As we approach the 2-year mark of PDPM implementation, it is important to review where your facility stands today compared to pre PDPM, in terms of therapy services as well as clinical outcomes and the drivers behind any changes. When PDPM was implemented, reimbursement shifted from primarily a therapy driven model based on the volume of services delivered, to patient characteristic driven reimbursement, where therapy minutes no longer played a role in reimbursement. There was much speculation regarding how the delivery of therapy services might change. There were many reports of major therapy contract providers laying off staff post PDPM which led to concerns regarding how this would impact the therapy services that patients were receiving. The patients had not changed at this point so an obvious conclusion one could make is that these layoffs were driven by an anticipated change in how therapy services would be delivered. CMS recently reported that the average number of therapy minutes delivered to a patient per day decreased for MCA patients from 91 to 62 minutes per day immediately post PDPM. At the same time, they saw concurrent and group therapy initially increase from approximately 1% to approximate 32% and 29% respectively. These numbers have since dropped to 8% and 4% respectively with the PHE declaration. It is important to note that with the implementation of PDPM, CMS stated: “We believe that financial motives should not override the clinical judgement of a therapist or therapy assistant to provide less than appropriate therapy, and we will continue to monitor these and other metrics to identify any adverse trends accompanying the implementation of PDPM.”
As a Nursing Home Leader, it is crucial to ask yourself how your facility would fair in the event of an investigation into the practices of your therapy department post PDPM. We recommend that you start by asking the following questions:
1.) Has your therapy utilization changed? This is relatively easy to determine by reviewing what the average number of minutes a patient received daily were prior to PDPM and what they are today post PDPM. Therapy services should be provided based on the assessment of the individual patient’s needs. You want to look for trends regarding the delivery of services to determine if therapy minutes a patient is receiving are need driven versus reimbursement driven and evaluate with your therapy provider any reasons why these trend patterns may have shifted since the initiation of PDPM.
2.) Has there been any change in your clinical outcomes related to therapy post PDPM? Unless you have seen a significant change in your patient characteristics, it would be expected that your facilities clinical outcomes have remained consistent. If your facility saw a significant change in minutes along with a decline in outcomes this should definitely warrant concern and further investigation on your facility’s part.
3.) Would your facility’s therapy documentation hold up under the scrutiny of an audit? It is important to note that the skilling criteria did not change with the implementation of PDPM. Therapy documentation must support that the services that were provided were at a level of complexity that requires the skills, judgement, and knowledge of a licensed therapist to safely and effectively carry out and that the services delivered were reasonable and necessary in relation to patient’s illness/injury. This includes that the services were delivered at a duration and quantity that was appropriate for the patient’s needs and accepted standards of practice. Documentation must also support the justification for use of group and/or concurrent including benefits to patient and how this mode of service delivery supports achieving that patient’s individual goals.
This being said, it is important for leaders to be prepared to answer these questions. The time for understanding is now so that you can ensure that your residents are receiving the appropriate levels of care to meet their needs and avoid the potential regulatory risk associated with potential decreases in care delivery where it is not clinically warranted.