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PDPM ACADEMY –Business Solutions for Better Patient Care
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AHCA Board: What are CMS’ Issues with RUGs?
Interviewed Members: What Do You Think About PDPM?
To Dos: What Did Interviewed Members Think SNFs Should Do?
PDPM Preparations Are Member Driven
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… Which Drive Our Goals Today and Our Designed Outcome
• Establish Understanding of SNF
Operational Changes;
• Learn About Patient Classification &
How it Drives Payment; and
• Gain Insights on How to Think
Creatively About PDPM
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PDPM Transition Plan
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Orientation to the Workshop
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Workshop Day is Experiential and Hands-On Rather Than a PDPM Overview
• Workshop Day Will Focus on How to Use AHCA/NCAL Designed PDPM Tools
• PDPM Basics Are Addressed in Pre-Recorded Webinars
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Workshop Overview
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More Resources Will Be Available – Workshop is Just the Start
Mon
thly
Web
inar
s • Q&As • Updates on CMS
Activities • FAQs from Each
AH
CA
Em
ail • [email protected]
• Responses drafted by AHCA staff or fielded with CMS as needed
• Answers synthesized into FAQs Weekly A
dditi
onal
Too
ls • Regular Release of Additional Tools
• Updates to Existing Tools as CMS Releases Information
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PDPM Academy Focused on Supporting Members for Transition –Reboot in Fall 2019 for Operations
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Module 1: Re-Thinking SNF Operations for PDPM Transition
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Module 1 Materials
Document (Follows Binder Materials Order) Purpose
Coversheet Orientation to the Module Activities
Core Competencies Summary SlidesFollow Along During Presentation & Group Exercise
SNF Case Examples & Worksheets Group Exercise
LTC TeamSTEPPS Overview Document Reference-Only & Take Home
CMS PDPM Webpage – Will All be at ahcancalED Reference-Only & Take Home
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As we progress through the binder, trainers will note which page and document to reference as needed
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Why is Assessing SNF Building Operations Important?
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Resource Utilization Group IV Patient-Driven Payment Model
Basis for Payment Fundamentally Changes
Key Competencies and Activities
Driven by Therapy Minutes
• Based on Clinical Characteristics
• ICD-10 Diagnosis and 188 MDS Items
Multiple, Regularly Scheduled Assessments
Driving Per Diem Payment
• Single Rapid Patient Assessment – 8 Days
• Variable Per Diem
Therapy Frames Care in Most Instances
• CMS Expectation for Holistic Care
• Coordinated, Team-Based Care
Understanding CMS’ Framework for PDPM is Key
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CMS Framework Element PDPM SNF Operational Implications
Remain within Existing Statutory Authority
• Sum of Per Diem Rates (PT, OT, SLP, Nursing, NTA, Non-Case Mix)• Accurate Assignment to Five Component Case Mix Groups (CMG)
Use Existing Data • PDPM Simulated Revenue and All Other Modeling Are Estimates • Assess Ability to Classify into PDPM CMGs • Develop capacity to collect supporting documentation
Develop a Readily Implementable System –October 1, 2019
• Hard Stop – No transition period• Do Not Wait to Start Transition Planning • Develop a Work Plan (Module 1)
Shifts Away from Therapy Minutes as Basis for Payment
• Payment Based on Patient Characteristics • Minutes only Counted at Discharge & Must Match Claims
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What Can Go Wrong If You Are Not Prepared for PDPM?
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Four Core Competencies for Successful Transition
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1
2
3
4
Understand New Payment Driver’s Impacts
Accurate Collection of Clinical Information
Strengthen Care Delivery Process
Optimize Resources to Support PDPM
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Core Competency #1 – Understand New Payment Driver’s Impact
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Understand PDPM payment drivers and expected facility adjustment if no changes to patient mix
Identify organizational gaps that will affect implementation and subsequent payment under PDPM
Make changes in organizational culture to support PDPM
Ensure operational staff understand overall model goals and individual components relevant to role on team
Build ICD-10 coding capacity to ensure payment
Option 1: Estimated Revenue Impacts on Your Building(s)
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Open the CMS Workbook
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Scroll Down to Provider-
Specific Impact
Double Click to Open the Impact
Analysis File
Quick Overview Demo on How to Find Your Revenue Data
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CMS Simulated Payment Data
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Option 2: AHCA PDPM Academy Resources
AHCA PDPM Resident Classification Toolkit◦ Includes today’s resources & more
AHCA PDPM Case-Mix Grouper Simulator Toolkit (early 2019)◦ Excel workbook◦ Variable per-diem impact estimator◦ Single and batch MDS data
AHCA PDPM ICD-10-CM Toolkit◦ 16 hour online certification program for coders &
clinicians◦ 4 hour online ICD-10 CE program for
administrators & non-coders
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Be sure to download and use the AHCA PDPM Academy Toolkits and Instructional Webinars
Core Competency #2 – Accurate Collection of Clinical Information
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Understand importance of clinical documentation
Ability to quickly capture admission information
Capacity to be proficient when determining ARD & initial coding
Ability to capture functional status correctly—Section GG
Develop process in to determine when an Interim Payment Assessment is needed
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Patient Characteristics Represented by MDS Items Drive Payment
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Five independently determined PDPM component rates set during 5-Day assessment window using 188 MDS item fields
PT: 37 OT: 37 SLP: 66 Nursing: 132 NTAS: 34
… Shifting Away from Therapy Minutes as Basis for Payment
Rehab RUG rates Determined by 20 MDS Item Fields
Over 90% of resident days reported via Rehab RUGs
168 Additional Auditable MDS Item Fields Apply to ALL Stays/Days
Compliance Policy & Medical Documentation Will Need to be More Robust in PDPM
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High Risk Behavior Examples
Motivation Implications
Upcoding Revenue Maximization CMS will have a direct line of sight via ICD-10 and other MDS document
Downsizing Therapy Overhead Reduction CMS is clear the SNF benefit and cover requirements remain the same and will be monitoring for outcomes (e.g., QRPs)
Over-Use of Interrupted Stay
Restart Variable Per Diem
Risk of losing VBP bonus or increasing penalty up to 2% for all SNF stays & risk of being placed under “heighten scrutiny”
Vague IPA Trigger Definition
Room to Argue +/- in CMGs and Rates
SNFs should follow clear internal IPA policies and demonstrate adherence
Download AHCA/NCAL Compliance Policy Checklist based on CMS priorities in FY19 Final Rule from ahcancalED.
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Compliance Policies Checklist Version 1.0 – for Reference-Only in Your Binder
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Compliance Checklist
Document is located between the Core Competencies Checklist and the Group Exercise materials.
Core Competency #3 – Strengthen Care Delivery Process
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Evaluate care planning team and processes
Assess communication between nursing and therapist staffs
Define how therapy practices may change to ensure best outcomes
Ensure ability to deliver exceptional restorative nursing
Ability to support complex patients
Evaluate and consider development of specialized clinical programs (e.g., cardiac, respiratory) and transitions program
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CMS Care Plan Expectations in PDPM and Requirements for Participation
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Sources: CMS PDPM Webinar (12/11); Final Rule, Page 39189
To develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident’s goals, preferences, and services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Sources: Section 483.21, Final Rule Page 652
PDPM Drives “Holistic” Patient Assessment
Comprehensive Person-Centered Care Planning Baseline Care Plan Audit Checklist
RoP-Required Comprehensive Person-Centered Care Planning
Available at ahcancalED
Utilizing Evidence-Based Tools for Redesigning Care Team Coordination
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Download TeamSTEPPs Long-Term Care Version 2.0 from ahcancalED and review care team assessment sheet in binder for reference purposes.
Knowledge◦ Shared Mental Model
Attitudes◦ Mutual Trust◦ Team Orientation
Performance◦ Adaptability◦ Accuracy◦ Productivity◦ Efficiency◦ Safety
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Teams That Perform Well …
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• Hold shared mental models• Have clear roles and responsibilities• Have clear, valued, and shared vision• Optimize resources• Have strong team leadership• Engage in a regular discipline of feedback• Develop a strong sense of collective trust and confidence • Create mechanisms to cooperate and coordinate• Manage and optimize performance outcomes
Core Competency #4 – Optimize Resources To Support Implementation
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Assess MDS coordinators’ abilities and growth potential
Identify the need for / investment in additional clinical staff (e.g., NPs)
Assess therapy contracts
Determine need for additional training to improve coding accuracy
Evaluate current business office capabilities
Discuss internal / vendor software readiness and schedule beta testing to ensure accuracy
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Resources Should be Assessed in Tandem to Ensure Optimal Outcomes
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View PDPM Impacts on SNF Benefit, QRP, and VBP Webinar ahcancalED PDPDM Academy page. ICD-10 training platform also is available at ahcancalED.
Assess PDPM Impacts on Quality Reporting Program
and SNF VBP Program
Assess Information Technology Needs
Using Specifications
Review Therapy Staffing/Contracting
Options Tool
Utilize AHCA/NCAL ICD-10 Virtual
Training Programs
Coordinated Resource Re-Alignment
MDS Coding Impacts QRP Outcome Measures and PDPM Classification
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PD
PM
Obs
erva
tions
• CMS and OIG will Track and Flag Declines in Patient Outcomes
• Pressure Ulcer Worsening or Appearing During a Stay often Indicative of Broad Problems with Care
• Importance of Restorative Nursing in These Outcomes
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Claims-Based Measures Will Be Tracked to Assess Provider Behavior
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• Total Estimated Medicare Spending Per Beneficiary (MSPB)MSPB
• Discharge to Community (DTC) and remained in community for 30 daysDTC
• Potentially Preventable 30 –day Post-Discharge Readmission Measure PPR
PD
PM
Obs
erva
tions
• Relative to MSPB, ensure coding is accurate
• Be thoughtful about variable per diems and DTC rates
• Be aware CMS has not clarified the impact of Interrupted Stay and related IPA use on PPRWebinars on AHCANCALED walk you through registration and
use https://educate.ahcancal.org/products/how-do-i-use-ltc-trend-tracker-as-a-skilled-nursing-facility
Interrupted Stay Use Has a Possible Two-Fold Impact – Tracking?
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Heightened CMS Scrutiny
• No new admission assessment if </= 3 days but can use IPA
• New admission assessment required if away >3 days
• Does return to day day-1 PT/OT/NTAS tapering
Bonus Payment Impacts? SNF VBP Program
1
2
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Therapy Staffing & Contracting Considerations
Person Centered
Care
Outcomes
Revenue
Cost
Skill Set
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Keep an eye out for the AHCA PDPM Therapy Staffing/Contracting Considerations Toolkit to download from the ahcancalED PDPM Academy page in early 2019
• PDPM Is an Opportunity To Rethink the Rehabilitation Mindset in your Organization
• Key areas to consider - in-house or contracted therapy: • How will any possible changes in therapy and
restorative impact my outcomes for short-stay residents and quality measures for all residents?
• Based on my current resident case-mix profile, will I see more or less therapy component revenue under PDPM?
• Are my therapy staffing/contracting costs/provisions in alignment with PDPM, QRP, VBP, and RoP incentives?
• Do I have the skill set to achieve outcomes goals?
CMS Offers Helpful Resources
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Good Samaritan Society PDPM Planning – SNF Re-Organization
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Member Video
Q&A on Core Competencies
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BREAK
SNF Building Assessment Exercise Objectives
1. Understand the operational and service delivery changes needed for the SNF to successfully transition to PDPM
2. Learn what current QRP and VBP trends position the SNF to be successful or would be indicative of the need for significant assessment of service delivery
3. Develop an understanding of what the top priorities for PDPM investment should be for the SNF case examples
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Group Exercise – SNF Case Example Assessment
1. Room divided into groups by SNF Case Example SNF A – Urban SNF B – Rural/Suburban SNF C – Rural
2. Materials SNF Case Example Core Competencies Summary Assessment
3. Report Out Using Instructions on Worksheets
4. Be Prepared to Offer Comments on Other Groups’ Work
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SNF Building Case Examples
SNF Market Patient Mix Revenue
A Urban Orthopedic/RehabilitationAll Medicare
BRural (suburban)
Mix of Rehabilitation and Some Long-Stay
Medicare with Some Medicaid
C Rural Mostly Long-Stay with Some Short Stay Post-Acute Care
Medicaid with Some Medicare
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Assessing SNF Case Example
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Core Competency Readiness Level Prioritization
High Med. Low High Med. Low
Understand New Payment Drivers Understand PDPM payment drivers and expected facility adjustment if no changes to patient mix
X X
Identify organizational gaps that will affect implementation and subsequent payment under PDPM X X
Make changes in organizational culture to support PDPM X X
Ensure operational staff understand overall model goals and individual components relevant to role on team X X
Build ICD-10 coding capacity to ensure payment X X
Examples of Key SNF Challenges1. Executive leadership has not examined patient case mix under RUGs
Compared to PDPM• Possible Course Action: Develop a PDPM Transition Team Effort to
Assess Referral and Align Those Patterns with Possible PDPM Specialization Areas
2. SNF needs an ICD-10 training program which includes an assessment of how coding works from admission to claims coding• Possible Course of Action: Interview In-Take Staff on how PDPM
ICD-10-CM and other Coding Could Be Improves and Develop Coordination/Collaboration Strategies Among MDS Coordinators and Billing Staff Through Similar Staff Dialogue
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Core Competency #1 – Understand New Payment Drivers Impact
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10 Minutes
Understand PDPM payment drivers and expected facility adjustment if no changes to patient mix
Identify organizational gaps that will affect implementation and subsequent payment under PDPM
Make changes in organizational culture to support PDPM
Ensure operational staff understand overall model goals and individual components relevant to role on team
Build ICD-10 coding capacity to ensure payment
Core Competency #2 – Accurate Collection of Clinical Information
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Understand importance of clinical documentation
Ability to quickly capture admission information
Capacity to be proficient when determining ARD & initial coding
Ability to capture functional status correctly—Section GG
Develop process in to determine when an Interim Payment Assessment is needed
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Core Competency #3 – Strengthen Care Delivery Process
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Evaluate care planning team and processes
Assess communication between nursing and therapist staffs
Define how therapy practices may change to ensure best outcomes
Ensure ability to deliver exceptional restorative nursing
Ability to support complex patients
Evaluate and consider development of specialized clinical programs (e.g., cardiac, respiratory) and transitions program
Core Competency #4 – Optimize Resources To Support Implementation
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Assess MDS coordinators’ abilities and growth potential
Identify the need for / investment in additional clinical staff (e.g., NPs)
Assess therapy contracts
Determine need for additional training to improve coding accuracy
Evaluate current business office capabilities
Discuss internal / vendor software readiness and schedule beta testing to ensure accuracy
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SNF Building A•150 bed SNF part of hospital system
•Major US city in popular Midwest retirement center
•Primary focus is short-term uncomplicated ortho rehab
•ALOS = 20 days
•Mix = 80% RU, 10% RV
•Restorative nursing = weak
•Therapy is delivered in-house
•MDS works for corporate reimbursement consultant
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•Section GG gathered by therapy only
•Most of referrals come from affiliated hospital
•3 other SNFs within 15 miles
•No medically complex patients
•QRP: will receive bonus payment
•Assessment measures: As expected
•Claims measures: Mixed
•Financial Projection: -21%
SNF Building B
•75 bed SNF
•Rural area outside of large east coast city
•20 bed ‘respiratory unit’ for ventilator patients, but plan abandoned
•ALOS = 30 days
•Mix = 20% RU, 50% RV
•Restorative nursing = strong
•Therapy is delivered by contractor
•MDS is an RN; active in care coord
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•Section GG discuss encouraged
•Most of referrals come from 4 hospitals and a LTCH
•5 other SNFs within 15 miles; one owned by same company
•5% patients with behavior &/or I/DD
•VBP: penalty
•Assessment measures: Mixed
•Claims measures: As / Better than Expected
•Financial Projection: +3%
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SNF Building C•110 bed SNF
•Rural town approximately 35,000 pop; relationship with satellite university
•Blend of therapy & CC patients
•ALOS = 27 days
•Mix = 10% RU, 10% RV
•Restorative nursing = strong
•Therapy is delivered by contractor that struggles with staffing
•MDS is an RN; not active with care plan documentation
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•Care team meetings short
•Reliant on IRF and small local hospitals
•2 other SNFs within 10 miles
•40% patients with dementia
•VBP: penalty of 2%
•Assessment measures: Lower than expected
•Claims measures: Too small/Lower than expected
•Financial Projection: +36%
Module 2: Assessing Market Position & Educating Partners About PDPM
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Module 2 Materials
Document (Follows Binder Order) Purpose
Coversheet Orientation to the Module Activities
Long-Term Care Trend Tracker Topline Report Reference & Take Home
Template PDPM Messaging Materials Discussion, Reference & Take Home
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As we progress through the binder, trainers will note which page and document to reference as needed
Core Elements for Market Position Assessment and Partnerships
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Good Intelligence
1. Market referral patterns
2. Know your relative performance
3. Understand your partner’s pain points and incentives
Readmission penalties
Value-based payment performance
VBC incentives (ACOs, bundles)
Strong Message
1. Articulate how your programs and performance will address pain points
2. It’s a product, not a bed
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Market Positioning Conceptual Map
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Strategy and Competition in Your Market
Identity and Reputation
Organization and People
Operations and Innovation
Services and Care Pathways
• Services Not Offered• Emerging Opportunities with Specialty Care
• Long-Term Care Trend Tracker• Quality Awards• Rehospitalization • Staff Skill Sets
• Services Which Will Remain Valuable • Other SNFs’ Services & Other PAC Providers• Re-Organizing to Align with New Opportunities
AHCA Market Positioning Resources –Current and Planned for Spring 2019
• Allows skilled nursing and assisted living organizations to benchmark personal metrics to those of their peers
• Examine ongoing quality improvement efforts
Long-Term Care Trend Tracker
• Limited Data Set (LDS) using claims• Will allow SNFs to track hospital referral
patterns • Inform clinical pathway development based on
patient characteristics and hospital needs
Patient Pathway Platform
(AHCA P3 ©)
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• Measures to watch in LTC Trend Tracker:
• Discharge to Community (AHCA)
• Length of Stay (AHCA)
• SS Improvement in Function, Risk Adjusted (Five Star)• LS ADL Decline (Five Star)• LS Worsening Mobility (Five Star)• Medicare Spending per Beneficiary (QRP)• Discharge to Community (QRP)• SS Improvement in Self-Care (AHCA – coming soon!)• SS Improvement in Mobility (AHCA – coming soon!)• SS Discharge to Community (Five Star)• Change in self-care (QRP – coming next year)• Change in mobility (QRP – coming next year)• Discharge self-care score (QRP – coming next year)• Discharge mobility score (QRP – coming next year)
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• Reports and publications in LTC Trend Tracker:o CASPER Resident Report
Gives a rough idea of how your resident population is changing
o Your Top-Line Publication QRP Feedback module coming soon – heavy overlap of variables between QRP
mobility measures and PDPM patient classification variables on MDS
o Your Resident Profile Publication Gives a more detailed profile of your residents than the CASPER report Previously included in Your Top-Line 2018-Q1 to assist with Phase-2 RoP facility
assessment requirements (will be released as free-standing report soon)
o Five Star PBJ Staffing Report Contains data on census
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• Webinars on AHCANCALED walk you through registration and use:
https://educate.ahcancal.org/products/how-do-i-use-ltc-trend-tracker-as-a-skilled-nursing-facility
• Email notifications are sent when new or updated publications come out
• Familiarize yourself with LTC Trend Tracker now so you are prepared to manage PDPM changes
• Reports and stats are constantly being updated and supplemented◦ What would you like to see? Please let us know!
Email [email protected]
How do I access LTC Trend Tracker and see my publications?
• Go to www.ltctrendtracker.com
• If you already have a username and password, click
• If you do not have a username and password, click
• If you do not know if you have a username and password, select
and then click
to search using your Provider Number
• Email [email protected] any needed assistance
Medicare LDS Offers a Longitudinal View of Patient Health Utilization
Longitudinal CMS Data Used to Provide Information on Health Care Utilization and Beneficiary Characteristics
Patient characteristics will include primary condition and comorbidities across settings
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AHCA-P3 – Understand Your Partner’s PAC Referral Patterns
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SNF 41%
HHA47%
LTACH 2% Hospice
10%
Example: Hospital PAC Discharges
Total hospital discharges to PAC: 5,040*
Takeaway:• Hospital has very low
referral volume to costlier care settings, suggesting that the hospital already has a PAC referral strategy in place to reduce costs
*Will exclude discharges to facilities with <11 referrals.
AHCA-P3: Understand Your Partner’s PAC Referral Patterns
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Total hospital discharges to SNF: 2,087*
Takeaways:• Hospital referred patients to 84
SNFs in 2017; 34 SNFs received >11 referrals from the hospital
• A lot of SNFs sharing small amounts of volume
• Two SNFs dominate referrals –why?
SNF A41%
SNF B47%
SNF C2% SNF D
10%
Example: Discharges by SNFs in Market
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CMS Ramps Down RUG IV Maintenance on October 1, 2020
Payers◦Medicare Advantage◦Bundling ◦Medicaid ◦VA
Referral Sources ◦Accountable Care Organizations◦Hospitals◦Physicians
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• Become a PDPM Resource for Your Partners
• Articulate your Value Proposition in PDPM
Market and PDPM Messaging Exercise Objectives
1. Understand how Long-Term Care Trend Tracker can be helpful both now and with PDPM
2. From the group discussion, develop ideas for how you might position your SNF(s) in a PDPM environment
3. Develop ideas for how to message about PDPM and your PDPM expertise to referral sources and payers
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Group Discussion
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1. How are you using Trend Tracker today to demonstrate value proposition?
2. Based on today’s work, what homework do you need to conduct to assess your PDPM market position?
3. What are some specific PDPM-driven changes you might make or services you might begin to offer to enhance your market position?
4. Are there key PDPM features you would want to highlight with payers and referral sources?
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LUNCH
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Module 3: Resident Classification
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Module 2 Materials Document (Follows Binder Order) Purpose
Coversheet Orientation to the Module Activities
SNF PDPM Hospital Information Collection Checklist (3 pages) Discussion, Reference & Take Home
MDS & Claim “High Impact” Item Fields to Each PDPM Case-Mix Adjusted Component (10 pages)
Discussion, Reference & Take Home
AHCA PDPM Academy MDS Core Items Mock-Up: Betty W (11 pages) Discussion, Reference & Take Home
AHCA PDPM Resident Classification Workbook: Betty W (18 pages) Discussion, Reference & Take Home
PDPM PT, OT, and NTA Component Variable Per-Diem and RUG-IV Rate Reference Tables (6 pages)
Discussion, Reference & Take Home
AHCA PDPM Academy MDS Core Items Mock-Up: Mary T (11 pages) Reference & Take Home
AHCA PDPM Resident Classification Workbook: Mary T (18 pages) Reference & Take Home
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As we progress through the binder, trainers will note which page and document to reference as needed
Download tools from ahcancalEDPDPM Academy.
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Resident Classification Happens in Three Stages
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1. 2. 3.
SNF Admits & Assesses
• SNF clinician diagnoses • 5-Day SNF PPS MDS
Assessment timing and accuracy
• MDS coordinator codes based on MDS items & ICD-10 codes
Hospital Discharges
• Typical discharge information sufficient
• Surgery information from hospital is new
Hospital Information Collection Checklist
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Download Hospital Information
Collection Checklist at PDPM Academy
page at ahcancalED
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“High Impact” MDS Items Reference Tool
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Download High Impact MDS Items
Reference and related tools at
PDPM Academy page at ahcancalED
Group Discussion
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Module 2: Resident Classification
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Welcome Nursing Home –Importance of Clinical Information
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Member Video
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Resident Classification - Three Stages
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1. 2. 3.
SNF Admits & Assesses
• SNF clinician diagnoses • 5-Day SNF PPS MDS
Assessment timing and accuracy
• MDS coordinator codes based on MDS items & ICD-10 codes
Hospital Discharges
• Typical discharge information sufficient
• Surgery information from hospital is new
PDPM adds variable per-diem payment adjustment
PT Base RatePT PT CMIPT Adjustment
Factor
OT Base RateOT OT CMIOT Adjustment
Factor
SLP Base RateSLP SLP CMI
Nursing Base RateNursing Nursing CMI
NTA Base RateNTA NTA CMINTA Adjustment
Factor
Non-Case-Mix Base Rate
Non-Case Mix
PDPM includes variable per-diem payment adjustments that
modify payment based on changes in utilization of these
services over a stay
• Day 4 – NTA rates drop by 2/3• Day 21 and every 7 days after
the PT and OT rates drop 2%
*RUGs HIV/AIDS add-on is replaced in PDPM with new 18% nursing component base rate adjustor and new NTA CMI factors (not shown)
Download AHCA PDPM PT OT NTA Component Variable Per-Diem Rate Tables on ahcancalED
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PDPM Daily Rate CalculationExample resident – Betty W – Days 1-3
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ComponentUnadj Fed
RateCase-Mix
IndexSpecial
AdjustorsVariable per diem
Payment (per diem)
PT $59.33 x 1.88 x x 1.00 = $111.54
OT $55.23 x 1.68 x x 1.00 = $92.79
SLP $22.15 x 1.46 x x = $32.34
NTA $78.05 x 1.34 x x 3.00 = $313.76
Nursing $103.46 x 1.34 x 1.00* x = $138.64
Non-Case-Mix Component
$92.63 x x x = $92.63
Total = $781.70*
Case Mix Group
Case Mix Index
Pat
ient
Cha
ract
eris
tics
from
MD
S
Spoiler Alert – Here’s the end of today’s classification exercise
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The engine that drives PDPM payments are Patient Characteristics represented by MDS items
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Five independently Determined PDPM
Component Rates Set During 5-Day PPS
Assessment Window Using 188 MDS Item Fields
PT - 37 OT - 37 SLP -66
Nursing - 132 NTAS -34
awareness of impacts all PDPM MDS items is key to success
Rehab RUG rates Determined by 20 MDS Item Fields
Over 90% of Resident Days Reported Via Rehab RUGs
168 Additional Auditable MDS Item Fields Apply to ALL Stays/Days
Exercise Objectives
1. Be able to apply the AHCA PDPM Resident Classification Worksheets to any resident to • Manually determine a resident’s PDPM case-mix group within each component
• Determine the resident’s PDPM per-diem payment rate (using federal rates) at any point during the stay
• Compare the relative difference in resident payment rates between RUG-IV and PDPM
2. Understand the relationship of clinical factors that identify greater resource needs and that impact PDPM payment rates
3. Describe how some clinical conditions will not receive higher payments unless linked MDS items are also coded properly.
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Resident Classification Exercise
◦ You do not need to be an expert on how to code the MDS to be successful with the following exercises.
◦ There will be 7 modules and we will walk you through each part of the classification process:
◦ Primary Diagnosis Clinical Category PT/OT/SLP
◦ Function Score PT/OT/Nursing
◦ PT and OT Component
◦ SLP Component
◦ NTA Component
◦ Nursing Component
◦ Total PDPM Federal Urban and Rural Per-Diem Payment Rate(s) at Different Points of Stay
◦ In each step, we will give you some time to use the complete the steps for each section of the worksheet and to locate data on the MDS. We will show you the correct answers!
◦ You may not master everything today, but you will have the knowledge necessary to be able to take these tools back into your facilities (and ongoing AHCA support)
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Ongoing support at [email protected] & FAQ’s, tools & resources
at ahcancalED
MDS Core Items Resident Example Mock-Up
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Download template MDS PDPM MDS Core Items and other resident classification tools from the PDPM Academy site at ahcancalED
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Resident Classification Workbook
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Download template Resident Classification Workbooks and other resident classification tools from the PDPM
Academy site at ahcancalED
Legend for Workbook
Blue Box with Italic Font-Module Name
Red Text within any box-correlated to MDS Item
start here
intermediate steps
final data for each step
PT and OT Component Drivers
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Primary Diagnosis Clinical Category Module
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Primary Reason for SNF Stay ICD-10 code in the example MDS for Betty W
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Primary Diagnosis Clinical Category Module
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Primary Diagnosis Clinical Category Module
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PDPM Flips SNF PPS Function Scoring Process
RUG-IV PDPM
MDS Section G MDS Section GG
4 Items 7 Nursing & 11 PT/OT Items
7-day Lookback Day 1-3 Before Intervention
Higher Score = Worse Function Higher Score = Better Function
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Functional Score Module – Activity
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Functional Score Module - Answers
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Functional Score Module – Activity
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Note: Typo in printed workbook – yellow box should say
= 07,09, 10 OR 88Online template is correct
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Functional Score Module - Answers
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Note: Typo in printed workbook – yellow box should say
= 07,09, 10 OR 88Online template is correct
Functional Score Module – Activity
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Functional Score Module - Answers
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PT and OT Component Drivers
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PT and OT Components Module – Answers
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SLP Component Drivers
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SLP Component Module – Activity
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SLP Component Module - Answers
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SLP Component Module – Activity
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SLP Component Module - Answers
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SLP Component Module - Answers
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SLP Component Module – Activity
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SLP Component Module - Answers
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SLP Component Module – Activity
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SLP Component Module - Answers
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NTA Component Drivers
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NTA Component Module – Activity
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NTA Component Module – Answers
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NTA Component Module – Activity
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NTA Component Module – Answers
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NTA Component Module – Answers
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NTA Component Module – Answers
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NTA Component Module – Answers
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NTA Component Module – Activity
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NTA Component Module – Answers
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Nursing Component Drivers
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Nursing Component Module – Activity
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Nursing Component Module – Answers
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Nursing Component Module – Activity
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Nursing Component Module – Answers
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Nursing Component Module – Activity
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Nursing Component Module – Answers
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Nursing Component Module – Activity
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I2000
Nursing Component Module – Answers
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I2000
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Nursing Component Module – Activity
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Nursing Component Module – Answers
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PDPM PT OT & NTA Variable Per-Diem & RUG-IV Rate Reference Tables
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Download PT OT NTA Variable Per-Diem Rate Tables from the PDPM
Academy site at ahcancalED
Total PDPM Urban and Rural Per-Diem Payment Rate(s) During Stay Module - Activity
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$299.73
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Total PDPM Urban and Rural Per-Diem Payment Rate(s) During Stay Module - Answers
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$299.73
Understanding Why This Exercise is Important – What Can Go Wrong?
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MDS IV Medication Item is Not Entered
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Failing to identify or incorrectly coding just one PDPM payment driver MDS item can have a significant impact on CMI
*resident has 2 NTA points for diabetes
30-Day Resource Impact
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Days Per Diem Rate
RUG-IVPDPM With
Accurate MDS
PDPM With Missing MDS IV Meds Data
1-3 $631.25 $914.60 $706.06
4-20 $631.25 $625.81 $556.20
21-27 $631.25 $622.26 $554.36
28-30 $631.25 $618.71 $$552.52
30 Day Total $18,937.50 $19,594.54 $17,111.70
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Implications of Poor Care Coordination & LOS Monitoring
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ComponentBase Fed
RateCase-Mix
IndexSpecial
AdjustorsVariable per diem
Payment (per diem)
PT $59.33 x 1.55 x x 0.76 = $69.89
OT $55.23 x 1.55 x x 0.76 = $65.07
SLP $22.15 x 2.85 x x = $63.13
NTA $78.05 x 1.85 x x 1.00 = $144.39
Nursing $103.46 x 1.43 x 1.00* x = $148.10
Non-Case-Mix Component
$92.63 x x x = $92.63
Total = $583.41*
*PDPM per-diem days 1-3 = $914.60*RUGs per-diem all days = $631.25*Except when resident has HIV/AIDS, then variable per diem adjustment = 1.18
Note: Rates are for urban facilities, CMS estimated if program went into effect FY19
Impact Over a Full 100-Day Stay
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$500
$550
$600
$650
$700
$750
$800
$850
$900
$950
1 3 5 7 91
11
31
51
71
92
12
32
52
72
93
13
33
53
73
94
14
34
54
74
95
15
35
55
75
96
16
36
56
76
97
17
37
57
77
98
18
38
58
78
99
19
39
59
79
9
RUG-IV Correct PDPM MDS PDPM MDS Missing IV Meds
100 Day Stay RevenueRUG-IV = $63,125
PDPM Correct MDS = $62,517PDPM Missing IV Meds
=$55,154
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Group Discussion
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BREAK
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Module 4: Pulling it All Together
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Ensign Vision for PDPM Re-Positioning
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Member Video
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PDPM Readiness Assessment and Transition Plan Development Kit Version 1.0
• Core Competencies
• Possible CMS Revenue Impacts
• CMS Patient Case Mix Group Distribution
• Staff Communication and Capability
• Referral Relationships (up and downstream)
• Quality and Performance Data
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1
Long-Standing AHCA Resources Useful for PDPM Planning
Long-Term Care Trend Tracker Topline Reports
IMPACT Act Quality Reporting Technical Support
SNF Rehospitalization VPB Technical Support
Reimbursement Policy Tools
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Download tools from ahcancalED.
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PDPM Readiness Assessment and Transition Plan Development Kit Version 1.0
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• Readiness Priorities Using the Core Competencies
• PDPM Case Mix Group Distribution
• Staff Training/Gaps (e.g., Restorative Nursing)
• Coding and Communication Pathways
• Care Management Capacity
• PDPM Messaging & Communication on New Services
2
Care Management Core Capabilities
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Primary Care Capabilities
(NPs or MDs)
Transitional Care Capabilities
(data sharing, partnerships)
Targeted Clinical Programming
(cardiac care, orthopedics)
Care Integration
(all work as team)
Alignment on objectives
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Break Out of the RUGs Mindset – Innovation Pathways Template
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Innovate
Blend Clinical Cultures –Nursing and Therapy
Revisit Communication Methods Using TeamSTEPPs
Interview IT Vendors and Compare Capacity
Keep it Simple – Find PDPM Overlaps with Other Work
Create Road Maps That Align with PDPM Mile Markers (i.e., HIPPS Codes, NPRM, etc.)
Drive messaging on PDPM with Partners Find New Ways to Collaborate
Co-Create Opportunities and Solutions with Upstream and Downstream Partners
Work Planning Inclusively and With a Deliberate Sense of Urgency
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4
• Aligned With Other Related Effort
• Mapped Against Key CMS Release Dates
• Timed with Realistic Capacity Building
• Inclusively to Ensure Buy-In at All Levels
• With a Progress Monitoring Plan
• Allowing for Time to Beta Test Changes
• Creating a Sense of Urgency
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Be Ready to Integrate To-Be-Released CMS Guidance
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Information Technology Specifications
Updated Claims Submission & Billing Guidance
Revised RAI Manual
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Source: What are the Newest Developments in Change Management Models to Increase Organizational Effectiveness, Agility and Change Readiness? Cornell University. Spring 2013
Organ
izational Chan
ge
Man
agement Schematic
146
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Module 5 – Upcoming Academy Events & Resources
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Academy Tools Under Development & Upcoming Events – All at ahcancalED …
Grouper Tool
Interim Payment Assessment Trigger Policy Options
Market Positioning & Linked Data Set
Monthly Webinars
Updates to Tools as CMS Releases Guidance
Coordinating SNF Programs and Policies with PDPM
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Suggestions for Other Tools? Email ideas to [email protected]
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Have We Addressed Questions & Concerns?
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PDPM ACADEMY –Business Solutions for
Better Patient Care
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THANK YOU FOR YOUR TIME & PLEASE PROVIDE FEEDBACK TO HELP AHCA IMPROVE
OUR MEMBER SUPPORTS