Will Be Tracked to Assess Provider Behavior


• Total Estimated Medicare Spending Per Beneficiary (MSPB)MSPB

• Discharge to Community (DTC) and remained in community for 30 daysDTC

• Potentially Preventable 30 –day Post-Discharge Readmission Measure PPR

PD

PM

Obs

erva

tions

• Relative to MSPB, ensure coding is accurate

• Be thoughtful about variable per diems and DTC rates

• Be aware CMS has not clarified the impact of Interrupted Stay and related IPA use on PPRWebinars on AHCANCALED walk you through registration and

use https://educate.ahcancal.org/products/how-do-i-use-ltc-trend-tracker-as-a-skilled-nursing-facility

Interrupted Stay Use Has a Possible Two-Fold Impact – Tracking?


Heightened CMS Scrutiny

• No new admission assessment if </= 3 days but can use IPA

• New admission assessment required if away >3 days

• Does return to day day-1 PT/OT/NTAS tapering

Bonus Payment Impacts? SNF VBP Program

1

2

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Therapy Staffing & Contracting Considerations

Person Centered

Care

Outcomes

Revenue

Cost

Skill Set


Keep an eye out for the AHCA PDPM Therapy Staffing/Contracting Considerations Toolkit to download from the ahcancalED PDPM Academy page in early 2019

• PDPM Is an Opportunity To Rethink the Rehabilitation Mindset in your Organization

• Key areas to consider - in-house or contracted therapy: • How will any possible changes in therapy and

restorative impact my outcomes for short-stay residents and quality measures for all residents?

• Based on my current resident case-mix profile, will I see more or less therapy component revenue under PDPM?

• Are my therapy staffing/contracting costs/provisions in alignment with PDPM, QRP, VBP, and RoP incentives?

• Do I have the skill set to achieve outcomes goals?

CMS Offers Helpful Resources


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Good Samaritan Society PDPM Planning – SNF Re-Organization


Member Video

Q&A on Core Competencies


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BREAK

SNF Building Assessment Exercise Objectives

1. Understand the operational and service delivery changes needed for the SNF to successfully transition to PDPM

2. Learn what current QRP and VBP trends position the SNF to be successful or would be indicative of the need for significant assessment of service delivery

3. Develop an understanding of what the top priorities for PDPM investment should be for the SNF case examples


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Group Exercise – SNF Case Example Assessment

1. Room divided into groups by SNF Case Example SNF A – Urban SNF B – Rural/Suburban SNF C – Rural

2. Materials SNF Case Example Core Competencies Summary Assessment

3. Report Out Using Instructions on Worksheets

4. Be Prepared to Offer Comments on Other Groups’ Work


SNF Building Case Examples

SNF Market Patient Mix Revenue

A Urban Orthopedic/RehabilitationAll Medicare

BRural (suburban)

Mix of Rehabilitation and Some Long-Stay

Medicare with Some Medicaid

C Rural Mostly Long-Stay with Some Short Stay Post-Acute Care

Medicaid with Some Medicare


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Assessing SNF Case Example


Core Competency Readiness Level Prioritization

High Med. Low High Med. Low

Understand New Payment Drivers Understand PDPM payment drivers and expected facility adjustment if no changes to patient mix

X X

Identify organizational gaps that will affect implementation and subsequent payment under PDPM X X

Make changes in organizational culture to support PDPM X X

Ensure operational staff understand overall model goals and individual components relevant to role on team X X

Build ICD-10 coding capacity to ensure payment X X

Examples of Key SNF Challenges1. Executive leadership has not examined patient case mix under RUGs

Compared to PDPM• Possible Course Action: Develop a PDPM Transition Team Effort to

Assess Referral and Align Those Patterns with Possible PDPM Specialization Areas

2. SNF needs an ICD-10 training program which includes an assessment of how coding works from admission to claims coding• Possible Course of Action: Interview In-Take Staff on how PDPM

ICD-10-CM and other Coding Could Be Improves and Develop Coordination/Collaboration Strategies Among MDS Coordinators and Billing Staff Through Similar Staff Dialogue


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Core Competency #1 – Understand New Payment Drivers Impact


10 Minutes

Understand PDPM payment drivers and expected facility adjustment if no changes to patient mix

Identify organizational gaps that will affect implementation and subsequent payment under PDPM

Make changes in organizational culture to support PDPM

Ensure operational staff understand overall model goals and individual components relevant to role on team

Build ICD-10 coding capacity to ensure payment

Core Competency #2 – Accurate Collection of Clinical Information


Understand importance of clinical documentation

Ability to quickly capture admission information

Capacity to be proficient when determining ARD & initial coding

Ability to capture functional status correctly—Section GG

Develop process in to determine when an Interim Payment Assessment is needed

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Core Competency #3 – Strengthen Care Delivery Process


Evaluate care planning team and processes

Assess communication between nursing and therapist staffs

Define how therapy practices may change to ensure best outcomes

Ensure ability to deliver exceptional restorative nursing

Ability to support complex patients

Evaluate and consider development of specialized clinical programs (e.g., cardiac, respiratory) and transitions program

Core Competency #4 – Optimize Resources To Support Implementation


Assess MDS coordinators’ abilities and growth potential

Identify the need for / investment in additional clinical staff (e.g., NPs)

Assess therapy contracts

Determine need for additional training to improve coding accuracy

Evaluate current business office capabilities

Discuss internal / vendor software readiness and schedule beta testing to ensure accuracy

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SNF Building A•150 bed SNF part of hospital system

•Major US city in popular Midwest retirement center

•Primary focus is short-term uncomplicated ortho rehab

•ALOS = 20 days

•Mix = 80% RU, 10% RV

•Restorative nursing = weak

•Therapy is delivered in-house

•MDS works for corporate reimbursement consultant


•Section GG gathered by therapy only

•Most of referrals come from affiliated hospital

•3 other SNFs within 15 miles

•No medically complex patients

•QRP: will receive bonus payment

•Assessment measures: As expected

•Claims measures: Mixed

•Financial Projection: -21%

SNF Building B

•75 bed SNF

•Rural area outside of large east coast city

•20 bed ‘respiratory unit’ for ventilator patients, but plan abandoned

•ALOS = 30 days

•Mix = 20% RU, 50% RV

•Restorative nursing = strong

•Therapy is delivered by contractor

•MDS is an RN; active in care coord


•Section GG discuss encouraged

•Most of referrals come from 4 hospitals and a LTCH

•5 other SNFs within 15 miles; one owned by same company

•5% patients with behavior &/or I/DD

•VBP: penalty

•Assessment measures: Mixed

•Claims measures: As / Better than Expected

•Financial Projection: +3%

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SNF Building C•110 bed SNF

•Rural town approximately 35,000 pop; relationship with satellite university

•Blend of therapy & CC patients

•ALOS = 27 days

•Mix = 10% RU, 10% RV

•Restorative nursing = strong

•Therapy is delivered by contractor that struggles with staffing

•MDS is an RN; not active with care plan documentation


•Care team meetings short

•Reliant on IRF and small local hospitals

•2 other SNFs within 10 miles

•40% patients with dementia

•VBP: penalty of 2%

•Assessment measures: Lower than expected

•Claims measures: Too small/Lower than expected

•Financial Projection: +36%

Module 2: Assessing Market Position & Educating Partners About PDPM


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Module 2 Materials

Document (Follows Binder Order) Purpose


Long-Term Care Trend Tracker Topline Report Reference & Take Home

Template PDPM Messaging Materials Discussion, Reference & Take Home



Core Elements for Market Position Assessment and Partnerships


Good Intelligence

1. Market referral patterns

2. Know your relative performance

3. Understand your partner’s pain points and incentives

Readmission penalties

Value-based payment performance

VBC incentives (ACOs, bundles)

Strong Message

1. Articulate how your programs and performance will address pain points

2. It’s a product, not a bed

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Market Positioning Conceptual Map


Strategy and Competition in Your Market

Identity and Reputation

Organization and People

Operations and Innovation

Services and Care Pathways

• Services Not Offered• Emerging Opportunities with Specialty Care

• Long-Term Care Trend Tracker• Quality Awards• Rehospitalization • Staff Skill Sets

• Services Which Will Remain Valuable • Other SNFs’ Services & Other PAC Providers• Re-Organizing to Align with New Opportunities

AHCA Market Positioning Resources –Current and Planned for Spring 2019

• Allows skilled nursing and assisted living organizations to benchmark personal metrics to those of their peers

• Examine ongoing quality improvement efforts

Long-Term Care Trend Tracker

• Limited Data Set (LDS) using claims• Will allow SNFs to track hospital referral

patterns • Inform clinical pathway development based on

patient characteristics and hospital needs

Patient Pathway Platform

(AHCA P3 ©)


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• Measures to watch in LTC Trend Tracker:

• Discharge to Community (AHCA)

• Length of Stay (AHCA)

• SS Improvement in Function, Risk Adjusted (Five Star)• LS ADL Decline (Five Star)• LS Worsening Mobility (Five Star)• Medicare Spending per Beneficiary (QRP)• Discharge to Community (QRP)• SS Improvement in Self-Care (AHCA – coming soon!)• SS Improvement in Mobility (AHCA – coming soon!)• SS Discharge to Community (Five Star)• Change in self-care (QRP – coming next year)• Change in mobility (QRP – coming next year)• Discharge self-care score (QRP – coming next year)• Discharge mobility score (QRP – coming next year)


• Reports and publications in LTC Trend Tracker:o CASPER Resident Report

Gives a rough idea of how your resident population is changing

o Your Top-Line Publication QRP Feedback module coming soon – heavy overlap of variables between QRP

mobility measures and PDPM patient classification variables on MDS

o Your Resident Profile Publication Gives a more detailed profile of your residents than the CASPER report Previously included in Your Top-Line 2018-Q1 to assist with Phase-2 RoP facility

assessment requirements (will be released as free-standing report soon)

o Five Star PBJ Staffing Report Contains data on census


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• Webinars on AHCANCALED walk you through registration and use:

https://educate.ahcancal.org/products/how-do-i-use-ltc-trend-tracker-as-a-skilled-nursing-facility

• Email notifications are sent when new or updated publications come out

• Familiarize yourself with LTC Trend Tracker now so you are prepared to manage PDPM changes

• Reports and stats are constantly being updated and supplemented◦ What would you like to see? Please let us know!

Email [email protected]

How do I access LTC Trend Tracker and see my publications?

• Go to www.ltctrendtracker.com

• If you already have a username and password, click

• If you do not have a username and password, click

• If you do not know if you have a username and password, select

and then click

to search using your Provider Number

• Email [email protected] any needed assistance

Medicare LDS Offers a Longitudinal View of Patient Health Utilization

Longitudinal CMS Data Used to Provide Information on Health Care Utilization and Beneficiary Characteristics

Patient characteristics will include primary condition and comorbidities across settings


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AHCA-P3 – Understand Your Partner’s PAC Referral Patterns


SNF 41%

HHA47%

LTACH 2% Hospice

10%

Example: Hospital PAC Discharges

Total hospital discharges to PAC: 5,040*

Takeaway:• Hospital has very low

referral volume to costlier care settings, suggesting that the hospital already has a PAC referral strategy in place to reduce costs

*Will exclude discharges to facilities with <11 referrals.

AHCA-P3: Understand Your Partner’s PAC Referral Patterns


Total hospital discharges to SNF: 2,087*

Takeaways:• Hospital referred patients to 84

SNFs in 2017; 34 SNFs received >11 referrals from the hospital

• A lot of SNFs sharing small amounts of volume

• Two SNFs dominate referrals –why?

SNF A41%

SNF B47%

SNF C2% SNF D

10%

Example: Discharges by SNFs in Market

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CMS Ramps Down RUG IV Maintenance on October 1, 2020

Payers◦Medicare Advantage◦Bundling ◦Medicaid ◦VA

Referral Sources ◦Accountable Care Organizations◦Hospitals◦Physicians


• Become a PDPM Resource for Your Partners

• Articulate your Value Proposition in PDPM

Market and PDPM Messaging Exercise Objectives

1. Understand how Long-Term Care Trend Tracker can be helpful both now and with PDPM

2. From the group discussion, develop ideas for how you might position your SNF(s) in a PDPM environment

3. Develop ideas for how to message about PDPM and your PDPM expertise to referral sources and payers


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Group Discussion


1. How are you using Trend Tracker today to demonstrate value proposition?

2. Based on today’s work, what homework do you need to conduct to assess your PDPM market position?

3. What are some specific PDPM-driven changes you might make or services you might begin to offer to enhance your market position?

4. Are there key PDPM features you would want to highlight with payers and referral sources?


LUNCH

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Module 3: Resident Classification


Module 2 Materials Document (Follows Binder Order) Purpose


SNF PDPM Hospital Information Collection Checklist (3 pages) Discussion, Reference & Take Home

MDS & Claim “High Impact” Item Fields to Each PDPM Case-Mix Adjusted Component (10 pages)

Discussion, Reference & Take Home

AHCA PDPM Academy MDS Core Items Mock-Up: Betty W (11 pages) Discussion, Reference & Take Home

AHCA PDPM Resident Classification Workbook: Betty W (18 pages) Discussion, Reference & Take Home

PDPM PT, OT, and NTA Component Variable Per-Diem and RUG-IV Rate Reference Tables (6 pages)

Discussion, Reference & Take Home

AHCA PDPM Academy MDS Core Items Mock-Up: Mary T (11 pages) Reference & Take Home

AHCA PDPM Resident Classification Workbook: Mary T (18 pages) Reference & Take Home



Download tools from ahcancalEDPDPM Academy.

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Resident Classification Happens in Three Stages


1. 2. 3.

SNF Admits & Assesses

• SNF clinician diagnoses • 5-Day SNF PPS MDS

Assessment timing and accuracy

• MDS coordinator codes based on MDS items & ICD-10 codes

Hospital Discharges

• Typical discharge information sufficient

• Surgery information from hospital is new

Hospital Information Collection Checklist


Download Hospital Information

Collection Checklist at PDPM Academy

page at ahcancalED

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“High Impact” MDS Items Reference Tool


Download High Impact MDS Items

Reference and related tools at

PDPM Academy page at ahcancalED

Group Discussion


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Module 2: Resident Classification


Welcome Nursing Home –Importance of Clinical Information


Member Video

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Resident Classification - Three Stages


1. 2. 3.

SNF Admits & Assesses

• SNF clinician diagnoses • 5-Day SNF PPS MDS

Assessment timing and accuracy

• MDS coordinator codes based on MDS items & ICD-10 codes

Hospital Discharges

• Typical discharge information sufficient

• Surgery information from hospital is new

PDPM adds variable per-diem payment adjustment

PT Base RatePT PT CMIPT Adjustment

Factor

OT Base RateOT OT CMIOT Adjustment

Factor

SLP Base RateSLP SLP CMI

Nursing Base RateNursing Nursing CMI

NTA Base RateNTA NTA CMINTA Adjustment

Factor

Non-Case-Mix Base Rate

Non-Case Mix

PDPM includes variable per-diem payment adjustments that

modify payment based on changes in utilization of these

services over a stay

• Day 4 – NTA rates drop by 2/3• Day 21 and every 7 days after

the PT and OT rates drop 2%

*RUGs HIV/AIDS add-on is replaced in PDPM with new 18% nursing component base rate adjustor and new NTA CMI factors (not shown)

Download AHCA PDPM PT OT NTA Component Variable Per-Diem Rate Tables on ahcancalED

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PDPM Daily Rate CalculationExample resident – Betty W – Days 1-3


ComponentUnadj Fed

RateCase-Mix

IndexSpecial

AdjustorsVariable per diem

Payment (per diem)

PT $59.33 x 1.88 x x 1.00 = $111.54

OT $55.23 x 1.68 x x 1.00 = $92.79

SLP $22.15 x 1.46 x x = $32.34

NTA $78.05 x 1.34 x x 3.00 = $313.76

Nursing $103.46 x 1.34 x 1.00* x = $138.64

Non-Case-Mix Component

$92.63 x x x = $92.63

Total = $781.70*

Case Mix Group

Case Mix Index

Pat

ient

Cha

ract

eris

tics

from

MD

S

Spoiler Alert – Here’s the end of today’s classification exercise


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The engine that drives PDPM payments are Patient Characteristics represented by MDS items


Five independently Determined PDPM

Component Rates Set During 5-Day PPS

Assessment Window Using 188 MDS Item Fields

PT - 37 OT - 37 SLP -66

Nursing - 132 NTAS -34

awareness of impacts all PDPM MDS items is key to success

Rehab RUG rates Determined by 20 MDS Item Fields

Over 90% of Resident Days Reported Via Rehab RUGs

168 Additional Auditable MDS Item Fields Apply to ALL Stays/Days

Exercise Objectives

1. Be able to apply the AHCA PDPM Resident Classification Worksheets to any resident to • Manually determine a resident’s PDPM case-mix group within each component

• Determine the resident’s PDPM per-diem payment rate (using federal rates) at any point during the stay

• Compare the relative difference in resident payment rates between RUG-IV and PDPM

2. Understand the relationship of clinical factors that identify greater resource needs and that impact PDPM payment rates

3. Describe how some clinical conditions will not receive higher payments unless linked MDS items are also coded properly.


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Resident Classification Exercise

◦ You do not need to be an expert on how to code the MDS to be successful with the following exercises.

◦ There will be 7 modules and we will walk you through each part of the classification process:

◦ Primary Diagnosis Clinical Category PT/OT/SLP

◦ Function Score PT/OT/Nursing

◦ PT and OT Component

◦ SLP Component

◦ NTA Component

◦ Nursing Component

◦ Total PDPM Federal Urban and Rural Per-Diem Payment Rate(s) at Different Points of Stay

◦ In each step, we will give you some time to use the complete the steps for each section of the worksheet and to locate data on the MDS. We will show you the correct answers!

◦ You may not master everything today, but you will have the knowledge necessary to be able to take these tools back into your facilities (and ongoing AHCA support)


Ongoing support at [email protected] & FAQ’s, tools & resources

at ahcancalED

MDS Core Items Resident Example Mock-Up


Download template MDS PDPM MDS Core Items and other resident classification tools from the PDPM Academy site at ahcancalED

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Resident Classification Workbook


Download template Resident Classification Workbooks and other resident classification tools from the PDPM

Academy site at ahcancalED

Legend for Workbook

Blue Box with Italic Font-Module Name

Red Text within any box-correlated to MDS Item

start here

intermediate steps

final data for each step

PT and OT Component Drivers


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Primary Diagnosis Clinical Category Module



Primary Reason for SNF Stay ICD-10 code in the example MDS for Betty W

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PDPM Flips SNF PPS Function Scoring Process

RUG-IV PDPM

MDS Section G MDS Section GG

4 Items 7 Nursing & 11 PT/OT Items

7-day Lookback Day 1-3 Before Intervention

Higher Score = Worse Function Higher Score = Better Function


Functional Score Module – Activity


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Functional Score Module - Answers




Note: Typo in printed workbook – yellow box should say

= 07,09, 10 OR 88Online template is correct

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Note: Typo in printed workbook – yellow box should say

= 07,09, 10 OR 88Online template is correct



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PT and OT Component Drivers


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PT and OT Components Module – Answers


SLP Component Drivers


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SLP Component Module – Activity


SLP Component Module - Answers


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NTA Component Drivers


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NTA Component Module – Activity


NTA Component Module – Answers


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Nursing Component Drivers


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Nursing Component Module – Activity


Nursing Component Module – Answers


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I2000



I2000

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PDPM PT OT & NTA Variable Per-Diem & RUG-IV Rate Reference Tables


Download PT OT NTA Variable Per-Diem Rate Tables from the PDPM

Academy site at ahcancalED

Total PDPM Urban and Rural Per-Diem Payment Rate(s) During Stay Module - Activity


$299.73

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Total PDPM Urban and Rural Per-Diem Payment Rate(s) During Stay Module - Answers


$299.73

Understanding Why This Exercise is Important – What Can Go Wrong?


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MDS IV Medication Item is Not Entered


Failing to identify or incorrectly coding just one PDPM payment driver MDS item can have a significant impact on CMI

*resident has 2 NTA points for diabetes

30-Day Resource Impact


Days Per Diem Rate

RUG-IVPDPM With

Accurate MDS

PDPM With Missing MDS IV Meds Data

1-3 $631.25 $914.60 $706.06

4-20 $631.25 $625.81 $556.20

21-27 $631.25 $622.26 $554.36

28-30 $631.25 $618.71 $$552.52

30 Day Total $18,937.50 $19,594.54 $17,111.70

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Implications of Poor Care Coordination & LOS Monitoring


ComponentBase Fed

RateCase-Mix

IndexSpecial

AdjustorsVariable per diem

Payment (per diem)

PT $59.33 x 1.55 x x 0.76 = $69.89

OT $55.23 x 1.55 x x 0.76 = $65.07

SLP $22.15 x 2.85 x x = $63.13

NTA $78.05 x 1.85 x x 1.00 = $144.39

Nursing $103.46 x 1.43 x 1.00* x = $148.10

Non-Case-Mix Component

$92.63 x x x = $92.63

Total = $583.41*

*PDPM per-diem days 1-3 = $914.60*RUGs per-diem all days = $631.25*Except when resident has HIV/AIDS, then variable per diem adjustment = 1.18

Note: Rates are for urban facilities, CMS estimated if program went into effect FY19

Impact Over a Full 100-Day Stay


$500

$550

$600

$650

$700

$750

$800

$850

$900

$950

1 3 5 7 91

11

31

51

71

92

12

32

52

72

93

13

33

53

73

94

14

34

54

74

95

15

35

55

75

96

16

36

56

76

97

17

37

57

77

98

18

38

58

78

99

19

39

59

79

9

RUG-IV Correct PDPM MDS PDPM MDS Missing IV Meds

100 Day Stay RevenueRUG-IV = $63,125

PDPM Correct MDS = $62,517PDPM Missing IV Meds

=$55,154

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Group Discussion



BREAK

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Module 4: Pulling it All Together


Ensign Vision for PDPM Re-Positioning


Member Video

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PDPM Readiness Assessment and Transition Plan Development Kit Version 1.0

• Core Competencies

• Possible CMS Revenue Impacts

• CMS Patient Case Mix Group Distribution

• Staff Communication and Capability

• Referral Relationships (up and downstream)

• Quality and Performance Data


1

Long-Standing AHCA Resources Useful for PDPM Planning

Long-Term Care Trend Tracker Topline Reports

IMPACT Act Quality Reporting Technical Support

SNF Rehospitalization VPB Technical Support

Reimbursement Policy Tools


Download tools from ahcancalED.

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PDPM Readiness Assessment and Transition Plan Development Kit Version 1.0


• Readiness Priorities Using the Core Competencies

• PDPM Case Mix Group Distribution

• Staff Training/Gaps (e.g., Restorative Nursing)

• Coding and Communication Pathways

• Care Management Capacity

• PDPM Messaging & Communication on New Services

2

Care Management Core Capabilities


Primary Care Capabilities

(NPs or MDs)

Transitional Care Capabilities

(data sharing, partnerships)

Targeted Clinical Programming

(cardiac care, orthopedics)

Care Integration

(all work as team)

Alignment on objectives

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Break Out of the RUGs Mindset – Innovation Pathways Template


Innovate

Blend Clinical Cultures –Nursing and Therapy

Revisit Communication Methods Using TeamSTEPPs

Interview IT Vendors and Compare Capacity

Keep it Simple – Find PDPM Overlaps with Other Work

Create Road Maps That Align with PDPM Mile Markers (i.e., HIPPS Codes, NPRM, etc.)

Drive messaging on PDPM with Partners Find New Ways to Collaborate

Co-Create Opportunities and Solutions with Upstream and Downstream Partners

Work Planning Inclusively and With a Deliberate Sense of Urgency


4

• Aligned With Other Related Effort

• Mapped Against Key CMS Release Dates

• Timed with Realistic Capacity Building

• Inclusively to Ensure Buy-In at All Levels

• With a Progress Monitoring Plan

• Allowing for Time to Beta Test Changes

• Creating a Sense of Urgency

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Be Ready to Integrate To-Be-Released CMS Guidance


Information Technology Specifications

Updated Claims Submission & Billing Guidance

Revised RAI Manual


Source: What are the Newest Developments in Change Management Models to Increase Organizational Effectiveness, Agility and Change Readiness? Cornell University. Spring 2013

Organ

izational Chan

ge

Man

agement Schematic

146

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Module 5 – Upcoming Academy Events & Resources


Academy Tools Under Development & Upcoming Events – All at ahcancalED …

Grouper Tool

Interim Payment Assessment Trigger Policy Options

Market Positioning & Linked Data Set

Monthly Webinars

Updates to Tools as CMS Releases Guidance

Coordinating SNF Programs and Policies with PDPM


Suggestions for Other Tools? Email ideas to [email protected]

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Have We Addressed Questions & Concerns?


PDPM ACADEMY –Business Solutions for

Better Patient Care


THANK YOU FOR YOUR TIME & PLEASE PROVIDE FEEDBACK TO HELP AHCA IMPROVE

OUR MEMBER SUPPORTS

PDPM ACADEMY – Business Solutions for Better Patient Care...Single and batch MDS data AHCA PDPM...

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