Why Signature Believes 18 Months of PDPM Prep Will Pay Off

The first round of earnings calls these past two weeks revealed few firm outcomes related to the new Medicare payment model for nursing homes, but one provider was identified as potentially ahead of the curve: Signature HealthCARE.

Omega Healthcare Investors (NYSE: OHI) chief investment officer Robert Stephenson on Wednesday praised Signature, one of its tenants, for having the potential for both revenue and expense upsides under the Patient-Driven Payment Model.

In particular, analysts on the call focused on Signature’s extensive prep work, while Stephenson also speculated that the company had already moved toward a more patient-centered model in the wake of a $30 million payment back in 2018 to settle allegations of improper therapy provision — charges the provider still denies.


SNN spoke to Mark Wortley, CEO of Signature Rehab — the operator’s rehab and therapy segment — on Thursday to find out why Omega seemed so upbeat about Signature’s PDPM prospects, as well as any early challenges the company has faced.

How is PDPM currently shaping the clinical care at Signature?

As a physical therapist, I’m excited that PDPM is patient-focused, and nursing is going to get the focus it needs to have in a skilled nursing facility. Therapists have a very important role, and still do as a team member as part of our interdisciplinary team. I’m excited and glad that nursing needs will primarily drive reimbursement.

What were some initial responses to PDPM in the industry to note from your perspective?

In the press early on, I saw some draconian approaches to layoffs, and walking therapists out on September 30, and some people mandating group and concurrent therapy. Those kinds of things concern me as part of the industry, because CMS paints with a broad brush — and then you see bad actors that overreact, which can have a negative impact on more than just themselves.


How did Signature change its therapy practices pre-PDPM, post-settlement?

I appreciate the shout-out from Omega, but in truth, the settlement played a small role in our preparation for PDPM. We didn’t agree there was any wrongdoing, but we did put more training and oversight into place — although we didn’t drastically retrain our therapy provision.

What clinical and billing practices did you update at the time, and what are you currently doing to remain diligent and successful with PDPM?

A year ago we formed an Agile [a management and training methodology] team for an interdisciplinary, laser-focused, multifaceted approach to prepare Signature for the payment reforms. The team, run by Deb Brunet, our CFO, and Christine Busby, VP of care coordination, led the clinical reimbursement MDS process and the clinical support at Signature.

To clarify, our training and preparation was not just for a rehab-focused group; the sub-committees included nursing, clinical reimbursement and MDS, and a technology and therapy subcommittee. Each sub-committee was tasked with an individual domain to get ready, with Christine and Deb coordinating the overall effort.

What specific initiatives were created to prepare for PDPM?

We conducted a five-facility pilot for 18 months with software that enabled us to measure how facilities were performing with the prior RUGs model, and how it would perform with PDPM in the future.

As we went through that over 18 months, we could provide laser-focused training on appropriate coding, and monitored performance. We were “live” under the prior payment system, while still complying with RUG-based requirements — and then simulated how they would perform if they were under PDPM.

In terms of more extensive training, we took every facility administrator across the organization and brought them to our home office in Kentucky, and spent half a day with them to do PDPM preparation training.

Believe it or not, we had them complete the MDS and code a made-up patient into the proper PDPM category. We simulated the process, and the administrators understood the need for data, proper coding, and the complexity involved. It was a great training experience and instead of watching a PowerPoint, they were here with a hands-on and deep-dive experience.

In addition to working with administrators, we did a road show and training for every facility MDS nurse, in a face-to-face [setting], for a day and a half. We have 115 facilities, so there were at least 300 nurses present. The MDS nurses need to complete the MDS, and we walked them through potential admission, to how to capture and code the first MDS appropriately — as well as discerning the criteria for IPA, the interim payment assessment, and what you need to capture on discharge. We covered, from A to Z, defining MDS’s role in the PDPM payment system.

What were and may continue to be some of the challenge areas in training and execution?

One of the challenges was probably getting the most appropriate data from the hospital referral source. You can’t code what you don’t know, and this is not a Signature-specific challenge.

For PDPM, it’s necessary to get a proper profile of that patient to get them in the appropriate payment category for initial coding. There are 28,800 potential categories in PDPM, so obviously it’s very important to capture appropriate data upfront in the initial MDS, which determines your payment for the stay – unless the patient has a significant change in condition, or what I call a sentinel event. [Then] you do what’s called an IPA, the interim payment assessment. You only do an IPA if there is a significant change in the patient’s condition.

We also provided training for every therapy operation and clinical leader. We did more generalized nursing training — and generally administrators, MDS nurses, and therapy teams were the deepest dives.

What kind of changes were made from individual to group and concurrent therapy?

I’m a physical therapist, and have personal experience with group and concurrent therapy.

They are great for patient outcomes, and more fun and engaging for our patients. With that being said, we’ll never mandate group and concurrent therapy, and share best practices as they emerge. It is always at discretion and professional judgment of the therapist.

We had to provide more education to the therapists with less than 10 years’ experience, because they typically would not have worked with those approaches in their career yet. The therapists who had been around longer were excited and looking forward to the group setting.

We’ve done an initial round of training for new therapists, and once our best practices are identified, we’ll continue to get the newer therapists up to speed.

How do you identify best practices for group and concurrent therapy?

Defining best practices is something we do on an ongoing basis. We identify the best practice in the field, and utilize our therapy leadership to package in-training modules to share with our training curriculum.

Group and concurrent therapy isn’t a one-size-fits-all approach. If you have a smaller patient volume, there’s less opportunity to apply that approach than a larger one. We don’t use a cookie-cutter method at Signature because that’s not patient centered.

I am pleased that CMS has acknowledged … that patients can also benefit from psychosocial aspects of groups as well. It’s great to see CMS recognize the clinical benefit and not just a cost savings measure.

Have you seen increased reimbursements in group and concurrent therapy after PDPM?

It’s still too early to tell, but we are confident that the training will be a worthwhile investment.

When do you think we’ll see the first set of financial and patient outcomes data?

I think we will start seeing some trends in the fourth quarter, but overall by the first quarter of 2020 is when we should have a good idea.

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