With all the focus on the impact of the new Patient-Driven Payment Model (PDPM) for skilled nursing facilities, it’s easy to forget that the payment system didn’t just spring up overnight — it was the product of research, debate, and input from a variety of participants across the spectrum.
Peggy Gourgues, chief operating officer of third-party rehab provider Reliant Rehabilitation, was one of many stakeholders who weighed in, serving on three technical expert panels (TEPs) that advised the Centers for Medicare & Medicaid Services (CMS) and its research partners during the PDPM development process.
The Plano, Texas-based Reliant offers rehabilitation services in more than 800 care facilities across 40 states, serving around 37,000 residents per day.
Skilled Nursing News spoke with Gourgues to learn more about the creation of the new payment model, as well as where providers should be in the preparation process with less than eight months to go until the implementation date — and whether the change is prompting more providers to shift their therapy in-house.
Reliant chief strategy, clinical, and operations officer David Tate joined the call as well to provide insight on strategies for success under the new model.
Tell me a little about your experience with the development of PDPM.
Gourgues: Through NASL [the National Association for the Support of Long-Term Care], I was asked to participate on the TEP with the Acumen research project.
Acumen was given the task, actually, of taking the current RUG model — which is PPS — and changing it, adapting it, and bringing it into the 21st century. They started two or three years ago, and I sat on three different technical expert panels, where they basically presented their research, and then we were asked to comment along with that.
Their research really was a cost analysis, so they looked at historically what had been done as far as either the amount of therapy or the amount of payment to the skilled nursing facility based on certain points, certain pieces of the MDS [Minimum Data Set]. They essentially were able to link cost analysis to certain sections of the MDS, and that ultimately drove the patient characteristics coming from the MDS that now we see in PDPM.
For example, if you were to look at PT, OT, and speech components, you would see that the PT and OT components actually are reduced by 2% after day 20, and then go down each subsequent seven days. But speech doesn’t. And again, people will say: Well, why did that happen?
It was all based on the research by Acumen, and essentially what they were able to show was: After day 20, PT and OT treatment and cost of therapy went down. It began to ramp down. However, for speech, they were able to show that it remained steady, and so hence we ended up with speech not being reduced after day 20, but PT and OT did.
A lot of the things that we see in PDPM come from that cost analysis of what’s been done historically. And there were a few wins that we had with the TEP, meaning PDPM actually was revised or changed because of some of the discussions with the TEP.
Initially, with speech, they were going to simply use the results of section B in the MDS — in a specific point that said, “Can the resident express themselves?” — to determine whether or not they had a cognitive impairment. And so myself, and there were others there from the American Speech and Hearing Association, said: “Hey, that’s not a real determinant of whether or not a resident has a cognitive impairment.” And so they moved toward the BIMS [Brief Interview for Mental Status] and this cognitive performance score. So we did have some wins along the way, but the majority was essentially cost analysis. And so that’s how we got to PDPM today.
You brought up the speech therapy reimbursements — is targeting speech residents a strategy, and will we see shifts in the kind of care, or is there truth to the idea that treating the whole patient, whoever he or she is, will result in success?
Tate: I’d say that we generally agree that the amount of care being provided, as far as physical therapy, occupational therapy, and speech therapy — we don’t anticipate a shift in the relative amount between the disciplines.
Gourgues: I think all three are at the table. Without a doubt, we certainly are cognizant of the fact that getting that MDS, getting all the sections of the MDS accurate with the specific patient characteristics, is super critical. So we do believe that speech, along with PT and OT, are huge participants in the interdisciplinary team meeting.
What should providers be doing right now to prepare for PDPM? Where should they be, and what should they be doing if they don’t feel prepared?
Tate: We’ve had an opportunity to meet with a number of the skilled nursing providers that we partner with, and that’s a common question that we’re approaching together. The real focus, to this point, has been to take a look at the current interdisciplinary team process and identify areas where improvement in that process will greatly benefit patient care and quality under PDPM.
For example, we see PDPM as a real opportunity. It’s an opportunity to emphasize evidence-based rehabilitation services that include comprehensive evaluations. And these evaluations are going to help our therapists develop quality treatments that are condition-specific, both in volume and in delivery type, and really result in patient-driven outcomes. So evaluations, not just by the three therapy disciplines, but by the physician, the nurses, the dietitians, the social workers — there are a number of important members of the interdisciplinary team who will all come together and perform comprehensive evaluations, and then get together quickly and have a discussion.
This isn’t so much a new process, but it’s reemphasizing a process that has been in the acute and post-acute space for a number of years. PDPM gives us an opportunity to really reemphasize the importance of the interdisciplinary process, the importance of quality, comprehensive evaluations, and then develop care protocols that are specific to the conditions that are being identified.
I’ve heard a lot about the importance of the interdisciplinary team when reporting on PDPM. Is that something that exists currently in most skilled nursing facilities?
Tate: We see some very good, strong interdisciplinary team processes, and we see some that have become over the years perhaps more truncated than they were prior to PPS.
Gourgues: There’s no doubt that the MDS has always been critical, but it becomes even more critical to get it right. And that is not obviously just the responsibility of the MDS coordinator, or assessment coordinator within the facility, but that entire interdisciplinary team. Essentially, the MDS doesn’t change a whole lot at all, but rather, the components of the MDS that are actually driving reimbursement obviously change, and we think rightfully so.
Should providers focus on hiring dedicated MDS coordinators and ICD-10 coders, or are these tasks that the interdisciplinary team can pick up?
Gourgues: The majority of the folks that we [work with] now have dedicated MDS assessment coordinators. More than ever, I think they are just planning to maybe even beef up those roles.
Tate: From the therapy side, as far as the earlier question: What are we doing to prepare? We believe that our PT, OT, and speech evaluators need to be prepared to evaluate the patient in all of their conditions, and be prepared to speak to all findings with the interdisciplinary team, and one of the ways that we’re preparing them is to help them be familiar — not only with the conditions and characteristics and diagnoses associated with the three case mix index scores for the three therapy disciplines — but to also be familiar with: What are the characteristics of a patient in the various nursing RUG levels?
Similarly, what are the characteristics that qualify for points within the non-therapy ancillary bucket? And as our therapists better understand how important it is to identify the entire patient, that really takes them right back to their foundation training, if you will, as evaluators.
Is PDPM prompting more providers to bring therapy in-house, or is demand for third-party services increasing?
Gourgues: One thing I can say is: My experience with PPS, 21 years ago, when PPS came around, is that folks looked at things a little differently. I guess the response is a little bit of both. We do find that people are looking for help, and they are looking for answers, and we are there to help our customers with those answers. But with PPS, folks sort of went in different directions, and then all came back to one place. And so I think that maybe a similar effect will happen now. A little bit of both. What would you say, Dave?
Tate: I feel like this is one of those topics where recency and primacy drives my opinion. The most recent conversations tend to dominate my current opinion. If you were to ask me this question four or five months ago, it seemed like a lot of providers in the space were talking about all the options, including: Maybe we should explore going in-house. In the last four to six weeks, what we’re hearing both from our partners and others in the space is that they’re looking for providers with expertise, with experience with large transitions, and those that have tools and pathways that will give them a sense of confidence around the quality and the volume of care being specific to the PDPM characteristics. So I can’t say that that’s where the industry is leaning, but that’s where the conversations that I’ve had recently are leaning.
Anything we haven’t touched on that you think is particularly important as we barrel toward PDPM?
Tate: We’ve referred to care pathways, and I’ve actually seen in a recent article from you about the importance of care pathways, and so I would just chime in as a second voice.
We decided early on that we needed to develop these clinical care pathways that are specific to the clinical categories as defined by PDPM, and the way we see that is that they’re guideposts, if you will. We’ve brought our clinicians together and included them in these conversations on how to develop these care pathways. They’re just so energized and excited about this opportunity, where their evaluations will help determine the level of care that the patients receive. Our care pathways are guideposts, and then within those guideposts, they can take patients who will benefit from more or less therapy and make determinations on the right level of care within those guideposts.
This interview has been condensed and edited for clarity.
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