AHLA's Speaking of Health Law

Expert Insights – The Nuts and Bolts and Operational Implications of CMS’ New PDPM for SNFs: What Providers Need to Know, Part 2

August 22, 2019
AHLA's Speaking of Health Law
Expert Insights – The Nuts and Bolts and Operational Implications of CMS’ New PDPM for SNFs: What Providers Need to Know, Part 2
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AHLA's Speaking of Health Law
Expert Insights – The Nuts and Bolts and Operational Implications of CMS’ New PDPM for SNFs: What Providers Need to Know, Part 2
Aug 22, 2019
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AHLA experts take a deeper dive into legal developments affecting the health care industry.
Show Notes Transcript

Are you ready for the new skilled nursing facility payment model on October 1? In this second of two podcasts, sponsored by the national long term care consulting firm, Polaris Group, Dan Hettich of King & Spalding talks to Mike Cheek of the American Health Care Association and Judy Kulus of Lantis Enterprises, examining what has changed under the new payment system, how it will affect reimbursement, and how to address the operational challenges in implementing the new system.



DH:
0:14
Hello everyone. This is episode two of um, a two part series on the new patient driven payment model. Uh, that's going to determine reimbursement for Medicare SNF patients starting October 1st, uh, 2019. Uh, in the prior episodes we focused on, uh, the nuts and bolts of the new payment system. Um, this episode we're going to focus on, uh, the day to day operational issues associated with implementing the system. Uh, but I wanna start by thanking our sponsor. Uh, this AHLA podcast is sponsored by Polaris Group, uh, a national long term care consulting firm specializing in Medicare compliance, clinical operational and financial consulting. The group performs mock surveys, MDS accuracy audits, PDPM training, independent review organization and more. My name is Dan Hettich. I'm a partner in King and Spalding's, healthcare practice group resident in Washington d c I just completed my six year term as a vice chair of AHLA's Regulation Accreditation and Payment Practice Group better known as, as the RAP group. Uh, I focused my career on, uh, medicare reimbursement issues of all types, both advising on them and litigating some of those same issues. I'm very happy to be joined, uh, today, um, by, um, Judy Kulus and Mike Cheek. Um, Mike, will you introduce yourself, uh, to the group?
MC:
1:47
Sure. Uh, I'm the senior vice president for reimbursement policy and business strategy with the American Health Care Association. Uh, we represent about 13,000 of roughly the 15,000 skilled nursing facility buildings in the country. Um, and I've spent about the past five years, uh, working with Judy and others. Um, uh, and with CMS on the development of the payment system we now know is the patient driven payment model. And then the majority of this past year traveling from state to state delivering trainings to our state affiliates and their members on how to operationalize, uh, the patient driven payment model.
JK:
2:33
And I'm Judy Kulus. I would, yeah, I'm the chief nursing executive for Lantis enterprises. We have, um, nursing homes, snfs, assisted living, home health and a staffing agency. And my role is to, um, help the facilities with the nursing systems as well as, um, implement the PDPM system in the facility. I also, as Mike said, worked with him and other organizations and I was privileged to serve on the technical expert panel, um, for the, uh, planning for the precursor to the PDPM system. So it's, uh, it's been great to work with the nursing teams and the therapy teams and facilities as we get ready for implementation on ten one.
DH:
3:18
Great. Again, thank you to you both for joining us. I'll be serving primarily as a moderator for this episode. And Mike, I want to kick it off with you. I mentioned the last episode was dedicated to kind of, um, the nuts and bolts of the new payment system, but I was hoping you could give us kind of a, a quick overview of what some of the key changes, uh, are between RUG 4 the prior system and the new PDPM payment model.
MC:
3:44
Sure. So from an operational perspective, I'm just, I'll, I'll, I'm gonna walk us through, um, uh, sort of a SNF stay experience from the, from the patient experience perspective and how SNF staff work with them. So under RUGs, uh, of course the primary, uh, primary vehicle for payment were therapy minutes. And that is what the SNF staff were focused on and as they, uh, assess the patient, spoke with, speak with the patient and if needed spoke, interacted with the hospital to arrive at some estimate of the number of therapy minutes that a patient might need and from subsequently be characterized or classified into our resource utilization group. Um, component based on those numbers therapy minutes. PDPM is a complete departure from that. Um, uh, a skilled nursing facility staff will need to look at a patient in a very different way. CMS is terminology for this is holistic patient care planning. And by that they mean interacting with the patient, assessing a broad array of clinical information that's used for all of the case mix groups, uh, service related, uh, service-related items to arrive at the most appropriate for each of the components. Um, that information in some instances will require, um, in a potentially notable new inreach and dialogue with hospitals, discharge planners to collect the information that may be needed. Some students may already have, um, relationships with hospitals where the hospitals share, um, large amounts of clinical information, um, with skilled nursing facilities and other, and other instances, hospitals do not. Um, so, uh, looking at how, uh, numbers, how skilled nursing facilities will collect information to complete, um, the new mds with, um, uh, roughly 188 MDS items that affect payment, um, will be particularly important. Um, reorganizing your admissions team, um, to be able to collect that information for the initial Medicare assessment. That's what CMS is calling the formally referred to five day assessment, um, is, will be challenging to collect all of that information and hit that eight day window. Um, if you go beyond eight days to nine, um, it, the, uh, the case mix group assignments, uh, default to the lowest paying case mix group, those can be adjusted. Um, but when that occurs for the variable per diem components on non therapy, ancillary, OT and PT, they do not restart at day one. So being able to be efficient and, um, organize with, uh, with your admissions team in particular, dialogue between therapists. Um, and nursing staff to ensure that the section GG functional items are scored in a collaborative fashion since they do overlap in terms of component case, mixed group assignment for PT, OT and nursing is important. And then also hinking through a holistic care plan for patient and CMS emphasizes this term as well in their, on in their presentations, individualized care and maintaining that individualized care plan across, uh, across this day or during this day. The role of the MDS coordinators really going to have to change as well. So the traditional role in some SNFs, not all, um, of the MDS coordinator simply completing the MDS for purposes of maintaining the care plan is going to change pretty dramatically. Um, an mds coordinator under PDPM will begin to look a lot like a care coordinator in order to make sure that the plan is truly individualized, truly holistic, um, and maintained in that fashion both for the patient as well as for the skilled nursing facility because MDS now drives payment in a way that it did it to the scale at which it formally did not. Um, also having, um, a policy and related protocol, um, for uh, for what the triggering event is for an interim payment assessment. When this, when what CMS refers to as stable characteristics, um, don't trend as projected and that change may be needed. And understanding what that again, holistic picture looks like. Um, on the previous segment we discussed that one component payment may need to go up while a while another may be able may need to go down. So being able to work with the interdisciplinary team and ensuring that they have a way of assessing in a comprehensive manner to ensure that that plan is consistent is important. And then finally, in terms of discharge, making sure that the discharge assessment accurately captures, um, the therapy discipline modalities is important. Making sure that the MDS coordinator is communicating effectively with the billing staff to make sure that the admission diagnosis and the discharge diagnosis, um, are as not seeing us as not requiring that they match, but they are encouraging or expecting those two diagnoses to match. So making sure that a dialogue occurs particularly around therapy, um, assessment or number of minutes. And the admission and discharge diagnosis, um, is important to make sure that, that that medical documentation is there to support any differences. There will be no hard edit, um, around admission and discharge diagnosis for FY 20 but I think at best practice going into the new system, um, is having a good solid medical documentation or record to show why they change over the course of the stay.
DH:
10:34
So Judy, anything you'd want to add to that?
JK:
10:37
You know, you were speaking of the challenges of the admission process and gathering information from the hospital and, and it is really nice when the physician can log into the hospital if it's an Epic chart or whatever the system is and look at the information on that patient to gather the appropriate information to make determination to accept that patient into your facility as well as to gather the important information. And if they don't have that access, the information can be kind of limited on occasion unless you do build that good relationship with your hospital discharge planners so that you get the information that you need. And I think one, one important aspect I think that the admission coordinators are going to have is to be familiar with what it is that they need to gather information about. Um, you know, we've, we've been struggling with this as we have been implementing an admission process in our organization and trying to get the information from the hospital. And I think with the challenge of census that's happening across the country and the speed to which we need to make admission decisions, this process that we're advocating of being thorough to determine a one, can we meet the needs of the patient, what will their needs be and gathering all the information so that we can, um, accept them. We're, we are being pushed to make decisions quickly. And so we'll have to become efficient at this process to gather the information, quickly, make determination about whether they're appropriate for our facility and then to, um, smooth that transition. And, and I, and I really am committed to encourage clinical teams to use this admission process to smooth that transition into the facility. So that I call it hit the ground running. Is that the care management organization, the setting up per the patient's needs before they even arrive in your building. This, the robust information that we need to manage the PDPM is also the information we need to set up good care management. Immediately as they come in that we know as much about that patient as possible so that we can set up that baseline care plan and get, get our protocols in place and so that we, we'd start, start well start that patient well in our building. The other thing about the importance of this robust, um, the granularity of the information that we're gathering is, is that the more complex the patient is, uh, the moral coarser is to manage and the care management, but also it, it really does inform the length of stay. And so as we meet as IPT teams with therapy and all of that, as we look at the protocol, the regimen that we're going to set up for a particular patient, that individually for them, um, we will be able to better, better determine the length of stay and, and the expectation for progress along that care continuum to be sure that the length of stays justified as well as, uh, we are making progress and tracking that part progress in the more complex in many cases the, the longer the Medicare A stay could be, um, and, and so, but also the, the inverse is true is if they're not complex, um, then then justifying longer stays would be inappropriate. And, and of course we need to be managing that tightly to, to have the appropriate length of stay. So again, I, as Mike said, reiterating the importance of gathering information, collaboration with the hospital and, and the care management is going to be a paramount for success in this system.
DH:
14:24
Great. Thank you Judy. So Mike, what are CMS' a PDPM provider performance priorities that compliance officers and attorneys should be aware of? Maybe more specifically, what do you expect a new audit target areas to be?
MC:
14:52
CMS has reinforced over and over again of its intent to use a, the impact tax quality reporting program measures, um, for assessing performance, um, of providers under PDPM. They have very specific lists that they've verbally articulated, um, and has indicated to us that they set benchmarks for performance, um, under, uh, the quality reporting QRP they'll be using at for assessing PDPM performance. So I think that that's an important area to consider in terms of how they view the quality of care. Um, under PDPM of course it will be well into the spring before they have data to make assessments along those regard. In that regard. In the final, um, FY 19 rule, um, they call out some very specific items, um, that they will be monitoring, um, that are important, um, for folks to pay attention to. Um, so they discuss at some links, um, appropriate ICD 10 coding, um, for purposes of case mix group assignments for the, uh, for the, uh, for the, for the components. Um, they specifically reference, um, the potential for upcoding, um, in some of their spoken comments. Um, they also discuss resident interviews, um, making sure that patient voice is, is included, um, as part of the initial, um, the initial Medicare assessment. Um, a good example of that is bins, um, and mood assessment and making sure that that's well documented. Um, as part of case mix group assignment, they'll be looking for that, um, diagnosis changes and admission and subsequent change and subsequent changes. Again, there'll be no hard edit for admission and discharge, but they will be looking for medical documentation to support that. Um, we talked about the definition of skilled care. Um, CMS will be monitoring to ensure that the definition of skilled care is being used as the framework for how services are delivered. Um, I think that under the Resource Utilization Group, we've wandered a bit from that by focusing on therapy so heavily. So they'll be looking for the, what the primary diagnosis is for an admission to a SNF. Um, why are they there? Because there's some specific regulatory language around that. And then from there, how that's um, leveraged in terms of the holistic care plan as it relates to skilled nursing, skilled nursing coverage, um, resource, uh, resource under utilization in particular therapy access. Um, so they'll be watching very carefully for um, and they've used, they spoken about this publicly, um, stinting on therapy, um, attempts to reduce overhead costs, um, by reducing therapy in some fashion or another. Another important area, um, is the interrupted stay policy. Um, the interrupted stay policy is a payment policy. It's in its there to ensure that patients are not being discharged for the purpose of restarting the variable per diems. CMS will be watching for use of the interrupted stay policy in scenarios where it could be gamed in some fashion or another. Um, and placing facilities that are doing that on what they refer to as heightened scrutiny. Um, of course, if you use the interrupted stay policy to discharge to a hospital, you're potentially impacting your value based purchasing potential bonus payment under the rehospitalization VBP program. But that 2% may, uh, or whatever your potential bonus payment may be. Maybe worth the risk financially, um, in order to restart in particular the non therapy ancillary variable pretty m. Um, so, but, uh, but it's, I don't, but it's certainly something that's not worth the risk of coming under heightened scrutiny and whatever that means. CMS hasn't defined that yet. Um, and then lastly, um, they've been pretty clear around what their expectations are around links of stay. Um, Judy mentioned that earlier. Um, they'll be looking for what they believe are inappropriately short length of stay, um, for what a patient may need their measures, uh, for that. Again, take us back to outcomes, um, for patients, which takes us a little ways out in terms of terms of them having a quarter or two of a QRP data to start to understand whether those lengths of stay are too short. Um, and the, the reason they were watching for that is primarily because of the variable per diem associated with physical therapy and occupational therapy. We've emphasized with our members that those decreases are spread out. So, um, it's such lengthy time intervals. Um, they don't start until day 21 and it decreases 2% every seven days subsequently across the a hundred day stay. Um, that, that's not a huge amount of money and it's certainly not a reason to discharge someone, um, early but it's something that they've indicated spelled be watching for. So that's a short overview of some of the compliance items, um, that soak should be aware of.
DH:
20:48
Thanks Mike. I mean this is an important topic. Do, do you have any thoughts about um, therapy minutes in particular or any of the other, um, items that you think are going to be a specific focus for compliance?
JK:
20:56
Absolutely. Yeah, as, as Mike mentioned, I think there is a worry and CMS has indicated they don't want to see, um, you know, the cliff where we have high levels of therapy on nine 30 and then a huge drop on ten one for those that are in a medicare stay during the transition. And that ongoing monitoring of potential sniffing is going to be something that CMS will be watching very carefully. And so when it gets right down to it, it's what, what is appropriate then. And as we no longer will be so focused on high levels of therapies that potentially might, may have been inappropriate in some cases. Um, what we really do need to focus on is appropriate use of therapies. So, um, what are some of the red flags that CMS might be looking for is, uh, again, a, a huge change in your therapy regimens that that is different than what we have been doing. Um, that is seemingly not appropriate for the comorbidities and the needs of that patient. And so I think what I'm encouraged by, at least with our therapy company that we've been collaborating with is they are working carefully to set up some, um, some skilled therapy protocols and some evidence-based, um, mapping of what type of therapy would be appropriate for different types of diagnoses and patients that that will be treating, um, moving into the new system so that we can create that individualized model. Um, but meeting the needs of specific protocols and targets and goals for particular types of diagnosis, which I think is gonna take some time to learn and grow and, uh, the nurses are going to have a huge opportunity to participate in setting up those protocols. And I look forward to to doing that. Um, with our therapy provider. Some, some red flags might be inappropriate use of group minutes. Now the current definition for group minutes is for patients with one therapist and in the proposal rule they're proposing that group be two to six patients. Um, and this would be patients doing, uh, with similar goals, doing, doing the same activities in a group. And, and I'm personally, I, I know that group therapy, it can be very therapeutic and it can be a wonderful way to be holistic and socializing, uh, patients during their treatment protocol and, and has an appropriate place in treatment regimen, but it should not be used simply for, um, for payment benefit. It has to really be focused on the, the particular patient and why the group therapy is appropriate for them. The other modality that we're probably gonna see more of that that needs within 25% limit for PT. And then another 25% limit for OT is that concurrent, um, treatment where the therapists would be treating two patients, doing different activities on different apparatus or different goals. Um, and we'll see more of that. And so we, we want to consider red flags for, um, for inappropriate use of concurrent inappropriate use of group therapy, but recognizing that they have their place as appropriate, um, protocols and treatment modalities for the patient that will help them to excel, um, effectively towards the goal of discharge. And, and again, I think the amount of therapy and the modality that we pick is going to help. It's going to really impact the length of stay. And I, and I think as a, as a profession and we need to look at the philosophy around, uh, high intensity therapy, uh, towards the end versus a tapering therapy. And, and there's some evidence based research that we need to consider to look at the types of modalities and the treatment philosophies that we're going to be using to meet the needs of the patient. Knowing that, um, again, being, being careful to justify our regimen, um, because CMS as they've indicated are going be watching carefully that, that whatever we do is patient centered and appropriate.
DH:
25:12
Mike, in the last episode we went through, um, in detail the many changes to, um, to the payment drivers. You know, previously there was three components that made up, uh, total payments. CMS made it six, including a separate component for non therapy, ancillaries like drugs, the variable per diem rate, uh, that you alluded to a change in the way HIV aids patients were going be, uh, paid. Um, how do you expect all of these significant changes to, to effect, uh, care delivery design? Um, and you know, um, provision.
MC:
25:50
So with, with CMS' new, a new approach to, uh, to its payment system by, by breaking out nursing and non therapy ancillaries, um, into, uh, distinct components, um, and their emphasis on individualized, holistic care. Um, they also go a step further by talking about PDPM as a, uh, focusing on delivery of, of more of care to more medically complex patients, um, by breaking out nursing and non therapy ancillaries and placing more emphasis, um, on those two particular elements. So I think that in terms of service delivery, um, many skilled nursing providers are looking at developing clinical care pathways that focus on patients with more clinically, more clinically intense care needs. Um, that's not to say that they are dropping to, um, their lines of rehabilitation therapy. Um, but there are, uh, an array of our members that are in there in dialogues with hospital systems, hospitals, um, managed care plans to discuss what the prevalence of particular conditions, um, or patients with specific types of, of comorbidities around which they could develop clinical care pathways, um, that would meet a need within a given market. Um, support, um, skilled nursing facility partners as well as service and new opportunity for the skilled nurse for the skilled nursing facility. Um, nursing in particular, um, is a big focus here. Uh, CMS has gone to a good deal of links, uh, in both and the FY 19 rule to discuss classification and why nursing is the linchpin and PDPM, um, and pain placing a great deal of attention on that. So I think that is where, where it's leading us is a focus, uh, again, a focus on clinical care for patients with multiple comorbidities, um, that, uh, that historically if not been the primary focus in most SNFs, um, where his, where historically under RUGS we focused more on therapy.
DH:
28:24
Thanks Mike. Judy, we've alluded to this already. So I don't know if you have anything to add about, um, how CMS is gonna monitor, uh, provider performance, uh, under the PDPM.
JK:
28:39
Well, there's an array of contractors that CMS has in place already that, uh, will likely be deployed or turn their focus on medicare payments in the PDPM system. Those organizations. Now of course, then one of the main audit entities that is looking at the current Medicare a system is the Medicare administrative contractors. Those that are billed for the, for the care that we're providing that are being provided. And the MACs. I'm, I'm assuming we'll continue to monitor on a prepayment as well as opposed payment basis. And Mike, Mike referred to the fact that he doesn't see some hard edits being put in place initially, but as the system is implemented and we look for a incongruences in the system in terms of the claims and how they're paid, we are going to probably see some edits put in place when we send the claim in that may stop that claim for a prepayment audit. And then of course they always, uh, are engaged in, uh, Mandan post payment items. There's other organizations that are contracted that likely will focus their attention, their recovery auditors. Um, there's the cert auditors that comprehensive error testing, which, uh, review the claims that the Mac pays, um, and they have other more punitive audit entities like the heat auditors', the healthcare fraud prevention that's really looking for a for clear fraud. Um, and then the, the United Program Integrity Contractors is another entity. So all of these I think will be deployed. They're focusing now on inappropriately paid medicare payments. And, um, as we move into the new system, their focus will be turned as well. And, and again, I think we've emphasized during this podcast the importance of, um, making sure that we are covering patients appropriately under the skilled care guidelines and then supporting the care that we provide with the medical record, uh, under audit. That's going to be important. And, um, and then as, as we move forward, I think we'll see some, uh, some hard fast edits put in place that will be indications of charts that need to be reviewed and then we can always be prepared for random audits, uh, that will occur based on the entities. Um, the office of Inspector General often also focuses on some different areas. Um, but, um, we'll, we'll again, we'll be seeing, uh, some focus put in some specific areas, uh, that CMS will indicate to their contractors of where to focus.
DH:
31:18
Thank you, Judy. Mike, we've, um, been focusing obviously on Medicare Part A, which is what, um, the PDPM specifically applies to, but what, um, can we expect to see with regards to non traditional fee for service such as managed care? And ACOs and, um, et cetera.
MC:
31:38
So, uh, this is quite a moving target. Um, so as most of you likely know, uh, CMS is statutorily prohibited, um, from engaging in any dialogues, uh, in regard to contract and payment between Medicare Advantage plans and contracted providers. Uh, so what CMS has done is essentially said that the plans can shift to PDPM if and when they see fit. Um, there's some questions around assessment information, um, that the plans will need, um, if there's, if they choose to remain under RUGS, uh, because the assessment schedule and assessment items and the MDS format itself, other than, um, change under PDPM the over assessments do not, it's possible that that information might be, uh, might be used, um, for plans that, uh, that remain under RUGS and don't shift to PDPM. So there's, there are a lot of moving parts to that. Uh, we're waiting for claims and billing guidance to come to be released from CMS to give us a little more guidance around how, um, they view claims and billing to work under Medicare Advantage based on the assessment information that plans may need that remain under RUGS. For plans that are shifting to PDPM, there are two national carrier, uh, carriers under MA that are, that will be transitioning to PDPM on. They've not articulated how or when they'll be doing that. Um, this is all very much, as I said, fluid and, and, and, and of an array of moving parts. Um, the other part I think that makes him a particularly challenging, um, is that even with national carriers, like, uh, you know, like an Aetna or Humana, um, they're operated through regional offices. So corporate may make a decision to move to PDPM, but the regional offices will make the decisions about when and how that happens. Um, so for multi-state skilled nursing facility providers, um, they will have to track carefully and remain in close communication with their contract officers, with managed care plans, um, around how and when those sorts of transitions, um, will happen with accountable care organizations. Um, and uh, and BPCI sites. Um, CMS has released very little information about how this work, um, have with be it with, um, with uh, accountable care organizations. Their benchmarks, um, will have to be recalculated. Um, under PDPM. The Centers for Medicare and Medicaid, Medicare and Medicaid Innovation, um, have discussed a methodology for cross walking RUGS um, into PDPM and from there calculating target prices. But I think one of the real challenges associated with, uh, with accountable care organizations is their efficiency imperative. Um, they've focused on length of stay that they view are as appropriate for certain types of rehabilitation patients, which takes us to somewhat of a cookie cutter approach to care. Um, which is the exact opposite direction that PDPM is taking skilled nursing facility providers in with individualized holistic approaches to care with highly variable links of stay based on what their needs are. So a lot of education and reconciliation needs to happen there. Um, and again, the Center for Medicare and the Center for Medicare and Medicaid innovation are still in discussions about how they're going to message to ACO is about that. Um, the theme is largely true around BPCI demonstration sites. Um, the episodic length of stay, um, under, uh, BPCI episodes. Again, those have links to stay that are targeted, um, by conveners, uh, for BPCI. Um, those all will have to be revisited, um, as well as, as well as the target pricing for episode condition categories for, um, for the BPCI demonstration sites. Um, so there's a lot of work there that has, it has yet to be clarified. Um, we're in discussions with CMS and CMMI about how that will be communicated, um, to ACOs and BPCI demo sites and conveners with BPCI, um, to try to make sure that this is as coherent and organized the transition process as possible. Um, but there's a great deal to be done in this area.
DH:
36:46
Thank you Mike. Um, Judy, I know this is near, near and dear to your heart. Um, we alluded to the change in a number of resident assessments and particularly the simplification of those, um, from periodic assessments, uh, mandatory assessments on the rug four to just a single mandatory one upon admission. Um, does that mean that fewer nurses will be needed to, to conduct those assessments?
JK:
37:14
Um, you know, that is that topic of discussion that is frequently brought up, uh, in our organization and even across the country as we look at, um, the MDS nurse or role of the MDS nurse, the role of clinical nurses with the, the complexity of care that we're going to see. And, and Mike talked about the need for care pathways to deal with the comorbidities and the complex care that's coming. Um, and we're seeing that as well, that as the reduction of the number of payment assesses assessments occurred, um, there's going to be importance put on that, that one very much longer initial assessment. And so doing that well and then using that assessment to really drive the care plan, the nursing, the nurse will have a role in that. Uh, very, very importantly, uh, one of the things that I, that I am hearing that we're going to be seeing more and more as not only the care pathways but also clinical decision support tool. Uh, and it's the idea of when certain conditions are in place for a complex patient that we have a, um, methodical pathways. So the care pathway to assess that patient, but then also to provide based on the answers to provide that clinical decision support of what to look for next or what to consider in terms of care planning. And, and as I have, I had the opportunity as a nursing informaticist in our organization to set up some user-defined assessments. It's been, it's been great to put some protocols in place that guide the nurse to care planning items that are specific for that patient. Then I think we're gonna see a lot more, um, need for the MDS nurse to be, to be that care management and to support the care pathways that are put in place for a particular patient based on their diagnosis. And to help look at our, the clinical decision support tools working effectively. Uh, is it helping the nurses that care for the patient on each shift, uh, provide good quality of care. And the MDS nurse I think has the opportunity to become, um, more of an analytic nurse that they will be looked at. Um, analyzing each day the charting, analyzing the care that's being delivered, the progress towards the goal for each patient on an individual case management level, but then also looking at the overall analytics of the care model. And as we've talked about, the, the MDSs will also drive our quality reporting, programming the value based purchasing with the rehospitalization measures and other things are so important. And I think the nurses can in many ways be retooled, uh, from spending so much time completing assessments to, to being more of a clinical nurse. A another role that that MDS nurse, um, we might see them having is that ICD 10 specialist. It's, it's a complex coding system to to accurately code the diagnosis. And we need trained skilled nurses in the building to do that. And that MDS assessment nurse can be the leader in that area. And, um, and I, I see them stepping up and doing that and getting trained. Um, and that, that's a good thing. We did a work study, we analyzed the workload of the nurse on the RUG 4 system. And so it was a, it was a clear time study and then we ran it again with, uh, with the potential anticipated number of PDPM assessments that would be needed. And the results were that the, the fulltime equivalent for the number of nurses required was the same as we looked at, uh, the, the, the slightly changing role of perhaps a little bit fewer time in, uh, the number of assessments completed, uh, to the increased time needed for the ICD 10 coding, uh, reviewing the charting and doing the case management. And it really is a wash. And I would, I would be careful, uh, for all any facilities to, to think that, you know, starting October one, they can cut their, uh, MDS department in half. Um, but to really look at the job descriptions, look at the role and look at the training of those nurses and equip them to be case management. Um, and care management of the, the particular residents. And as Mike mentioned, that the complexity of dealing with the management Medicare Advantage program, we're seeing a rise in the number of patients that are Medicare Advantage and managing those, um, alongside your traditional Medicare a is also, uh, an important task that these nurses can have to be sure that they're doing case management for all of those, um, types of Medicare patients, whether traditional or part of a managed care entity. And as, as he noted, there is, there's a lot of variety in our requirements, length of stay, uh, the authorizations and all that for those Medicare Advantage. And I think nurses will be tapped even more and more to manage that effectively for the patients that they receive.
DH:
42:21
Great. Thank you Judy. So Mike, Given all these, uh, pretty significant changes in the payment model, um, I imagine the relationships and potentially even, you know, the contracts that existed between SNFs and outside providers like outside therapists or, um, long term care pharmacists are probably going to change as well. Can you give us your, uh, your thoughts on that?
MC:
42:47
Um, so I think that in particular the relationship between skilled nursing facilities and, um, those, that contract, um, for therapy delivery is front and center. Um, so I think that, you know, there's a great deal of discussion that has been underway, um, around revisiting those relationships. And for the most part we've been, we've heard from our members and what we've been talking to our members about, revisiting those relationships, um, such that they are value based in nature. Um, so that they link out to out be outcome measurement approach that CMS has laid out for the patient driven payment model and looking at what the uh, impact act, QRP measures, um, that are, that are most appropriate, um, for potentially serving as about, as about as value based relationships with therapy contracting companies. Um, so for example, for therapy, CMS has discussed, um, change in self care and mobility, discharge, self care and mobility, um, functional items such as that under QRP as measures for SNF performance, um, under PDPM. So looking at some of those l some of those items as potential value based purchasing, um, arrangements between skilled nursing facilities and therapy contractors, um, is important. Um, as far as long term care pharmacies, uh, relationships with, with skilled nursing facilities when again, those are contractual relationships or when they're in house. Um, I think that there's, there's the opportunity to really revisit the relationships in terms of how communication happens and particular gathering as much clinical information as possible, um, to make sure that the appropriate, uh, number of points for non, for the non therapy ancillary component are identified so that a patient is categorized in the appropriate case mix group. And again, that's critical because the starting point, um, uh, the starting point relative to where you drop on day four, um, is a considerable amount of money drop. It drops by two thirds. So if your starting point is too low, then where you are for the remainder of the stay, um, could be under cost. Um, so making sure that you have a strong partner if you're using a contracted long term care pharmacy and, or making sure that your long term care pharmacy, if they're in house, um, are heavily engaged in the intake process using the initial medicare assessment, um, is important.
DH:
45:53
Thank you, Mike. So before we wrap up, any closing thoughts, Judy or Mike?
MC:
45:59
I think, you know, for from my, from our perspective with the American Health Care Association, um, PDPM is a welcome relief, um, in terms of moving away from, um, from a minutes based system that interestingly the evaluation reports on RUGS from 2000 and 2001 note that there would likely be problems with therapy minutes under the payment system. So moving away from a system that appeared to have challenges in its fundamental design from its inception, um, is a welcome one. Um, and then secondly, the opportunity to have a payment system that focuses on an individual and it is more flexible. Um, and it emphasizes the full definition of skilled care, empowering nurses and other clinical professionals. Um, I think is something that the vast majority of our members are really excited about.
DH:
47:04
Great. On that note, we'll, um, wrap up. Thank you again for everybody who joined us. Um, thank you again, especially to Mike and Judy for sharing their expertise with us and to our, our sponsor.
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