Prepping for PDPM: Strategies for ASAP

SpeakersBecky Finni, DHS, OTR/L, RAC-CTSenior SRS Appeals Specialist, RehabCarePresident, Ohio Occupational Therapy Associationbecky.finni@rehabcare.com | finni@oota.org

Sabrena McCarley M.B.A.-SL, OTR/L, CLIPP, RAC-CT, QCPDirector of Quality, RehabCare Sabrena.McCarley@kindred.com

Jeremy Furniss, OTD, OTR/L, BCGDirector of Quality, AOTAquality@aota.org | www.aota.org/value

History & Overview of PDPM

OT & PT & PDPM

PDPM vs. RUGS-III

AOTA Resources

How did we get here?

• Countless CMS audits and reviews found that under the current RUG-IV model:– Skilled Nursing Facility (SNF) per diem payments are based almost

exclusively on the amount of therapy received by the resident, regardless of his or her “unique characteristics, needs, or goals.”

– SNF residents with significant variation in nursing needs, costs, or care often receive the same reimbursement for nursing services.

• Final Rule July 30, 2018: – CMS finalized a new case-mix classification model, the Patient Driven

Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.

In short…

This is a BIG change in payment perspective…Fee-for-service (volume, e.g. minutes of therapy) Value-Based (quality, performance)

PDPM in a Nutshell

Calculating Per Diem

PT/OT Components: What to Know

Comprehensive Evaluations & Plans of Care

• ICD-10 selection on OT Evaluation– Primary diagnosis/reason for SNF stay

– Medical diagnosis

– Treatment diagnosis

• Standardized Tests

• Occupational Profile

PT/OT Components: What to Know

Section GG of the MDS

• Outcomes functional reporting for CMS

• Used in SNF, HH, IRF, LTACH (replacing FIM in IRF as of 10/1/2019)

• Scores prior to admission, admission, and discharge

• “Usual performance”

PT/OT Components: What to Know

Functional Treatment Strategies and Interventions• Continued options for modes of delivery:

individual, group, concurrent, co-treatment• Occupation-based will help show our distinct value• Quality of documentation is still a critical piece—

our documentation must clearly articulate what separates occupational therapy interventions from other services being provided

PT/OT Components: What to Know

“I heard cognition can only be provided by SLPs now?”

• BIMS score is used to calculate the SLP case-mix

• This does not mean cognition cannot be addressed as part of the occupational therapy plan of care

• Functional cognition continues to be a focus for OT with SNF patients under PDPM as it is now

Summary: What hasn’t changed…

• Older adult population in the SNF/LTC setting will continue to need high quality therapy services that are evidence-informed and occupation-based.

• CMS requirements for medically necessary skilled services are not changing! Therapy services must be reasonable, medically necessary, and clinically appropriate to meet the resident’s unique and specific needs.

• Occupational therapy’s scope of practice has not changed. OT practitioners can still evaluate and treat for functional cognition, feeding, eating, and swallowing under PDPM.

Summary: What has changed…• No more specific minute utilization requirements

– No longer in constant assessment reference period (No more COTs!)– Minutes will be tracked during the entire stay, but no longer dictate the per diem

rate

• Group and concurrent therapy combined can be up to 25% of treatment over course of the stay

• IDT communication/collaboration/documentation will be critical for success: – ICD-10 coding of reason for skilled stay– Admission/5 day MDS assessment is only required MDS for payment– Section GG to establish PLOF, status on admission, and discharge status for

outcomes reporting

At the end of the day…

• Resources are available for you and your members

• CMS will be monitoring for drastic changes in utilization

• Continued support through both our organizations will help make a smooth transition

VALUE RESOURCES FOR STATE ASSOCIATIONS

CMS Resources

• Patient Driven Payment Model at CMS.gov

• Concurrent and Group Therapy Limit

• PDPM Functional and Cognitive Scoring

• PDPM Presentation

• PDPM FAQs

Resources from AOTA

All resources are linked on www.aota.org/value• AOTA Occupational Profile Template• Section GG Template & Link to CMS Training• SNF, HH, & Medicare OP Evaluation Checklists• PDPM Webinars & CMS Q&A Recordings• Evidence Based Practice Resources• Choosing Wisely• Quality Toolkit

www.aota.org/value

www.aota.org/value

AOTA Occupational Profile Template

• Free for members and nonmembers atwww.aota.org/value

• Part of the OT Evaluation

• Why is it important?

– Care and services that are based on the client’s perspectives and goals contributes to the patient experience

– Sets the stage to identify occupations that have meaning for clients

www.aota.org/value

AOTA Occupational Profile Template is FREE for anyone to

download

• www.aota.org/value

• Skilled Nursing & Med B Outpatient

• Occupational Profile

• Core Areas to AddressAnalysis of OccupationalPerformance

Evaluation Checklists

www.aota.org/value

All Evaluation Checklists are FREE

for anyone to download

Webinars & Education available atwww.aota.org/value

• Payment Shift from Volume to Value**

• CE Article: OTPF: A Foundation for Documentation

Volume to Value

• Policy & Quality Requirements of PDPM in SNFs

• PDPM as an Opportunity to Improve the Value of OT

• How OT Practitioners Can Prepare for the new SNF Payment Model**

• PDPM: Occupational Therapy Professionals' Opportunity to Improve Quality of Care

• Skilled Nursing Facilities 101: Documentation, Reimbursement, and Ethics in Practice, 2nd Edition

• CMS Answers Questions & Staff Busts Myths of PDPM & Home Health’s PDGM

SNF PDPM

• Overview of The Quality Payment Program: Are you Ready to Succeed in 2019?

• Medicare Quality Payment Program Part 1: Demonstrate High Quality OT through MIPS

• Medicare Quality Payment Program Part 2: Using MIPS in Practice to Distinguish the Value of OT

Other Programs

Most webinars are FREE for AOTA Members and

available for purchase for non-members

** only available to AOTA members

One Day Conferences

On-Demand: Purchase the entire conference or

individual sessions at store.aota.org

November 19: Silver Spring, MD & Live Streamhttps://www.aota.org/Conference-Events/PDGM

www.aota.org/value

Quality Toolkit is only available to AOTA Members

The Quality Toolkit lists standardized tools that are used by members across the country to address core areas.

Shirley Ryan Ability Lab

A link is provided at the top of the Quality Toolkit on www.aota.org/value

www.aota.org/value

Section GG Template is

FREE for anyone to download

www.aota.org/value

www.aota.org/value

Sharing with your members

• Investment in clinical tools & education

• Please share widely!

• Provide links to the resources on aota.org rather than sending as attachments

• Number of downloads and clicks is the only way to gauge interest which informs development of future resources

Questions?

quality@aota.org

ONLY IF NEEDED FOR QUESTIONS

Checklist: Occupational Profile Reason for OT Services

Successful Occupations

Interests & Values

Occupational History

Performance Patterns

Habits Routines Roles Rituals

Environment Supports & Barriers (Physical, Social)

Context Supports & Barriers (Cultural, Personal, Temporal, Virtual)

Client’s Priorities & Desired Outcomes

We recommend starting with the AOTA Occupational Profile

Template (www.aota.org/profile). The checklist includes the categories as reminders.

ADLs Addressed Priority

IADLs Addressed Priority

Functional Cognition Addressed Priority

Vision Addressed Priority

Psychosocial/Behavioral Skills Addressed Priority

Fear of Falling Addressed Priority

Habits, Routines, Roles Addressed Priority

Safety Screen Addressed Priority

Checklist:Analysis of Occupational Performance

Aim for 100%

Unique for ea. Client