Nursing Home Dialysis Demand Drives Post-PDPM Push to Specialty Services

Dialysis services have recently been highlighted as a major growth area under the new Patient Driven Payment Model (PDPM) — both financially and clinically — especially as reimbursements are recalibrated for higher acuity patients.

In July, the Centers for Medicare & Medicaid Services (CMS) rolled out the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) model, a plan that would increase dialysis treatment reimbursements.

Operators and third-party dialysis companies have diligently prepared for both payment shifts, with technological innovations involving upgraded bedside dialysis units and increased staffing and training to help partners provide improved care for residents.

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Concerto Renal Services. for example, announced it that it’s currently in the fourth of six consecutive weeks of new unit openings, welcoming Bella Terra Morton Grove in Illinois as the latest of Concerto’s SNF dialysis partnerships.

On the heels of these increased partnerships, Concerto chief executive officer Shimmy Meystel described an uptick in higher acuity skilled nursing partners throughout the calendar year 2019, as well as just a few months into PDPM.

“Most of our operator partners have been preparing for PDPM for some time, which has meant reorienting many of its internal processes the last year to better prepare its staff and systems for higher acuities,” Meystel said. “We’re along for the ride in that respect, as our partners depend on us to assist them with the transition.”

Josh Rothenberg, CEO of the Neptune Township, N.J.-based Dialyze Direct, and one of its skilled nursing partners — Mark Friedman, CEO and founder of Eastbrook Health in Cleveland — also recently sat down with SNN to describe their shared dialysis plans.

Eastbrook Health began working with Dialyze Direct a year and a half ago to begin shifting to higher-acuity patients in preparation for PDPM.

Today, it looks like the prep work is starting to pay off.

Dialyze Direct provides the in-house dialysis machines and staff for Eastbrook Health, a 99-bed facility with 10 to 20 beds dedicated to skilled services.

“We have seen a significant decrease in rehospitalizations for our dialysis residents due to the fact that they are dialyzed in-house. Now residents can function 30 minutes after dialysis, they can go back, and they can do rehab and continue functioning throughout the day as opposed to coming back from a five-hour session and then being pretty much done for the day, as they just would go to bed because they’re worn out,” Friedman said.

Friedman also noted an upgrade in the facility’s ventilator systems, which enables Eastbrook to treat ventilated residents with data in real time, helping to decrease rehospitalizations post-PDPM.

“The facility that we took over was originally a lower-acuity building,” Friedman said. “Being set up for higher-acuity individuals helped position us for PDPM. We also opened the vent unit and with Dialyze Direct, we can now offer bedside dialysis as well,” Friedman said.

Dialyze Direct, which provides home hemodialysis on-site in SNFs — including equipment, training, and caregivers — has seen a major uptick in requests from nursing homes seeking partnership “so that we can come in and provide our care,” Rothenberg said.

Although Dialyze Direct is beginning to expand its dialysis programs into the home, their core business has their staff providing home dialysis in the institutional setting.

“They have their caregiver, they care for the patients between the treatments, and we make sure there’s a true coordination of care that will provide the results we need,” Rothenberg said.

Both CEOs pointed to increased revenue potential under PDPM.

“PDPM shifted the focus to be able to treat more acute patients — and people definitely pick up on it. We see that from talking to our partners in the nursing home, and we find that if they if they list the correct comorbidities and acuity of the patients, they will see an uptick in revenue for a few hundred dollars a day,” Rothenberg said. “So this has become a very important for them.”

Rothenberg added that this quarter, his company has seen significantly higher requests from nursing homes as they are becoming more educated under PDPM.

“It’s definitely increased although it’s not something that can give an exact percentage right now,” Rothberg said.

Clinically speaking, dialysis removes uremic toxins and excess fluid from the body. Past strategies for dialysis included an “artificial schedule of three days a week” in order to address more patients at a time, and worked in three-day shifts,” Rothenberg explained. Although old models of dialysis enabled treatment to more patients, there were side effects — with blood pressure issues, incremental damage to the heart, and gut problems, he said.

Additionally, patients that went on dialysis in a very short amount of time were forced to have as much fluid removed as possible, which was an aggressive treatment. This new kind of slower and gentler treatment with a “next stage” machine allows more frequent dialysis over five days.

“This is very beneficial to patients — especially elderly patients that have multiple co-morbidities because it allows the body to really try to rehabilitate — as opposed to recover from an aggressive dialysis. There are millions of treatments done this way, and the major studies point to this, and that’s part of the push that you see from the Trump administration for the push to home dialysis in recent years,” Rothenberg said.

Friedman suggested that when you incorporate a specialty like dialysis, “you can go out there and market it as opposed to just being a building that takes everything.”

Rothenberg suggested that local hospitals are now more attuned to building an increased referral relationship with buildings that can handle the harder and more complex cases. Under PDPM, “they’re moving more from the rehab, just pure walkie-talkie rehab or knee surgery or hip surgery, to see programs that can handle more acuity. Dialysis is definitely up on this list,” Rothenberg said, and also suggested that dialysis is also being attached to other services such as vents and wound care.

In terms of processes needing ironing out under PDPM, both companies take specific precautions and care to ensure proper coding for appropriate reimbursements.

Rothenberg said Dialyze Direct works hand-in-hand with its nursing home partners to best communicate the right diagnosis for particular patients, and his team disseminates the correct diagnosis for these patients.

Eastbrook Health ensures that every patient is submitted at the end of the month, Friedman said, and then combs through the data thoroughly with PointClickCare and another systems to see if anything has been missed.

“You could have coded something incorrectly. So it’s really up to everyone to be thorough and make sure that everything is everybody’s on the same page,” Friedman said.

He added that staff need to meet in an interdisciplinary way in case “somebody may have noticed something with a resident that another department may have not. And that could be a crucial change, which can knock you up to up to the next category.”

Under the old system, when a patient needed more therapy, they would simply be reimbursed more. Now that reimbursement is more tied to nursing, Rothenberg said, the opportunities for proper payments have expanded.

“So when somebody has COPD and other comorbidities, that’s something that can now push them to a higher level — as opposed to the old system that was more related to how much therapy you were getting,” Rothenberg said.

Friedman suggested a prime example of a patient who could once move around and fully function, but just needed light rehab on an arm or leg. In the past, they could have received the highest category of rehab, and facility would have been reimbursed for a significant amount. Someone who was too ill to receive much therapy would have received a much lower rate —which may not have been commensurate with the actual treatment performed.

“Obviously, you’re spending a lot more time on [that] and that’s something that’s been corrected in this in this model — where it’s not just based on getting them a certain amount of therapy, it’s more focused on their daily living and what kind of nursing skills are needed to take care of them,” he said.

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