July 22, 2019, Maggie Flynn, Skilled Nursing News - With the Medicare Part A reimbursement overhaul taking effect in just a few months, skilled nursing providers across the country are in countdown mode. But the clock is moving at different paces for different providers, several experts said. Some SNFs began their analysis and preparations months ago; others are barely getting started.
That’s led to similar variations in the state of preparedness. Skilled Nursing News reached out to a range of players in the SNF space – operators, lenders, rehabilitation providers and technology vendors – to get a sense of how ready the industry is and what providers must do as the October 1 implementation date draws near.
Below are their responses, edited for length and clarity.
Anne Tumlinson, Founder & CEO of Anne Tumlinson Innovations
I see a lot of organizations doing all the right things to make sure they can get the diagnostic information they need, in the time period they need it, and to code appropriately. I see fewer organizations figuring out the role of therapy going forward.
Therapy companies are really embedded in this industry. As a result, I think SNFs are going to be trying to put a round peg in a square hole for a while, using therapists to drive things and do things that work better with another type of clinician.
The SNFs I see are playing defense pretty well, but I’m not seeing anyone playing offense. That is, I believe there’s an opportunity to create entirely new, high revenue programming for new types of patients that hospitals are desperate to discharge but can’t. I’m not sure anyone’s ready to go down that road just yet.
Allan Swerdloff, Vice President of Value-Based Care and Procurement at AristaCare Health Services
I would assume that with all the talk over the last 15 months, the industry as a whole has been planning for this change. What remains to be seen is how receptive our hospital partners will be to these changes, especially in regards to flow of information from one setting to the next.
Actions providers should take:
- Create a process to allow you to accept the patients that you can clinically care and accurately document on.
- Create a work flow that will maximize the ability to provide the right care at the right time, based on a accurate clinical assessment.
- Perfect communication between all disciplines and create a solid care plan from admission through discharge, while trying to anticipate and treat any barriers.
- Insure that all clinical information past and current is obtained in a timely manner.
Brian Cloch, Chairman of AttunedCare
I believe those operators that have been focused on managing high-acuity, short length-of-stay volume, they have been ready for a long time. This change is a tailwind for them. For those facilities that have been used to taking volume that was there primarily for a therapy or rehab stay, they aren’t going to be ready, and this change will create a headwind. I see the SNFs that are part of continuing care retirement communities (CCRCs) at risk the most.
In addition, SNFs that are not currently receiving higher-acuity volume will have challenges.
In order to get ready, I would be focused on retraining Minimum Data Set (MDS) coordinators to become coders.
Chris Chirumbolo, CEO of Carespring
There has been a lot of available training from the associations, consultants and contract therapy providers. Operators have had ample time to get prepared. I think with any change, there will be the prepared and the not-so-prepared. We have heard some providers who understand what PDPM will entail but have not actualized a game plan of how to operationalize it. I think most providers with a higher skilled volume will be prepared and will catch on quickly once the new system gets going.
Providers should understand the PDPM system and how are they going to operationalize it in the facility. That means knowing:
- How many skilled patients does each facility have that are Medicare and managed care, that will pay via PDPM? This determines the volume of work needed at each facility.
- Who is going to perform the Brief Interviews for Mental Status (BIMs)/Patient Health Questionnaires (PHQs)?
- How will the facility capture the items in sections GG?
- How will the facility get the pre-admission patient records, and who will review for the diagnoses and non-therapy ancillaries?
- Who will work with the physicians/extenders to capture all the diagnoses?
How is each facility going to deliver their therapy services? Based on the skilled patient population, what percentage of group or concurrent therapy will be delivered?
Steve LaForte, Director of Strategic Operations, General Counsel at Cascadia Healthcare
At Cascadia Healthcare, an operator with 16 Facilities in the Pacific Northwest, we feel as ready as we can be, notwithstanding uncertainty as to the practical implementation and how CMS will react to unexpected results, i.e. reimbursement not being revenue-neutral. Our state associations and the American Health Care Association (AHCA) have been very responsive and exhaustive in providing educational opportunities, as have many other trade organizations, consulting and rehab providers.
From our standpoint, having taken advantage of those opportunities and having enough scale to create internal teams to try to get ahead of the implementation, we are optimistic. Ultimately the move to more patient-centered, needs-driven care – and reimbursement reflecting the same –makes absolute sense, and the operators who deliver on that should succeed.
For providers who don’t feel prepared, the best course would be to access their state association’s educational opportunities. The real challenge for smaller operators is the expense of both getting ready and creating a platform for the proper coding and management of the resident on admission. A hope is that CMS will be flexible as results start to shake out.
And all that said, we are all crossing our fingers and knocking on wood…
Deb Freeland, Health Care Principal at CLA
We are less than three months away from the implementation of the PDPM, and the industry is at various stages of readiness. The education and training opportunities have been vast and most providers have at least attended some education regarding PDPM. However, there is wide variation on what providers have done with that education.
Most providers have gained an understanding of the overall financial impact to their organization [and] if PDPM will be beneficial or not. Beyond that, the readiness of providers varies. Many providers have spent significant time analyzing processes and procedures, gaining an understanding of skill sets that need shored up before implementation, and implementing change that will make the transition to PDPM smoother.
Unfortunately, there is a large group of providers who have done little in preparation for the change. These providers are just now reaching out to vendors and consultants to determine what changes they should be considering, or are doing nothing at all.
These providers should look at their entire interdisciplinary team, the processes in place for this team to coordinate the admissions, assessments and coding for patients within the facility. Providers should be reviewing the documentation processes to highlight opportunities to better capture clinical information with a reimbursement impact.
Alissa Meade, President & CEO of Curavi Health
Based on the conversations we have had with clients and potential clients, the industry has put material time and effort into readying themselves for the changes. There will be a certain “learn as we go” aspect, since it is not possible to predict exactly how the implementation will be operationalized. That said, the industry overall appears to have done a nice job of preparing its front line for the change.
As providers get their arms around the operational aspects, the next horizon is thinking through the downstream implications of PDPM. For instance, how do providers attract and serve higher acuity residents who will be better reimbursed under PDPM? We believe technology can play a large role in helping SNFs during this transition.
While increasing acuity, it is imperative that SNFs have in place the capabilities to ensure those residents do not bounce back to the hospital. This is especially important in the post-acute care space where patients are too often transferred to a hospital at any sign of trouble.
Providers will need to balance their resources carefully to ensure they are focused on delivering value to residents and managing them effectively. Telemedicine can help them to do that cost-effectively.
Jeff Marshall, Senior Vice President of Operations at Omega Healthcare Investors, Inc. (NYSE: OHI)
Based on discussions with many of our operators, particularly those with significant Medicare fee-for-service census mix, we believe the SNF industry has dedicated a great deal of time to training and preparation for the conversion to PDPM, with the possible exception of those heavy-Medicaid facilities in which Medicare FFS mix is relatively low.
Aside from operator-developed training and preparation protocols, AHCA has conducted day-long, in-person PDPM training sessions in every state, as well as follow-up online training and separate ICD-10 coding training, to assist facility staff in preparing for the conversion on October 1.
For those facilities that have spent little time in training and/or preparation, the most critical steps at this time would require the involvement of MDS nurses, care coordinators, medical records personnel, and billers in learning the nuances of the revised MDS and the new ICD-10 coding protocol to minimize loss of revenue due to inappropriate or incomplete classification of patient conditions and capabilities.
Denise Gadomski, CPA Partner at Plante Moran
As we are eight to 10 weeks out from the implementation of PDPM, we are optimistic that many providers will be ready. However, we also expect there will be some harsh reality for providers who have not adequately prepared.
At this point, the educational focus has been on the basics of PDPM: ICD-10 coding, new MDS requirements, rate tapering and overall rate drivers. As we are nearing the home stretch, providers should be sharpening their clinical and operational strategies.
Specifically, providers should be testing their new processes and then evaluating the financial impact to determine if their education and process redesign is paying off.
Unfortunately, some providers might find out two to four months into PDPM that they are not as prepared as they had thought. However short, there is still time to prepare. Final training and process development, including impact evaluation should be their priority now.
David Tate, Chief Strategy Officer at Reliant Rehabilitation
There are many industry recommendations for how to prepare, but the one common truth is this – if a SNF operator doesn’t change anything about the way they evaluate, assess, treat and document that treatment for patients after October 1, they will not be successful under PDPM.
Rather than relying on sound bites and webinars for educating your team, we recommend going to the source for the changes: CMS. CMS.gov provides fact sheets, FAQs, a training presentation and several valuable resources for operators to use as source materials for implementing these important changes.
Operators need to realize that CMS has given zero transition time to move to PDPM. The change will happen like a light switch on October 1, but there are ways an operator can prepare and start training their teams today to get ready. Here are some recommendations for what can be done now.
- Go beyond admission paperwork for patient assessments. Under PDPM, SNFs have an opportunity to identify and treat conditions and diagnoses in the patient beyond the primary condition that caused the SNF admission. An admission team should review and improve the interview tools that evaluators are using and incorporate additional test results that may not have been included in the initial admission paperwork.
- Improve evaluations and coordination of evaluation results. As the interdisciplinary team focuses on more comprehensive evaluations, it’s key to have the tools in place to more systematically capture, coordinate and document these results. Without a process in place, this valuable information won’t drive changes in the way that care is delivered and documented.
- Measure quality of MDS coding today.
Rick Matros, President & CEO of Sabra Health Care REIT (Nasdaq: SBRA)
All of our operators in the space have been preparing for PDPM for months and remain optimistic about the system with no exceptions. Additionally, we recently had Sabra’s Operators Conference and featured education on PDPM, as well as other reimbursement topics such as value based payments. Our tenants actively engaged with each other to compare and contrast approaches. Very productive.