Nursing Homes Can Disrupt ‘Rehabbed to Death’ Cycle With PDPM-Based Palliative Care

By Kristin Carroll

Skilled nursing facilities can leverage the Patient Driven Payment Model (PDPM) to provide more palliative care to people near the end of life, helping to drive value-based care goals while improving the patient experience.

However, much more needs to be done on the policy level to disrupt the current status quo, in which people commonly go through several care transitions near the end of life, driving up costs across the health care system while patients receive services that are not aligned with their own goals. Enabling concurrent SNF and hospice care is one change that could lead to improvement.

These are assertions in the recent article “Rehab and Death: Improving End-Of-Life Care for Medicare Skilled Nursing Facility Beneficiaries,” published in the Journal of the American Geriatrics Society. The authors explore potential remedies within PDPM and they propose policy changes to prevent patients being “rehabbed to death.”

“The PDPM offers an opportunity for palliative care to be considered a skilled need requiring nursing care when, for example, medications are adjusted frequently and require nurse monitoring. The payment model incentivizes and can reimburse SNFs for providing this type of care that is largely absent in the SNF setting,” the study authors wrote.

They called for the Centers for Medicare & Medicaid Services (CMS) to issue notifications to nursing home providers about how PDPM can be leveraged to improve end-of-life care in their facilities, and to educated Medicare Administrative Contractors (MACs) about the legitimacy of such billing.

Lead author Sarguni Singh, MD, Assistant Professor of Medicine University of Colorado School of Medicine and an American Political Science Association Health & Aging Policy Fellow, spoke with Skilled Nursing News to discuss the article’s implications for skilled nursing providers. The following has been edited for length and clarity.

What’s the importance of this article for SNFs?

SINGH: Skilled nursing facilities take care of really, really sick older adults who are coming to their facility to try to give rehab a shot to see if they can get stronger. And oftentimes, or a lot of times, that doesn’t work. I think this article provides opportunities for SNFs to improve care for that patient population at an individual facility level through strategies to use the Patient Driven Payment Model (PDPM) in slightly different ways than they might be using to get reimbursement for palliative care services provided.

On a larger scale, what information do we need at a federal level about how many people are using the SNF benefit at the end of life? And, if you were to move forward, what would a concurrent model of SNF care and hospice care look like?

It’s strategizing and learning more about the problem, and then trying to provide some solutions and ideas to get more information to try to improve care.

What are some key points from the article for providers?

SINGH: The PDPM has the opportunity to be used in different ways, particularly around palliative care delivery. It can be billed to provide nursing care, especially if medications are being adjusted frequently or people are being assessed frequently towards the end of life. This might not be ways in which the PDPM is currently being used, but there’s an opportunity within the existing payment model to get billed for palliative care services.

We are proposing a concurrent time limited test of the SNF benefit with hospice care. In our proposal, the first 20 days of care are provided where patients get SNF rehabilitation care, [and] they’re also supported by having iterative, value-based goals of care discussions. A lot of times people need that trial of the rehabilitation stay to get more information about their prognosis and their rehabilitation potential.

At the end of the 20 days if a patient and family want to continue on the SNF benefit, they could start incurring the copay like they would under the normal Medicare benefit. But if at that time, after 20 days, they say, “Look, I’ve gotten 20 days of rehab. I’m not improving. I’m actually feeling worse. I do want to transition to hospice,” then those discussions have already been happening. They could either transition to home with caregiving support, or continue to stay in a long-term care facility and pay room and board like they would under the Medicare hospice benefit.

You open the article with a story about Mr. Z, who bounces from SNF to hospital several times before finally transitioning to hospice and dying. How do SNFs help disrupt this cycle that commonly occurs?

SINGH: From a skilled nursing facility standpoint, I think it’s about having value-based goals of care discussions with patients and their families. It takes time, and it’s hard to do. Through education around palliative care principles and training about how to have serious illness conversations, providers can be better equipped to have these discussions with patients and families, and maybe patients then don’t automatically get sent back to the hospital.

Facilities can be aware that these patients exist, that it’s a national problem, and that educating their own staff and partnering with community palliative care agencies, hospice agencies and health care systems to deliver palliative care in the SNF space has huge potential to improve care and decrease healthcare utilization that is oftentimes unwanted for this patient population.

How should providers apply this article to their practice?

SINGH: This is kind of an advocacy article. From a clinical standpoint, as a SNF clinician, look at how they are delivering palliative care in their nursing home, and how they are billing for it, and see if there are opportunities within the PDPM that can provide them reimbursement for the care they are delivering. That’s probably the most clinically applicable part of this paper. The other aspects of this paper are more trying to shift policy towards helping facilities and hospitals take better care of these patients.

Why do you think SNFs aren’t fully embracing palliative care and hospice care under PDPM?

SINGH: I think it’s really, really hard. You know, it’s very easy for us to say you need to do X, Y or Z. We recognize that delivering palliative care is challenging. Having goals of care discussions is really challenging. It takes time, and providers are super overloaded and very overworked. So to sit down and have a 45-minute, hour-long conversation with a patient and family is really challenging, to carve out that time.

I also think it’s really hard when our culture is very much [sending the message], “There’s always one other thing we can do,” whether it’s another line of cancer treatment, another hospitalization, something is always being offered, and so it’s really hard to to change that clinical momentum and bring up ideas around palliative care and hospice.

I think the education and training that nursing facilities have around palliative care can also be augmented. There [are] not clear financial incentives to deliver this care. There aren’t really clear benchmarks around are [they] delivering good palliative care in the SNF setting, that they’re being graded on. I think all of these things kind of coalesce together to limit the amount of palliative care in this space.

SNN: What, in your opinion, is the biggest barrier to adopting hospice and palliative care in the skilled nursing space?

SINGH: I think the biggest barrier is stigma. There is a stigma around palliative care itself. Any time you mention palliative care, a lot of patients and families think it’s hospice care and end of life care. It’s not.

Nursing homes themselves have a lot of stigma that they face. Patients go from an acute care hospital – where they’re intensely monitored by a variety of teams – to a nursing home. Oftentimes [there are] biases around how good nursing homes are. I think that if something goes wrong in the facility, patients and families can advocate to just be sent back to the hospital when facilities might be equipped and might be able to actually provide care in the facility setting.

So it’s the stigma around palliative care and the stigma around the care that nursing homes deliver that are pretty significant barriers, along with the regulatory and financial disincentives I mentioned earlier.

Anything else you want to share?

SINGH: If you do design a model where you’re providing SNF rehab and hospice care, we want to make sure that patients and families aren’t unintentionally being forced or pushed into hospice against their will. That’s a big, big deal, because we want to provide value-based care. An unintended consequence of this model could be that people use palliative care excessively, or that patients and families aren’t choosing hospice when they’re ready.

We talk about the Liverpool Care Pathway for the Dying in our paper, which [has been suspended in the U.K.] and is essentially where hospitals get people into hospice and end of life care for financial gain. I think that’s really important to point out that we do need to make sure we have key palliative care process and outcome measures to test this model, to make sure that patients and families are getting care that aligns with their values. Especially with nursing home ownership and concerns about private equity in that space, it’s a really important part of this proposed model.