Tick, Tock…PDPM is Fast Approaching!
The Medicare payment classification system change to Patient Driven Payment Model (PDPM) for SNFs is October 1, 2019. Medicare payments will be based on the PDPM classification system instead of the RUGS IV classification system.
There will be no transition period to PDPM. Nursing facilities need to perfect their systems that impact PDPM now. Help your team prepare with the following 90-day plan:
July 2019: Educate and Review
- Complete staff education about the PDPM classification system and ICD10 CM Official Coding Guidelines for admissions staff, billing staff, MDS staff, social workers, nurse leaders, HIM staff, Case management staff and Administrative staff.
- Review Medicare technical and clinical coverage criteria, as they have not changed.
- List changes to make to standard clinical document:
- Update the pre-admission intake forms to collect primary diagnosis and other co-morbidities.
- Identify a PDPM estimator for use with pre-admission reviews.
- Update discipline-specific Admission assessments to refer to the clinical conditions used in the PDPM classification system.
- Update daily skilled nursing charting format to refer to the clinical conditions used in the PDPM classification system.
- Revise the Medicare meeting agenda to review the skilled residents’ progress toward goals related to their clinical conditions.
August 2019: Identify and Revise
- Determine changes needed to the E.H.R. care plan library to capture the monitoring and treatment provided for residents’ clinical conditions.
- Review Medicare Advantage contracts to validate payment structures and confirm the internal processes for calculating RUG categories, if relevant for Medicare Advantage plan billing.
- Identify the mechanisms to monitor and decide about completing an Interim Payment Assessment.
- Write and revise policies and procedures for managing the PDPM system:
- Interim Payment Assessment criteria and process
- Use of the Other State Assessment item set
- Review and revise as needed, the assignments of MDS section completion (e.g., Section I, Section K, and Section O).
- Review diagnosis codes and sequencing for Medicare Part A stays.
September 2019: Monitor and Implement
- Begin to estimate PDPM payments for new Medicare Part A admissions.
- Monitor the number of Medicare Part A admissions to plan for transition IPA scheduling.
- On September 25, identify the residents expected to still be in the facility on October 1, 2019. Review their diagnosis codes and sequencing. Review Section GG coding and each resident’s current status.
- On September 28, schedule Interim IPA assessments with ARD between October 1 and October 8.
Click here to download and print the complimentary tool.
PDPM Insight, Expertise and Knowledge.
Pathway Health PDPM experts can assess your organization’s readiness and provide a detailed action plan for enhancing or improving these processes. Our PDPM consulting services and tools can support your busy leaders and staff to effect a smooth transition to the PDPM system. Pathway Health also offers expert PDPM training – classroom, onsite and web-based. Contact us to learn more.
Trauma-Informed Care with LeadingAge Kansas
Pathway Health’s Leah Killian-Smith presents the first installation of the new 4-part webinar series hosted by LeadingAge Kansas on trauma-informed care. The webinar, titled, “Overview of Behavioral Health Services,” will provide participants with information on the new requirements for behavioral health services.
The information provided will give providers the definitions of behavioral health disorders and ways to help the resident attain or maintain the highest practicable mental and psychosocial well-being.
- Describe and clarify terminology related to behavioral health services
- Identify how to determine if a resident needs specialized services for behavioral health
- Learn three leadership strategies for providing behavioral health services for residents
The webinar will take place on April 4 starting at 2 p.m.
- Overview of Behavioral Health Services hosted by LeadingAge Kansas
The Heart of Health Care: The Many Roles of Nursing Leaders in Post-Acute Care
In today’s vastly changing health care environment, the role of nursing leadership is one thing that remains consistent. It is and always will be the heart of health care.
My role as an operational leader was to set the strategic direction of the organization while working side-by-side with my nursing leader. I found organizational success unattainable without the contributions of my nursing leader and her team.
Nursing leaders focus on setting standards, setting policy, dealing with compliance, and overseeing quality measures and clinical outcomes. They spearhead innovation and transformation within their teams and the organization as a whole.
As I reflect on my career, and the dynamic nurse leaders that I have had the opportunity to work with, I note the following are the cornerstones of successful nursing leaders:
Nursing leaders provide direction for their department while holding staff accountable. Nursing leaders oversee many responsibilities, including:
- resident care delivery
- customer and staff satisfaction
- clinical processes
- financial outcomes
Nursing leaders continually expand their knowledge and understanding of industry changes. Their main goal is caring for our residents. Staying on top of the changes that affect the organization can challenge nursing leaders. It is important that nursing leaders continue accessing education, tools and outside resources. Education provides a level of support for their organizations’ priorities, as well as expected outcomes.
Translating the information and knowledge into organizational best practice is another responsibility. Aligning industry changes with facility and department goals helps to relieve some of the pressure felt by nursing leaders. Implementing best practices allow nursing leaders to focus on targeted, high-level priorities and clinical processes for successful outcomes.
Align Talent and Clinical Success
Nursing leaders continue to work with their team at all levels. They identify the knowledge, skills and abilities of their team. Then, they align those talents with the clinical priorities of their organization. This allows for ongoing mentorship and development of future nursing leaders. Successful nursing leaders help build upon their success by surrounding themselves with an amazing team. Team building is essential to leading a diverse group of people with distinct personalities and skills. Fostering an environment of collaboration and professional growth is a key strategy for successful nursing leaders.
Motivate and Innovate
Given all the changes faced by nursing leaders, they possess a unique ability to motivate staff, especially in times of challenge. They know when to talk and when to listen. They are often confident and optimistic while inspiring enthusiasm in those around them. Today’s nursing leaders also spark and support innovation, knowing change is necessary to succeed in the new health care environment.
Being a leader is an amazing journey. It continues to provide opportunities for innovation, as well as personal and professional growth. Working next to dynamic nursing leaders in post-acute care is an honor and a privilege. Thank you for being at the center of our organizations, and for being the heart of health care.
Happy Valentine’s Day!
Chief Strategy and Marketing Officer
Contact Pathway Health for more information on how we can expand the education and expertise of your long term care staff.
A Case Study for Quality Outcomes with LeadingAge KS
The event, titled “QAPI– A Case Study for Quality Outcomes,” is part of a series hosted by LeadingAge Kansas that breaks down new regulations in order to prepare nursing facilities for changes that go into effect November 28, 2019.
Tune in on February 19 from 2:00-3:00 p.m., and gain the following insight:
- Build upon lessons from earlier event titled, “5 Elements of QAPI Interactive Workshop,” presented in January 2019
- Perform a root cause analysis of your existing procedures in quality assurance and performance standards
- Identify an area of deficient practice and work through systems review and improvement.
What Do You Really Need to Do Now to Prepare for PDPM?
When the Medicare payment model changes for nursing homes on October 1, 2019, the drivers of reimbursement will be dramatically changed. Under the current payment model, the amount of therapy provided to the resident in a seven-day period is the major determinant of the amount of daily payment the nursing home will receive from Medicare. Additionally, the resident’s level of dependence in activities of daily living (ADL) impacts the final payment category and amount. The higher the level of ADL dependence, the higher the payment rate. The nursing assistant staff documents the supporting charting of each resident’s ADL dependence level.
The new payment model, Patient-Driven Payment Model (PDPM), uses the resident’s clinical conditions as the main determinant of payment. The resident’s ADL dependence score is derived from an area of the Minimum Data Set (MDS) that is assessed and documented by the professional staff. There is no impact on the payment rate from the amount of therapy services provided. Payment is higher in the Physical Therapy (PT) and Occupational Therapy (OT) components of PDPM for residents who require some ADL help but are not totally dependent. These residents are more likely to be able to participate in and benefit from therapy services.
The PDPM system is comprised of six components:
- Non-Case-Mix Base Rate
- Physical Therapy
- Occupational Therapy
- Speech therapy
- Skilled Nursing
- Non-therapy Ancillary
Each component is scored separately and has federally established rates for each Case-Mix category in the component. The Case-Mix rates for each component are summed to establish the overall daily payment rate for the resident’s skilled stay under Medicare Part A.
There will be no transition period to PDPM. On September 30, 2019, Medicare payment will be from the RUG-IV classification system. On October 1, 2019, Medicare payment will be determined by a new MDS that established the PDPM payment rate. Because there will be no transition, nursing facilities need to perfect their systems that impact PDPM now.
The triad of systems, or M-I-P, that support PDPM are highlighted below:
- MDS coding accuracy, especially in Section GG, functional performance and Section I, diagnoses
- ICD-10 diagnosis coding accuracy and management
- Pre-bill claim check review
MDS Coding –
Section GG of the MDS was added in October 2017. Confusion remains about the best process for obtaining an accurate assessment of the resident’s USUAL performance in the first three days and last three days of their Medicare stay. The most effective approach is to have the nursing and therapy staff collaborate on coding Section GG. If the resident only performs the activity in therapy, that is the resident’s usual performance. If the resident performs the activity multiple times per day with nursing staff and only once with therapy, the resident’s performance with nursing staff best represents their usual performance.
ICD-10 Diagnosis Coding –
Section I of the MDS is dependent upon accurate ICD-10 diagnosis coding and management so that the MDS and the Medicare claim contain the same information in the same order. There are few resources for staff education for ICD-10 coding for nursing homes. Most nursing facilities do not have a professionally certified medical coder on staff. Ensure that the staff responsible for coding understands the Official Coding Guidelines as published by the CMS and NCHS.
Most clinical software used in nursing homes automatically enters the diagnosis codes onto the bill. There must be processes in place to ensure that the admitting and primary diagnoses are entered in the correct location on the bill and the coded conditions entered on the bill provide the clinical “story” that supports the amount being billed.
Pre-bill Claim Review –
Pre-bill Claim Review involves an interdisciplinary team process that starts with the draft bill or claim and validates the information on the bill as well as the supporting documentation in the resident’s medical record. When this process is conducted effectively, the facility submits a “clean claim” that is a much lower risk for audit or medical review, thus is paid quickly and accurately.
PDPM Solutions to Start Preparing Now
Pathway Health PDPM experts can assess your facility’s M-I-P systems and provide a detailed action plan for enhancing or improving these processes. Our PDPM consulting services and tools can support your busy leaders and staff to effect a smooth transition to the PDPM system. Pathway Health also offers expert PDPM training – classroom, onsite and web-based. Contact us to learn more.
New! Complimentary PDPM Resource
The Non-Therapy Ancillary (NTA) component of PDPM presents an opportunity to capture reimbursement for resident comorbidities and special treatments. This one-page tool is a quick reference to those items that qualify in the NTA component of PDPM. Download now>
Ready to start preparing for PDPM? Contact us.
Director of Reimbursement and Clinical Consulting,
Fighting the Flu is Nothing to Sneeze At!
The influenza season is hitting hard across the U.S.
In fact, the Weekly Influenza Surveillance Report indicates that influenza-like illness (ILI) shows an elevated activity of Influenza A (H1N1)pdm09, Influenza A (H3N2), and Influenza B viruses as they continue to co-circulate. (Source: CDC)
Check out the ILI activity as listed on the CDC Weekly U.S. Influenza Surveillance Report for the week ending January 5, 2019.
Vital indicators include:
- Viral Surveillance: Influenza A(H1N1)pdm09 viruses have predominated in most areas of the country.However, Influenza A(H3) viruses have predominated in the southeastern United States (HHS Region 4).
- Geographic Spread of Influenza: The geographic spread of influenza in 30 states was reported as widespread; Puerto Rico and 17 states reported regional activity; two states reported local activity; the District of Columbia, the U.S. Virgin Islands and one state reported sporadic activity; Guam did not report.
- Influenza-associated Hospitalizations: A cumulative rate of 9.1 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported. The highest hospitalization rate is among adults 65 years and older (22.9 hospitalizations per 100,000 population).
Did you know?
- 1 to 3 million serious infections occur every year in SNFs.
- Infections include urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others.
- Infections are a major cause of hospitalization and death; as many as 380,000 people die of these infections each year.
Having a well-written and effective infection prevention and control plan is key to success. Preventing influenza and treating it promptly may reduce the risk of influenza-associated complications, including hospitalization and death.
It is estimated that 90 percent of seasonal influenza-related deaths and more than 60 percent of seasonal influenza-related hospitalizations in the United States each year occur in people 65 years and older. Hospitalizations also are often sentinel events in this population group, precipitating disability and potentially resulting in loss of the ability to live independently.
Preventing transmission of influenza viruses and other infectious agents requires a multi-faceted approach that includes developing a system with policies and procedures for the following:
- Infection Control
- Antiviral Treatment
- Antiviral Chemoprophylaxis
Preventing influenza and treating it promptly may reduce the risk of influenza-associated complications, including hospitalization and death. Consider the following:
- Policies: ensure staff members are performing appropriate hand hygiene and that appropriate infection control measures are being utilized facility-wide.
- Procedures: prepare the staff for what to do in case of an outbreak and what steps can be taken to minimize the number of Influenza cases as the season moves forward.
- Resources: Pathway Health has many resources to assist related to infection control and outbreak management, as well as online resources through the PathwayLearningNetwork.com.
For more information on preventing seasonal influenza and the 2018-2019 influenza Season, check out the CDC Resources available to health care organizations.
- Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities
- Prevention Strategies for Seasonal Influenza in Healthcare Settings
- Healthcare-associated infections and long-term care settings
Need assistance with infection control processes, systems and training? Pathway Health’s team of experts and trainers are ready to assist. Contact us today.
Director of Education
October 1, 2018 = The Beginning of a New Era for Skilled Nursing Facilities
The clock is counting down for skilled nursing facilities across the nation. This Monday, October 1, 2018, marks the beginning of transformative change, sweeping through our industry, leaving us breathless on a daily basis.
Below are some of the changes affecting organizations and how we do business today and in the future:
- SNFVBP, SNFRM, SNFPPR– The implementation of Skilled Nursing Facility Value Based Purchasing (SNFVBP) and the Skilled Nursing Facility Readmission Measure (SNFRM) as well as the continued data collection and comparison of each facilities outcomes for the Skilled Nursing Facility Potentially Preventable Readmission measure (SNFPPR). After years of beta testing and study, we are commencing the transition from fee-for-service to value-based-care. Utilization of your organization data to determine your facility “value” in the new marketplace, leading the quality incentive payment on your base Medicare rate (2% earn back potential via the SNFVBP requirements).
- Patient-Driven Payment Model (PDPM) – Commencement of the conversion from RUGs to PDPM – how we receive reimbursement for the care and services we provide. Facilities will have a year to transition to PDPM from RUG-IV by the October 1, 2019 implementation date. The new payment methodology focuses on resident characteristics and value-based care.
- MDS/RAI Process – MDS 3.0 changes effective October 1st with an updated RAI Manual, specific section and coding changes and more. These changes will impact calculations in the Skilled Nursing Facility Quality Reporting Program (SNFQRP), SNF PPS, SNF VBP – ultimately impacting our organization data, quality outcomes and reimbursement. These changes mark the transformation towards PDPM and reimbursement methodology changes coupled with quality measure changes.
- BPCI Advanced – Bundled Payments for Care Improvement Advanced, CMS’ newest bundled payment model, begins Oct. 1. This bundle payment model includes 32 clinical episodes with seven specific quality measures that will determine quality and reimbursement outcomes for acute care providers/practitioners. Two of the measures are required for all clinical episodes – all cause readmission measure and the advance care plan measure. Hospitals and practitioners will align with post-acute care partners that can effectively improve these quality benchmarks. Readmissions/hospitalizations are key for ALL health care providers starting October 1st!
These changes continue to stretch our leadership skills and organization resources as we prepare for all that is now upon us. I recommend following the below leadership strategy, to assist you in guiding your team through change:
- First take a deep breath and know that your team has skills and talents that have gone untapped!
- Collaborate – The changes require staff at all levels. Gather your key team members!
- As a team, enhance your knowledge and understanding of the changes (regulatory, reimbursement, quality measurement)
- Pull together with your team, what requires attention and what needs to be completed
- Review the list with the team and ask: what is immediate (which could have a serious and immediate negative impact) and what is important (that which needs to be accomplished, however there are possibly a few more days to complete some of the tasks).
- Determine if any of the tasks listed are inter-related or have inter-dependencies.
- Assess the status of the listed priority items to determine the actions needed to align with the change requirements (often times the current system or policy needs a slight revision and can be accomplished with minimal actions needed)
- Determine top priorities with your team – remember during change, many leaders believe everything is a priority which is not realistic. Through an organized process, you and your team (including staff at all levels), can achieve successful results related to all of the changes.
- Assess organization current status as it relates to the specific change needs
- Determine the actions needed to revise current processes, training, potential competency testing as well as monitoring of implementation outcomes, identifying improvement opportunities
- Assign priority leads for each priority area agreed upon
- Create an overall education plan to include related to the priorities, engaging staff at all levels. The more your team collaborates, the more engaged your staff will become.
- Communicate! Leading through change requires an increased level of communication to all layers of the organization. Why are things changing? How are we going to get there? What is my role?
- Present your vision for change and the transformation needed
- Monitor outcomes and integrate into the facility QAPI process
- Determine areas requiring modification or improvement
- Communicate outcomes with your team and key stakeholders as applicable
- Don’t forget to celebrate successes with your entire team
With the health care environment increasing in complexity, transforming the way we lead and how healthcare is delivered and managed within our organization and in collaboration with our partners is the key to success. The key competitive advantage today is the ability to change, adapt, and evolve, in order to achieve sustainable and successful outcomes.
Pathway Health can support and assist the implementation of SNFVBP.
Contact us to learn how.
Antibiotic Stewardship Insights: Prepare. Plan. Implement.
Especially now, leaders need to assure that their organizations have followed all the required steps for the development and implementation of a comprehensive Antibiotic Stewardship policy in accordance with the new Requirements of Participation (RoP).
F881 §483.80(a) – Infection prevention and control program states that “The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
- §483.80(a)(3) – An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use.
- §483.45(c), F756, Drug Regimen Review – In relation to pharmacy services, the assessment, monitoring and communication of antibiotic use shall occur by a licensed pharmacist.
The Core Elements of Antibiotic Stewardship, outlined by the Centers for Disease Control and Prevention to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use” include:
• Leadership Commitment
• Drug Expertise
As leaders, it is vital that your Antibiotic Stewardship Program is incorporated into the overall infection prevention and control program and reviewed on an annual basis and as needed. For continued success, the Infection Preventionist and clinical team should focus and incorporate the following into your clinical systems:
- Ensure that documentation related to antibiotic selection and use is complete.
- Track antibiotics used to review patterns of use and determine the impact of the antibiotic stewardship interventions.
- Monitor for clinical outcomes such as rates of C.difficile infections, antibiotic-resistant organisms or adverse drug events.
- Report of communicable disease per your specific state requirements.
- Assist prescribing practitioners in choosing the right antibiotic using antibiograms (Recommend using AHRQ Toolkit).
- Provide reports related to monitoring antibiotic usage and resistance data to the QAA committee.
Consider implementing the following to maintain compliance:
- Review, revise and institute an Antibiotic Stewardship Program Policy and Procedure with elements for compliance with F88.
- Update staff education materials for orientation, annual education and agency staff orientation, as needed.
- Attend the Infection Preventionist Bootcamp to assure your staff is up-to-date on role, responsibilities, surveillance techniques, best practices and needed resources to be successful.
- Provide a written education program for prescribing practitioners on the facility’s
Antibiotic Stewardship Policy and Procedure.
- Collaborate with your pharmacy consultant to assure the review of antibiotic use with the monthly medication regimen review, and as needed.
Pathway Health Focuses on Delivering Insights, Expertise and Knowledge
Our Pathway Health team presents educational series or attends conferences all month long. We look forward to meeting with you in South Carolina, Las Vegas and more.
Lisa Thomson will deliver an association training—The New World of Managed Care: Creating Operational Strategies for Success—to the South Carolina Health Care Association (SCHCA), from 9 a.m. to 3 p.m.
Lisa Thomson, Dan Bilings and Sue LaGrange will represent Pathway Health, as they exhibit at the American College of Health Care Administrators’ (ACHCA) 22nd Annual Winter Marketplace, in Las Vegas.
At 11:45 a.m. on Dec. 5, Lisa Thomson will deliver the presentation ‘VBP, HRRP, OIG = OMG! Are You Ready?’
At 10:15 a.m. on Dec. 6, Dan Billings will present ‘Know Your Stars: Understanding the Five-Star Rating System.’
Colleen Toebe will present during the Iowa Health Care Association’s Winter Quarterly Education Conference in West Des Moines, Iowa.
If you are attending, be sure to check-out two must-see presentations: ‘Infection Prevention and Control for CNAs and Direct Caregivers,’ from 12:45 p.m. – 2:15 p.m. and ‘Continence Management,’ from 2:30 p.m. – 4:00 p.m.
Judy Morey will deliver an association training to the Main Health Care Association, focusing on how the new QMs impact wounds, wound care updates and program essentials.
Rebecca Case will host an online association training (Rules, Regs, Policies and Procedures: How to Stay Current) to the Ohio Health Care Association (OHCA) from 2 p.m. to 3:30 p.m. (Eastern time).
Keep on the Right Path through a Servant Leadership Focus
From daily desk calendars to leadership posts on LinkedIn, it seems like my professional and personal life is flooded with inspirational quotes, the next best business success book or “must-attend” leadership seminar.. It all can be overwhelming and confusing to choose the right course to ensure ongoing success. For me, staying focused on simple, leadership principles that combine a Servant Leader’s attitude and mindset keeps me grounded. The idea of Servant Leadership is an ancient philosophy, however, Robert Greenleaf coined the phrase nearly 50 years ago. “The servant leader is servant first … It begins with the natural feeling that one wants to serve, to serve first.” Read more here.
Modern Servant Leader identified top Servant Leader companies that are also on Fortune’s 100 best Companies to Work for list include:
- SAS (#1 on the list of Best Companies to Work For)
- Wegmans Food Market (3)
- com (6)
- Nugget Market (8)
- Recreational Equipment (REI) (9)
- Container Store (21)
- Whole Foods Market (24)
- QuikTrip (34)
- Balfour Beatty Construction (40)
- TD Industries (45)
- Aflac (57)
- Marriott International (71)
- Nordstrom (74)
- Men’s Wearhouse (87)
- CH2M Hill (90)
- Darden Restaurants (97)
- Starbucks (98)
As an emerging leader, one might ask if it is possible to be both a servant and a leader? Throughout history, successful leaders have proven you can be both. It is important to implement a leadership style that is conducive to promoting teamwork throughout your organization. In the book “Setting the Table: The Transforming Power of Hospitality in Business” by Danny Meyer he succinctly stated a philosophy that I have tried to lead by and communicate and he has put into such simple words. “Creating positive, uplifting outcomes for human experiences and human relationships is what counts the most. Business (or leadership) is all about how you make people feel. It is that simple and that hard.” People who get promotions should earn them not just cause they are ambitious, but primarily because they embody the company’s character traits in abundance. At Pathway Health, this is a key to our success and my belief in the long term success of our organization. Danny Meyer list nine character traits in “Setting the Table: The Transforming Power of Hospitality in Business” which are listed below:
- Infectious Attitude
- Charitable Assumptions
- Long-Term View of Success
- Sense of Abundance
- Approving Patience and Tough Love
- Not Feeling Threatened by Others
The idea of service before leadership not only speaks to my core, but also the mission of Pathway Health. The above traits are not the normal list of items to find in a leader on the surface, but as you dig into them are essential to continued success and the basic principles of servant leadership. Character is a very broad term, but the traits that measure character for Meyer and his team are honor, discipline, consistency, clear communication, courage, wisdom, compassion, flexibility, ability to love and be loved, humility, confidence and positive self-image. The traits will mean different things to different people but in aggregate create a great leader. In order to lead, you need a critical mass of people to that are attracted to your leadership. I observe many seasoned and “up and coming” leaders throughout the post-acute care continuum exemplifying the characteristics of true servant leadership.
Because staff, clients and patients place their trust in Pathway Health, I take the ideals of a servant leadership role to heart – mentoring, building community, and to keep focused on the right path. What are the top servant leader characteristics you and your team focus on for success?
Resources- Modern Servant Leader
President and Chief Operating Officer