Physician & Practitioner Engagement Strategies for PDPM/PDGMNovember 5th, 2019

Dr. Steven Buslovich, MD, MSHCPMGeriatrician & Co-Founder Patient Pattern

Margaret Sayers, MS, NPVP, Product and Research Patient Pattern

LIVE POLL

AGENDA

1

Month 1 of PDPM Feedback

2

PDPM Recap

Diagnostic Strategies

4

Facilitating Collaboration

3 5

Measuring Clinical

ComplexityMeeting the 5-day MDS

deadline

1 Month of PDPM Feedback From You

● Hospitals do not provide enough information● Doctors and APPs are not engaged● Our communication workflow is inefficient● It is hard to determine the “Primary Diagnosis”● Our EHR is not helpful for PDPM● Increased medical documentation takes time● There is a learning curve for the facilities & providers

Encouraging Words

● You are not alone - we have heard this from around the country● There are solutions - some easy to implement● Most facilities are creating new workflow processes● Software exists to enhance your current EHR offerings● All disciplines are working on communicating more● Physician groups in some facilities are engaged - even taking the lead

Our goal is to help you with whatever PDPM difficulties you are experiencing.

A Brief Recap of PDPM

Therapy nolonger drives

reimbursement

Admission MDSsets rate for stay

ICD-10 Codingnow drives

reimbursement

Clinical Complexitymust be captured and supported

PT/OT/NTA ratedecreases over LOS

There is no:‘1 perfect diagnosis’‘720 min of therapy’

Things are Different under PDPM

1. ICD-10 Codes2. Primary Diagnosis3. Secondary Diagnoses4. Function scores5. BIMS 6. PHQ-9 or PHQ-9 OV7. Depression Scale8. Recent surgical codes9. Clinical Complexity

10. MDS completion schedule

It is a NEW DAY &

We Need a NEW APPROACH

It Takes a Village

All Professionals Must Contribute

ADMISSION MDS

Moving Forward as a Team

Step 1

Admission Screening

◉ Current screening processes can be incorporated◉ Keep what is beneficial to facility policies◉ Add what is required for optimizing PDPM◉ Educate hospital Discharge Planners

Moving Forward as a Team

Step 2

Nursing & Therapists Complete:

● Preliminary Diagnoses● Function GG● Assures completion of

○ PHQ-9○ BIMS○ Behaviors○ Treatment plans

Moving Forward as a Team

Step 3

Engaging the Physician and APPs

● Inform them of facility (PDPM) expectations● Provide as much patient information as possible, soon after admission ● Expect them to verify ICD-10 codes to best describe the patient ● Make sure their medical documentation is comprehensive

Moving Forward as a Team

Step 4

MDS REQUIREMENTS

● Comprehensive● Complete● Correct● Communicated● Compliant

RESULTS

● Per diem rate optimized● Patient outcomes improved● Compliance is achieved● Audits are avoided● Patient centered care

How to Achieve Engagement

The Need to Know

• Skilled nursing facilities will be accepting more medically complex resident under PDPM. Physicians and APP will need a way to predict the degree of risk for adverse outcomes and stay alert to changes in condition such as the Frailty Risk Score.

• Medical staff must be prepared to receive many requests for additional and/or clarification of ICD-10 codes to best describe each resident upon admission. It is important to understand the need for such requests and the value of responding to them in as timely a manner as possible.

• Remember that this is the biggest change in reimbursement for SNF in 20 years. There will be a learning curve in the beginning for both the facility and the practitioners.

It Is Not the Strongest of the Species that Survives But the

One Most Adaptable To Change.

– Charles Darwin

Payment Models Are Changing

Driven by CMS

Value Based Purchasing

ACO

iSNPs/dSNPs/cSNPs

Patient-Driven Payment Model (October 1st, 2019)

Patient-Driven Grouping Model (January 1st, 2020)

PDPM: WHY NOW?

OIGSkilled Nursing Facilities

12/2010: Questionable billing practices in SNFs:$500 million in overpayments

02/2013:SNFs fail to meet discharge planning:$5.1 billion in overpayments

06/2015: Billing Changes in Therapy: Improvements needed$143 million in overpayments

02/2019: 3-Day Qualifying Stay:$84 million in improper payments

06/2019: Incidents of Potential Abuse /

Neglect not reported at SNFs

Due 2020: Involuntary DC from SNFs for dual eligible beneficiaries in SNFs

Office of Inspector General Audits 2010-2020

Moving Forward:

•CMS will monitor therapy provisions under PDPM to identify facilities that have significant billing changes•CMS will be monitoring changes in MDS/therapy/diagnoses•CMS will compare part B billing diagnoses to part A diagnoses•What strategies do you have in place in case of an audit?

SNF FINANCIAL IMPACT

What are the strategic options for medical providers?

Option 1: Become an ICD-10 Expert

● Medical Practitioner’s coding practices differ from those required for PDPM

● Simply increasing quantity of diagnoses does not ensure accurate or improved Case Mix Index (CMI) payment for the building

● 28,000+ permutations

Importance of Primary Diagnosis

Option 2: Rely on Facility’s EHR

● Focus on the building’s needs

● Not designed to help practitioners or consultants

● No mechanism for ICD-10 accuracy or alignment

● Most practitioners rely on external workflow for documentation and billing

THE EHR IS 2019’sTELEPHONE GAME

pssst…

HospitalRecord

Pre-AdmissionScreen

NursingDocumentation

TherapyDocumentation

PhysicianDocumentation

Option 3: Rely on Your Facility’s MDS Coordinator

PDPM STRATEGY

+ Educate All Staff - including medical staff

Team Focused

+ Pre-Admission Assessments

+ Assess MDS Integrity

+ Consider Measuring Risk

+ Collaborate Today

D

CUT THERAPY (PT & OT)

O

DECREASE LENGTH OF

STAY

RELY ON HOSPITAL DIAGNOSES

NEXPECT YOUR MEDICAL STAFF TO AUTOMATICALLY ENGAGE

T

PDPM STRATEGYDON’TS

- MDS will still document therapy minutes

- Therapy will always be needed for rehabilitation & discharge planning

- SNF post-acute market has been based upon the need for therapy.

PDPM incentivizes shorter lengths of stay, however shorter LOS may negatively impact:

- Patient Satisfaction- Census- Claims-based QMs- Value based purchasing

PDPM STRATEGY DO’S

Coding

NursingTherapyPre-Admission

Screening

MedicalProviders

PatientCharacteristics

COMPREHENSIVEDOCUMENTATION!

- Analyze your facilities’ medical staff presence and determine if more time and support is needed under the new model

- Understand your staffing/admission review levels

- Ensure your medication indications/diagnoses are accurate

- Don’t lose sight of priorities: ○ Five-star quality measures○ Hospital ED admissions/ 30-day Readmissions○ Patient/Family Satisfaction

CONTRIBUTE, COLLABORATE & be aware of the TIMELINEAll disciplines must:

Major Joint Replacement or Spinal Surgery

Non-Surgical Orthopedic/Musculoskeletal

Orthopedic Surgery

Acute Infections

Medical Management

Cancer

Pulmonary

Cardiovascular and Coagulations

Acute Neurologic

Non-Orthopedic Surgery

CLINICAL CATEGORIES

CLINICAL CATEGORY

ICD-10 DIAGNOSIS

SPECIFICITY IN CODING

THE IMPORTANCE OF CLINICAL DIAGNOSIS

DRIVESPDPM

PAYMENT

Populates a Clinical Category

Patient’s Primary Diagnosis into the Skilled Nursing Facility (SNF)

Refinement of the Diagnosis promotes better documentation

Practitioner Diagnosis helps drive PDPM Payment

DiagnosesThe Focus On

.

Presenting an effective strategy to involve the

medical team in SNF operations

PDPM is as much of process challenge

as a coding enigma

How do the diagnoses you choose impact the PDPM rate?

Will the primary diagnosis for the encounter under part-B billing change?

Optimization is Key

What is the most accurate source for primary diagnosis?

Cases: What is the Primary Diagnosis?

95 y.o. M w/ a UTI, develops sepsis and HCAP, and delirium. Now is deconditioned, unable to transfer and has uncontrolled hypertension?

Cases: What is the Primary Diagnosis?

80 y.o. F w/ a Right MCA embolic stroke, left hemiplegia, aphasia, homonymous hemianopsia resulting in gait instability and a fall and fracture?

IPA: Interim Payment Assessment

● Only additional opportunity to change payment

● When is it appropriate to perform an IPA?

● What defines a significant change in condition?

● Requires new diagnoses that are relevant for PDPM

Collaboration Is Key

Facility Challenges

Diagnosis, surgical, comorbidity or other coding issues

Timelines of practitioner visits/documentation

Improper IPA assessments

Collaboration with MDS coordinator/administrators

Diagnoses discordance

Role of Consultant Pharmacist

Admission medication review - critical

Medication indication accuracy

Review opportunities to optimize medications

Review documentation of diagnoses in practitioner encounter notes and work on cadence

Ensure alignment between facility MARs and practitioner documentation

Another Key Resource to Consider

Role of Consultant Pharmacist

Admission medication review - critical

Medication indication accuracy

Review opportunities to optimize medications

Review documentation of diagnoses in practitioner encounter notes and work on cadence

Ensure alignment between facility MARs and practitioner documentation

HOW TO:

COLLABORATE

SMART DATA

EXCHANGE

Strategize for helping SNFsmost impacted by PDPM

TO REITERATE:

Facility EHR is not going to make PDPM easier for us.

Opportunity to collaborate, design new care pathways, and maximize outcomes

ICD-10 Problem…

Building Tools to Assist Engagement

PDPM Coach Workflow Optimization

CCDA (Hospital)

PDPM Coach (SNF)

Medical Practitioner Verification

PDPM Rate

Optimizer

Payment$$$

Risk Stratification and Outcomes Management The Hidden Key to Success for

Post-Acute Care

What’s the Difference?

Patient AMale, 74 years

Patient BMale, 74 years

Health-care associated pneumonia

Health-care associated pneumonia

Triple antibiotic therapy & fluids

Triple antibiotic therapy & fluids

• Becomes temporarily debilitated

• Becomes debilitated quickly with cognitive decline, delirium.

● Quick recovery

● Discharged Home

• Falls, fractures hip and develops GI bleeding from drug - drug interactions.

• Requires Hospitalization

Mildly Frail Severely Frail

Frailty is the #1 Cause of

Death Among

Older Adults

Indexing Enables Clinicians to Focus Their Care and Not be Overwhelmed by Data Overload

Statistically Significant

vs.

Clinically Significant

Moves healthcare from single-organ focus to multisystem,

multi-organ care

= patient centered care

Frailty affects a patient’s response to stressors

Moderately Frail

Severely Frail

Mildly Frail

Severely Frail patients may never get back to baseline function after a stressor

Frailty Risk alerts clinicians to the likelihood of a decline before other clinical indicators

It also illuminates why some patients might still decline despite proactive, excellent care

Communicate Frailty to Family Members

Visual depictions of a patient’s Frailty Risk Score sets realistic expectations of care

Frailty Indexing is an Accurate Predictor of Clinical Risk

• Risk of re-hospitalization

• Length of stay

• Adverse health outcomes and functional change

• Clinical outcomes: wounds, falls, delirium, mortality

• Reduce polypharmacy risks

• Avoid non-beneficial care

• Enhance quality in late life

• Inform Patient-Centered Care

• Mitigate Litigation

• Provide “Value”

Practical Uses:Helps Predict:

Uses 70 data points to determine a patient’s physiological age

Value = Quality+Service Cost

Accessible, Visible Definition

Readmission Dramatically Reduced With Risk-based Care Plans

23%22%

16%18%

14%

10%

Avoidable Deaths Reduced by Early Detection of Decline

31%

16%15%

8%

12%

4%

Huge Reduction in Litigation Due to Improved Communication with Family

Facility OpenedFrailty Approach

Integration

SimpleAnalyzer™

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LIVE POLL

QUESTIONS & ANSWERS

Handouts and recording available at simpleltc.com/practitioner-engagement

THANK YOU FOR JOINING US!

@agingischangingsteve@patientpattern.commargaret@patientpattern.com