Are you playing PDPM whac-a-mole?

On October 1, 2019 a monumental Medicare regulatory change was implemented. The federally mandated “Patient-Driven Payment Model” (PDPM) is having massive impacts on how nursing homes get reimbursed for care provided to their residents. It was designed to reward nursing home operators for providing patients the highest quality of care, instead of calculating reimbursements based on the amount of therapy minutes delivered. There has been a lot of anticipation and trepidation along with a tremendous amount of preparation, and with only a week under their belts, I reached out to some of the MDS leaders in the trenches for some early feedback on the changes.

There was across the board agreement that the communication on PDPM was comprehensive and that preparation and training was an absolute necessity. Training of all kinds was offered, and MDS professionals reported having taken some form of training (in-house, webinars, off-site, etc.), even multiple training sessions, and felt prepared. However, even early on, some of the most trained nurses felt caught off guard, primarily on the downstream impacts of the changes. For example, new demands are being made of the MDS teams to provide leadership with preliminary financial projections. Additionally, leadership is seeking to report early “wins” up to their executive team, so on top of all the changes, the unexpected executive pressure appears to be rolling downhill.

Support from leadership has varied greatly between organizations, but most surprisingly between buildings in larger long-term care (LTC) groups. So, while executive support may be in place, for this to be a smooth transition, the Administrators and Directors of Nursing (DONs) need to be on the same page. It seems as though the DONs set the tone for the building; those that drove buy-in and education through all staff levels are seeing the most success, while those that left the responsibility primarily with the MDS Coordinator are struggling now to get necessary documentation from staff and are scrambling now to train them. In some cases, the onus has been placed on the MDS Coordinator(s) to develop and provide this education to them. This additional pressure could have tremendous impacts on the morale of the MDS leaders in the organization.

To quote an accomplished MDS Director of over 15 years from New Jersey, “It’s not easy.” An initial challenge has been dealing with misconceptions that PDPM will lessen the MDS Coordinators’ workload because of the elimination of the 14d, 30d, and OMRA MDSs. MDS personal are actually finding that in addition to their traditional role, they need to take on a sort of “case manager” function, as they have to dissect the hospital record prior to admission to ensure skilled services are captured.

In one short week, some other immediate impacts have been realized and MDS Coordinators are responding nimbly; new processes are being developed/implemented and new daily skilled meetings are taking place. These huddles are to review the primary diagnosis/MDS section GG documentation/skilled progress note documentation in near real time and also to talk about the best assessment reference date (ARD) for new admissions who have been admitted as of October. Whatever the situation, organizations are realizing the need for fluidity in response to the changing environment.

Most nurses are not reporting any other huge surprises, other than the EMR and rehabilitation department software glitches and transmission issues with the CMS. There have been some surprisingly early staffing reductions fueled by the expected decreased reimbursements related to rehabilitation services, so this is very likely to have an impact on patient experience and outcomes, but it is still too early to say.

All in all, PDPM appears to be going well. All involved seem to realize it will require critical thinking at all levels of the organization. The design should enhance patient outcomes, but change can be shocking and most unwelcome. So, while some report it seems like a cruel game of whac-a-mole right now, all agree that these early kinks will work themselves out.