The PDPM Journey: Implementation, Adaptation, and Future of Value-Based Care for Therapists

Editor's note: This text-based course is a transcript of the webinar, The PDPM Journey: Implementation, Adaptation, and Future of Value-Based Care for Therapists, presented by Kevin Cezat, PT, DPT, GCS, RAC-CT.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to list three or more patient-driven payment model (PDPM) Clinical Categories.
• After this course, participants will be able to list two or more changes to PDPM effective 10/1/24.
• After this course, participants will be able to list two or more impacts on therapy delivery models post-PDPM transition.

Introduction

I’m happy to be here and ready to dive into the presentation. I want to note that obtaining permission for media, images, videos, and other elements to be included in presentations can sometimes be challenging. I realize these visuals make presentations more engaging, so if you learn better with visual aids, I suggest keeping a Google window open or using your phone to look things up as we go. That way, you can explore it in real time if you’d like to see or clarify something visually.

I commend you if you’re here as a therapist working directly with patients. This may not be a topic that your average clinician is excited to dive into, especially regarding regulatory and reimbursement systems. However, I’ve seen firsthand how valuable it can be when clinicians understand the "why" behind what we do. It’s easy to focus solely on treating patients—and of course, that’s the most important thing—but a lot is happening behind the scenes that directly impacts our care.

Before we get into the content, I want to share some background about myself because I think it’s helpful to know more specifically where my perspective comes from, especially when I share opinions or statements throughout this presentation. I’ve spent my entire career—about 15 years now—in some form of long-term care, exclusively working with older adults. This includes skilled nursing facilities, assisted living, independent living, and home health. I was a staff clinician focused on direct patient care for many years. I later transitioned to a rehab director role, where I served for several years before moving into my current position. Currently, I oversee clinical quality education across numerous facilities nationwide.

I’m currently licensed and primarily treat in Florida, though I also provide some treatment in Arizona and Ohio. These days, I only treat about five hours a week, significantly less than I used to. Most of my time is spent on the bigger picture, focusing on clinical quality and program development. My background and biases are tied to skilled nursing facilities, where most of my experience lies. While today’s discussion is largely centered on skilled nursing, much of what we’ll cover is relevant to long-term care.

Definitions

Let’s quickly review some key definitions to ensure everyone has a general understanding before we dive deeper into the content.

CMS refers to the Centers for Medicare and Medicaid Services. Managed care encompasses various systems to control costs and improve quality by managing access to care, often through models like HMOs or PPOs. In long-term care, we often encounter Medicare Advantage plans.

Case mix and HIPPS codes are related concepts we’ll touch on frequently today. Case mix is part of the PDPM payment system, aligning payments with the expected level of care and services based on diagnostic categories. HIPPS codes are a ranking system used by insurance companies to calculate payments, often displayed as two-letter abbreviations like TN, SH, NE, CB, and so on.

QAPI, which stands for Quality Assurance and Performance Improvement, is a federally required program in skilled nursing facilities. It uses data-driven approaches to address quality management through assurance and improvement. Typically, facilities hold monthly QAPI meetings, and therapy teams are often involved or should be.

The CASPER report, which stands for Certification and Survey Provider Enhanced Reporting system, provides detailed insights into care quality at skilled nursing facilities. It includes approximately 15 quality measures over a specified look-back period. If you work in long-term care and are unfamiliar with CASPER, it’s worth becoming familiar with this tool.

The MDS, or Minimum Data Set, is a standardized, federally mandated assessment required for nursing home residents in both subacute rehab and long-term care settings. The RAI, or Resident Assessment Instrument, includes the MDS and additional components like Care Area Assessments (CAAs) and utilization guidelines, which provide detailed instructions for completing the MDS. This process is designed to gather specific care information to create individualized and best-practice plans of care. We’ll spend time discussing section GG and other MDS sections in detail today.

Now for a few value-based care definitions. The QRP, or Quality Reporting Program, is a pay-for-reporting system requiring facilities to provide specific information through the MDS. Incomplete or missing data can lead to financial penalties. Value-Based Purchasing (VBP) rewards skilled nursing facilities that perform well in specific categories with incentive payments. This program is already in effect.

The Five-Star Quality Rating System is a public report card summarizing facility performance in areas like health inspections, staffing measures, and quality measures. It’s available online and helps guide consumers in choosing care providers. You can visit Nursing Home Compare or Care Compare to look up your facility’s ratings and see how it compares nationally and within your state.

With these definitions in mind, we’re ready to move forward with the content.

Evolution of CMS Payment Structure

Now, let's discuss payment structure—everyone’s favorite topic. Before we discuss where we currently stand with Medicare reimbursement, I think it’s important to take a step back and review where we’ve come from and how things have evolved over time.

CMS Evolution

So, starting in 1966, Medicare was implemented, enrolling about 19 million people. One of the next significant changes came in 1973 with the passage of the HMO Act. This legislation allowed the Department of Health to provide startup grants and loans to develop HMO organizations, provided they met specific federal guidelines.

The term HMO, which falls under the managed care model, evokes various experiences depending on who you ask. The HMO Act itself was an interesting concept at the time, stemming from the ideas of President Nixon and Dr. Paul Ellwood. Dr. Ellwood, a pediatric neurologist in the late 1960s, retired from practice and dedicated himself to reforming national healthcare. His concept was to improve the quality of care while simultaneously reducing costs. He envisioned large nonprofit organizations competing for patients by offering the best care at the lowest cost, focusing on preventive care like regular physical exams, well-baby checkups, mammograms, immunizations, and more. The goal was to keep people healthier and save money in the long run.

Dr. Ellwood’s chance meeting with a Nixon official on an airplane helped bring this concept to the forefront of Nixon’s national policy. The idea was to provide consumers with a broader choice of health plans, stimulate competition in the marketplace, and ultimately improve the quality of care while reducing costs. While HMOs have developed a complex legacy over time, the initial intention made a lot of sense.

In 1977, the Healthcare Financing Administration, which we now know as CMS (Centers for Medicare and Medicaid Services), was created. At that time, Medicare operated under a cost-based system, which led to escalating spending and challenges in controlling costs. By the late 1990s, it was clear that reforms were necessary to address these issues.

The Balanced Budget Act of 1997 introduced the Prospective Payment System (PPS) to curb rising expenses, implemented in 1998. Under this system, fixed daily rates replaced the older cost-based system. Payments were determined based on Resource Utilization Groups (RUGs), which evolved several times in the following years. In 2003, the Medicare Modernization Act refined the RUGs categories and updated payment structures, adding a mechanism to account for inflation and other economic factors.

In 2010, further changes came with implementing the RUG-IV system, which I started with as a clinician. This period saw the introduction of initiatives aimed at improving care quality, including the Value-Based Purchasing Program and other programs centered on care provided in skilled nursing facilities.

Problems With PPS

The Prospective Payment System (PPS) was implemented in 1998, with RUG-IV introduced in 2003. Under this system, the amount of therapy provided directly correlated with the highest financial return, creating incentives to deliver the maximum therapy levels and extend lengths of stay regardless of the patient’s presentation or outcomes.

This misaligned incentive structure led to a significant increase in the number of skilled nursing facility (SNF) days where high levels of therapy were provided. The percentage of cases in these higher therapy categories grew from 29% to 82%, with a notable rise in the use of ultra-high therapy, although not as pronounced as the basic high group. This escalation in therapy provision drove costs upward. Importantly, this increase occurred without any corresponding rise in patient acuity levels, raising concerns within Medicare.

Additionally, the system lacked penalties for keeping patients the full 100-day maximum allowed under Medicare Part A benefits. As a result, there was a steady increase in residents reaching the full benefit limit. While this system created a boom for therapy jobs and generated significant revenue within the industry, it also came with drawbacks that arguably devalued the therapy profession. This led to a stigma surrounding the SNF setting and its practice patterns.

I often pose this question to others: if you had to identify the setting within physical therapy that provides the highest clinical quality—defined by outcomes per dollar, outcomes per time, or adherence to best practices—how many would point to long-term care? Likely very few, particularly over the past 15 years. I believe this perception is largely due to the RUGs system, which distanced therapy from measurable outcomes.

When therapy is delivered at the highest volume and for the longest duration across the board, regardless of individual patient needs, it dilutes the connection between therapy and outcomes. Studies during that time revealed little correlation between the amount of therapy provided and patient improvement. This led to misguided conclusions that therapy might not significantly impact recovery—a notion we know to be false.

The system’s design obscured the true relationship between therapy and outcomes. Therapy absolutely impacts recovery and both the quantity and quality of care matter. Unfortunately, the structure of RUGs impaired our ability to demonstrate this, and the resulting stigma has left a lasting impact that we are still working to overcome.

PDPM

That brings us to 2019—it’s been five years already—when the Patient-Driven Payment Model (PDPM) was introduced. This system replaced the RUG and PPS systems with a model focused on the patient's clinical characteristics and perceived needs rather than the volume of services provided. The goal was to improve payment accuracy and incentivize quality of care over quantity. On paper, it made perfect sense.

Transitioning to PDPM was a significant shift in terms of the system itself and the mindset required to implement it. The RUG system had been in place for so long that most people understood how it worked, including its limitations and how to maximize returns. Naturally, the announcement of PDPM caused concern across the industry. It was a huge adjustment for facilities and therapy teams, and the transition was no small task.

I can share a bit of personal experience here. PDPM is actually what allowed me to step into a rehab director role. At the time, I’d been a staff clinician for about seven or eight years. When my rehab director saw the changes PDPM would bring and realized the extent of the shift, he decided it was time to retire. He didn’t want to deal with the transition, so I got my shot as a rehab director about six months before PDPM went into effect.

It was quite the transition, and it was definitely nerve-wracking. Many clinicians were deeply concerned about how the changes would impact the profession, and for good reason. We’ll discuss those impacts in more detail shortly.

Transition from RUGS IV to PDPM

A lot goes into PDPM, but I’ve distilled it down to what I think are the most significant takeaways, particularly for physical therapists. I’ve broken it into these three key items.

Key PDPM Changes

One significant change under PDPM was the removal of penalties for using group and concurrent therapy. Under PPS, there were financial restrictions that discouraged the use of group and concurrent therapy, which is why it wasn’t commonly utilized. With PDPM, group and concurrent therapy are reimbursed the same as individual therapy. However, there is still a cap—no more than 25% of the total therapy minutes per discipline, per patient, in a covered stay can be provided through group or concurrent sessions.

Another key change is the shift to a patient-specific reimbursement rate. Unlike the previous system, reimbursement is no longer tied to the volume of therapy provided. Whether a patient receives 100 minutes, 200 minutes, or 15 minutes of therapy daily, the reimbursement rate remains the same.

Additionally, PDPM introduced reduced payments based on the length of stay. After day 20, the per diem reimbursement rate steadily declines, creating financial incentives to manage stays efficiently while focusing on patient outcomes.

Calculating Group/Concurrent Therapy Limit

Let's break down the 25% limit with an example to review. Suppose you provided 2,000 individual PT minutes, 600 concurrent PT minutes, and 1,000 group PT minutes during a stay. Adding these together gives a total of 3,600 minutes. Out of those, 1,600 minutes were group and concurrent combined.

To calculate the percentage, divide 1,600 by 3,600, which equals 0.44 or 44%. This means 44% of the total therapy minutes were provided under a group or concurrent format for PT, exceeding the 25% limit.

If this happens, the facility receives a non-compliant warning message indicating the group limit has been exceeded. As of now, there is no official penalty for this non-compliance. However, if a facility consistently exceeds the 25% threshold, it could trigger a more detailed audit. At present, exceeding this threshold results only in an error on the validation report, with no direct penalties. It’s worth noting that CMS may continue to evaluate compliance trends and potentially introduce penalties in the future, though none are in place, to my knowledge.

Payment Under PDPM

I know everyone is excited to delve into the payment aspect of PDPM, and it might seem like the intent was to simplify the process compared to PPS. After all, you no longer have to deal with levels or ARDs, so theoretically, it should be easier. However, that’s not the reality. The payment model under PDPM is significantly more complex than under PPS.

The numbers alone tell the story. Under the PPS RUG system, there were about 66 possible Medicare payment rates. With PDPM, that number skyrocketed to over 28,000 possible rates. This complexity has made the role of the MDS coordinator even more critical. Not only is completing the process correctly a challenge but doing so without leaving money on the table—or trying to maximize it—adds another layer of difficulty. One of the toughest issues I see across the industry is maintaining stability and high levels of expertise in the MDS coordinator role. It’s a very challenging position.

Accurate assessment coding plays a huge part in this. MDS coordinators must handle over 150 items, often with limited time to ensure all items are completed accurately and within the appropriate time windows. It’s a tall order, and the accuracy of these assessments directly impacts reimbursement.

Let’s break down how payments are calculated under PDPM. Your daily rate is derived from six components, five of which are case-mix adjusted based on patient presentation. These are:

• PT component
• OT component
• Speech component
• NTA (non-therapy ancillary) component
• Nursing component

The sixth component, which is not case-mix adjusted, covers general SNF resources that should not vary based on patient characteristics. This includes general room and board, capital costs, and overhead. Together, these six components determine the daily reimbursement rate.

PT/OT Component

Each component—PT, OT, speech, and so on—is multiplied by a case-mix index determined by the patient’s case-mix group. This index is then wage-adjusted and further modified by a variable per diem rate, which decreases over time to discourage excessively long lengths of stay. Reviewing these adjustments, the maximum rate is applied for days 1 to 20 (a factor of 1.0), and then it steadily decreases: 98% for days 21 to 27 and down to 76% by the last few days of a maximum-length stay. This structure incentivizes efficient care and shorter stays.

Let’s walk through an example calculation to understand the process. Imagine a hip replacement patient. First, their principal diagnosis places them in the major joint replacement clinical category. Next, we calculate their PT/OT functional score, which is derived from:

• Eating performance
• Oral hygiene
• Toileting hygiene
• Bed mobility (average of types)
• Transfers (average of types)
• Walking (average of distances)

Coding follows a specific scale:

• 05/06 (independent or setup) = 4 points
• Supervision = 3 points
• Partial assist = 2 points
• Substantial/max assist = 1 point
• Did not occur = 0 points

Here’s an example for this patient:

• Eating: Independent (06) = 4 points
• Oral hygiene: Setup (05) = 4 points
• Toileting hygiene: Moderate assist = 2 points
• Bed mobility: Moderate assist for both types = 2 points
• Transfers: Moderate to max assist, averaging 1.66, rounded to 2 points
• Walking: Able to walk 50 feet with turns, but not 150 feet = 1 point

Adding these gives a total PT/OT functional score of 15.

Next, referencing the patient’s clinical category (major joint replacement) and functional score (15) on the PDPM grid, the case-mix group is TC, with a PT case-mix index of 1.88 and an OT case-mix index of 1.69.

What’s interesting is how these metrics are broken down. Some case-mix categories favor PT more, while others favor OT. Nursing and NTA categories are not shown here, but their interplay adds complexity. This makes it difficult to manipulate the system to maximize rates artificially. The complexity of these calculations and categories has made it challenging to game the system effectively. As a result, most facilities focus on accurately coding based on patient presentation and let the reimbursement rates align naturally. This approach seems to align with the intent of the PDPM system.

PDPM Rate Formula

Let’s compile the base numbers for a hip replacement patient with a functional score of 15, focusing on PT and OT as examples. For simplicity, we’ll assume some values for the other categories.

For PT:

• Case-Mix Index (CMI): 1.88 (based on the clinical category and functional score)
• Base Rate: [Assumed value specific to PT]
• Variable Per Diem (VPD) Adjustment: The adjustment factor for days 1–20 is 1.0, meaning there’s no reduction.
• The calculated amount represents the facility's reimbursement for the PT portion each day during this period, regardless of whether PT is actively involved in the case.

For OT:

• Case-Mix Index (CMI): 1.69 (based on the clinical category and functional score)
• Base Rate: [Assumed value specific to OT]
• Variable Per Diem Adjustment: The adjustment factor is 1.0 for days 1–20.

For the other components like SLP, nursing, and NTA:

• Base Rates and CMIs: Assumed values are calculated similarly to PT and OT but are based on different factors like speech-language needs or non-therapy ancillary requirements.

For the non-case-mix adjusted component:

• Base Rate: This remains fixed, covering resources like room, board, and overhead that don’t vary by patient characteristics.

When you combine these components, the facility is reimbursed a specific daily rate for the first 20 days to cover all patient care—nursing, therapy, and other services—regardless of the services provided. Beyond 20 days, the variable per diem adjustment reduces the daily rate incrementally, aligning with the system’s intent to de-incentivize excessively long stays.

While this calculation process can be overwhelming, especially when considering the interplay of all components, it’s valuable to see how reimbursement is derived. These calculations depend heavily on accurate coding within the Minimum Data Set (MDS), underscoring the importance of precision in completing the assessment.

MDS Changes Under PDPM

The MDS underwent significant changes under PDPM, but today we’ll primarily focus on the more recent updates.

To provide some background, the MDS originated from the Omnibus Budget Reconciliation Act of 1987, which pushed for standardized assessments across care settings. CMS began using the MDS in 1991 to track data and improve care quality in skilled nursing facilities. As discussed earlier, the MDS is a comprehensive assessment required for all skilled and non-skilled residents in facilities that accept Medicare or Medicaid. Its purpose is multifaceted: guiding care planning, influencing quality measures, and directly impacting reimbursement calculations and value-based programming decisions.

The MDS consists of various sections, currently labeled A through Z, with some variations. Sections like GG are critical for therapy involvement, while sections such as O capture therapy minutes. However, most clinicians tend to focus only on a few specific sections, like GG, leaving much of the MDS work to MDS nurses or other designated staff. Unfortunately, this siloed approach often diminishes interdisciplinary collaboration, which is a missed opportunity for optimizing care planning.

Under PDPM, the MDS became even more central. Before PDPM, during PPS, multiple MDS assessments were required at regular intervals (days 5, 14, 30, 60, and 90) for Part A patients. This was labor-intensive and involved hitting precise minute thresholds tied to ARD dates to achieve specific RUG levels. PDPM simplified this, reducing the required assessments for Part A patients to just two: an admission assessment (completed within five days) and a discharge assessment. The admission MDS determines reimbursement, while the discharge MDS captures the patient’s status upon leaving.

PDPM also introduced the optional Interim Payment Assessment (IPA). Facilities can use the IPA when significant changes in a patient’s condition potentially alter clinical categories—often in the NTA or nursing components rather than PT or OT—and affect reimbursement rates.

In 2023, the MDS underwent a substantial overhaul after minimal changes during the COVID-19 pandemic. The most significant updates focused on Section GG, previously limited to Part A subacute rehab patients. Historically, Section G, the nursing-focused version of functional assessment, played a critical role in quality measures and reimbursement. Section G coding was relatively straightforward, with clear algorithms and instructions that nursing staff had become accustomed to over years of practice.

CMS, however, decided to eliminate Section G, merging its essential elements into Section GG. As a result, Section GG expanded in scope and importance. It now applies to all residents, regardless of payer source or assessment type. Section GG coding influences reimbursement, quality measures, and broader care decisions, filling the void left by Section G.

This shift makes Section GG far more integral to care planning and facility evaluations, highlighting the need for precision and collaboration across disciplines in completing the MDS. For therapy professionals, these changes underscore the growing importance of understanding the nuances of Section GG and its role in shaping patient outcomes and facility performance.

Section GG

Section GG, as it currently exists, includes eight self-care items and ten mobility items. Typically, self-care items are assigned to OT, while PT handles the mobility items. The SLP is often left out of the equation depending on how the facility approaches these assignments. In addition to performance levels for self-care and mobility, Section GG also requires documentation of prior functional levels, prior and current device use, upper and lower extremity range of motion, admission performance, a goal, and discharge performance.

The self-care items cover key aspects of daily function, such as eating, oral hygiene, and toileting hygiene, while the mobility items focus on activities like bed mobility, transfers, and walking. While Section GG might not capture every detail of what therapists work on during a Part A stay, it represents the core functional activities for most subacute rehab patients.

Specific coding instructions for each GG item are detailed and precise, yet many therapists might be unaware of this. Therapists often fill out GG items in their EMR using their best interpretation of each question. For example, when coding an item like "picking up objects," therapists may guess whether it refers to objects on the floor, seated or standing, with or without a device, or involving a specific object size. Without consulting the official definitions, there’s a risk of inconsistent application and scoring.

The key takeaway is that the RAI manual, available on CMS’s website, is the definitive source for coding each GG item. Accurate coding is critical because GG data impacts numerous areas, including quality measures, reimbursement, and facility performance trends. If GG scoring is inaccurate, the data becomes unreliable and essentially useless. However, when done correctly, GG scoring provides valuable insights into performance, highlights clinical strengths and weaknesses, and helps guide where to focus clinical efforts.

Accurate, consistent GG data benefits the facility; it also ensures that patient care is appropriately documented and evaluated, creating a clearer picture of therapeutic outcomes and opportunities for improvement.

Continued Changes

Many other changes occur annually regarding the payment structure under PDPM beyond just those related to the MDS. These include case mix index value updates, ICD-10 code mappings, and minor tweaks and adjustments. However, these changes often feel nuanced and peripheral, and I believe they don’t hold significant value for therapists in day-to-day practice. Therefore, I’m not going to delve into those details today.

PDPM Impact on Practice From Implementation to Now

PDPM has brought significant changes to physical therapy practice, and its impact has been evident across the field. Let’s break down these effects by examining the three major changes: patient-specific reimbursement rates, payment reductions based on length of stay, and updated group and concurrent therapy policies.

Patient-Specific Reimbursement Rates

The shift to patient-specific reimbursement rates removed therapy as the primary payment driver, and many facilities responded by reducing therapy services to cut costs. This reaction was particularly evident in facilities already operating on the edge of compliance, leading to a race to the bottom in some cases. Therapy minutes dropped sharply—by an average of 80 minutes per day per patient within the first six months of PDPM. Daily therapy provision fell to approximately 60 minutes, divided among PT, OT, and SLP, compared to the previous norm of 60–75 minutes per discipline. This reduction posed significant challenges for therapists, who were expected to achieve comparable or better outcomes in less time.

PT and OT minutes were similarly affected nationwide, but SLP often experienced greater reductions. The decline in therapy minutes also led to staffing cuts, especially in facilities heavily reliant on subacute rehab. While some facilities managed to offset reductions by growing their Part B or long-term care census, many struggled to maintain adequate staffing. Therapists expressed frustration, feeling that therapy cuts were motivated by profit rather than patient care. However, rising costs—particularly for nursing staff, PPE, and general operations—played a significant role in facility decision-making. Despite stable gross revenue under PDPM, many facilities faced tight margins, exacerbated by the financial pressures of the Public Health Emergency and staffing mandates.

Reduction in Payments Based on Length of Stay

The variable per diem adjustment reduced reimbursement rates after 20 days, with payments declining to 76% of the initial rate by the end of the stay. Initially, this raised concerns that facilities would push for shorter stays to maximize revenue. However, studies showed no significant shift in the average length of SNF stays. While facilities with high turnover potential might discharge patients earlier to free up beds, others—particularly those without waiting lists—continued to benefit from keeping patients longer. The result was minimal overall change in length of stay, though there was a slight decline in very long stays (beyond 40 days).

Group and Concurrent Therapy Policies

PDPM removed disincentives for group and concurrent therapy, allowing these formats to count equally toward therapy minutes. Concurrent therapy involves treating two patients simultaneously with different activities, while group therapy includes two to six patients performing the same or similar activities. Under PPS, only 1% of stays included group or concurrent therapy, but this jumped to over 30% immediately after PDPM implementation.

The rise in group and concurrent therapy was briefly disrupted by COVID-19 restrictions, with usage dropping to below 10% during the Public Health Emergency. Since then, it has stabilized, with many facilities using group and concurrent therapy for up to 25% of therapy minutes, the maximum allowed.

According to CMS, higher group and concurrent therapy usage has not negatively impacted patient outcomes. Professional organizations like APTA, AOTA, and ASHA support group therapy, citing potential benefits such as improved motivation, social engagement, and visual feedback. However, the effectiveness of group therapy depends on its execution. While research suggests positive correlations between group therapy and outcomes, factors like patient selection and implementation quality play critical roles.

In practice, well-designed group therapy can enhance patient engagement and outcomes, particularly for specific interventions that thrive in a group setting. Group therapy can be more effective than individual sessions for certain populations. However, it requires careful planning and can be more demanding for clinicians.

In summary, PDPM has significantly reshaped therapy practice. While the industry adapts to these changes, thoughtful, patient-centered approaches remain central to maintaining quality outcomes and addressing evolving challenges.

PDPM Changes for 2024

All right, so what changes can we look forward to this year? The good news is it's much less than last year, which is positive. There, of course, are some changes that we don't get heavily involved in from the therapy side, as well as various changes in the reimbursement rates based on those market basket inflation numbers we discussed earlier. Medicare changed how they can find people on a federal and state level, allowing them to be more punitive. And some changes in the ICD-10 mapping typically happen every year. The ones that touch us more are things related to the MDS and quality measures.

MDS Changes 10/1/24

We have a couple of MDS changes coming up on October 1, 2024. One of the notable ones is related to Section GG, specifically the goal column (GGD). If you’re filling out Section GG in your therapy documentation system, you likely record the admit performance level—what the patient is doing at the time of evaluation—and a goal column indicating the expected functional level at discharge. That goal column is being removed.

This change comes for several reasons. First, there was a quality measure (QM) requiring facilities to include at least one goal in Section GG. However, this created inconsistency in how goals were applied. Some facilities set goals for just one or two items, while others set goals for all. Since the QM only required a single goal, it wasn’t providing meaningful data, and the variability caused confusion. Additionally, there was a lack of clarity on whether GG goals needed to align exactly with therapy goals and how these goals should be determined. Medicare appears to have concluded that the goal column no longer adds value, so it will no longer be required on the MDS or therapy documentation.

It’s important to note that Section GG is an MDS component and a collaborative tool. The MDS coordinator or assigned personnel gathers input from multiple sources, including therapy, nursing, CNAs, the patient chart, and interviews, to determine the patient’s usual performance level. What therapists enter into the EMR for Section GG serves as one piece of this broader process—it’s not directly submitted on the MDS. Typically, the MDS coordinator uses this information to populate the MDS, although practices may vary by facility.

Another update involves Section O, which now includes the resident’s COVID-19 vaccination status. Tracking vaccination status remains a priority, and facilities must report this data to residents and staff on the MDS. Failure to do so could result in financial penalties. This adds to the workload for MDS coordinators, who must track and verify this information alongside other responsibilities.

Section N, which addresses high-risk medications and their indications for use, also has changed. Medicare now requires additional documentation to justify the use of anticonvulsants. In QAPI meetings, antipsychotic use is already a heavily regulated focus, with facilities required to monitor usage closely and implement gradual dose reductions when appropriate. Recently, some facilities have turned to anticonvulsants as alternatives to antipsychotics, given their similar effects in certain situations and lower scrutiny. Medicare appears to be responding to this trend by increasing oversight of anticonvulsant use to ensure it’s not being used as a workaround for antipsychotic regulations. If you’re involved in QAPI meetings, expect anticonvulsant use to gain more focus, similar to antipsychotics.

These changes reflect ongoing efforts to refine the MDS and ensure the accurate, ethical use of medications and quality care measures in skilled nursing facilities.

Quality Measures

We’ve also seen various changes to quality measures, and while these aren’t the only updates, they include some of the most significant ones.

One notable change involves the short-stay measure called "Residents Who Made Improvement in Function." This measure focused on Part A rehab residents and assessed their functional improvement. However, it was based on Section G data, which relied on nursing input and wasn’t directly connected to therapy, even though it should have been. With Section G removed, this measure is replaced by a new QM called the Discharge Function Score. We’ll discuss this very impactful measure in more detail shortly.

Another change involves the "High-Risk Residents with Pressure Ulcers or Injuries Present" QM. The "high-risk" language has been removed, and the measure now applies to all residents who enter without a pressure ulcer and subsequently develop one. This expands the scope and emphasizes overall skin integrity and preventative care.

Additionally, QMs related to "Residents Who Need Help for ADLs" and "Functional Independence in Movement" have been adjusted. These measures previously relied on Section G data, but with Section G eliminated, they have been updated to use Section GG data instead. This shift aligns quality measures more closely with the new functional assessment framework, ensuring continued resident independence and functional outcomes tracking.

Discharge Function Score

The Discharge Function Score is a crucial measure for therapy teams to track, particularly as value-based care models continue to evolve. This metric reflects our effectiveness in improving functional outcomes for Part A subacute rehab patients and is tied to future value-based care initiatives.

Here’s how it works: Medicare evaluates all Part A subacute rehab admissions, looking at their admission GG scores, prior level of function, medical history, diagnoses, and about 70 other covariates. Using a complex formula, Medicare predicts where each patient should be functionally at discharge. The measure then calculates the percentage of patients who met or exceeded these expectations. For example, if 76% of your subacute rehab patients meet or exceed Medicare’s predicted functional levels, that becomes your facility’s Discharge Function Score.

This measure provides a direct and objective assessment of therapy performance on Part A. Unlike past measures, which often relied on broader or indirect data points, the Discharge Function Score is firmly rooted in GG data and reflects the actual functional progress of patients under your care. This makes it arguably the most significant measure we’ve had for therapy performance.

The metric uses a core set of ten GG items, which differ slightly from those used in PDPM calculations. The items include:

• Eating
• Oral hygiene
• Toileting hygiene
• Rolling left/right
• Lying to sitting
• Sit to stand
• Chair to bed transfer
• Toilet transfer
• Walking 10 feet
• Walking 50 feet (or wheeling 50 feet if walking isn’t possible)

Some may question why these specific items were chosen—for example, why tasks like dressing or putting on pants aren’t included. Medicare hasn’t provided a clear explanation for its selection, but these ten items are the standard for this measure.

The importance of this measure extends beyond individual outcomes. It is a benchmark for comparing performance to state and national averages and is tied to future value-based care components. For therapy teams, this metric reflects clinical performance and carries weight in shaping the facility’s broader quality and reimbursement outcomes.

PDPM and Value Based Care Key Focus Areas for the Therapist

What areas do you, as a clinician, need to consider and focus on? My opinions come from my anecdotal experience in the field, what I hear from the APTA, and other data I've gathered personally. So take that with a grain of salt.

Do More With Less

As we said, we're essentially being asked to do more with less, a recurring theme for a long time. The question becomes, how do we make that work effectively? One approach is to focus on selecting goals that are the highest priority for a safe discharge or align closely with Section GG, as this is the standard by which we are being judged. This means we need to be deliberate and purposeful when setting goals. It’s not enough to identify every possible deficit; instead, we must choose goals that are truly meaningful and impactful.

Once we’ve established those goals, the next step is to ensure that the interventions we select directly support them significantly. The focus should be on choosing high-value interventions that make a noticeable impact on the progress toward those prioritized goals rather than relying on a scattershot or generalized approach.

Another critical area to address is dosing and progression. Overall, this has been a weak spot for the long-term care industry. To achieve meaningful outcomes, interventions must be appropriately dosed and progressed to maximize their effectiveness, particularly when time and resources are limited.

Finally, removing outdated practices and de-implementing low-value interventions that no longer serve us under the current system is essential. These might include exercises and activities such as sitting exercises, cones, dowels, or using equipment like the NuStep, which often don’t require skilled care. Many were holdovers from when therapists were tasked with filling 70 to 90 minutes with patients, sometimes with little focus on meaningful progress. The time has come to deprioritize those interventions in favor of strategies that deliver measurable and impactful outcomes.

De-implementation and Dosing

Let’s explore implementation and dosing in more detail, particularly when choosing high-impact interventions. While there isn’t a perfect "one-size-fits-all" best practice when selecting interventions to address prioritized goals, there are guiding principles to help maximize outcomes.

The first step is to focus on interventions with the highest potential impact. Consider which approaches will yield the best outcomes relative to the time spent and where you can eliminate low-value interventions. Specificity is a key principle here. The body’s response to physical activity is highly specific to the task. For example, if the goal is to improve transfers, practicing transfers directly will generally be more effective than focusing on related components like pregait skills. While task breakdown has its place, prioritizing it often provides the most value.

Intentional and objective dosing is another critical factor. In long-term care, dosing is frequently overlooked or treated randomly. This can result in unstructured approaches to therapy, such as choosing arbitrary walking distances, resistance levels, or rep counts without a clear rationale or measurable progression. Effective dosing requires a structured, evidence-based approach to ensure the intervention is challenging enough to drive improvement.

This is similar to how progressive overload works in fitness. The exercise must be performed at sufficient intensity for strength and functional gains to create a physiological response. Random or inconsistent dosing is akin to taking medication without knowing the correct dosage—it's unpredictable and unlikely to achieve the desired effect. This means having specific targets for intensity, duration, and progression in therapy.

On the PT side, especially with exercises like therapeutic exercise or gait training, using tools like RPE (Rate of Perceived Exertion), percentage of one-rep max, or heart rate monitoring can help prescribe and monitor intensity. For example, aiming for a moderate intensity level in aerobic or strength activities can ensure the patient is being appropriately challenged to see progress.

Most research now supports high-intensity interventions across various populations and diagnoses. While the debate over whether moderate or high intensity is ideal continues, having any structured dosing method is far superior to the lack of dosing strategy that often exists in long-term care. These evidence-based dosing strategies are becoming more common in inpatient rehab and outpatient settings but have yet to be widely adopted in long-term care. Integrating these approaches into daily practice would significantly enhance outcomes and efficiency.

Understand Delivery Models

As we move forward under PDPM and value-based care, understanding the broader picture and the "why" behind everything becomes increasingly important. It’s essential to have a solid grasp of PDPM and its components and other aspects of reimbursement and care delivery that are rapidly evolving, like managed care. We’ve recently crossed a significant threshold where there are now more Medicare Advantage patients than those on traditional Medicare, and this shift aligns with Medicare’s ultimate goal of transitioning entirely to managed care models.

Managed care comes in many forms, and it’s important to understand the differences. HMOs, for example, require in-network providers and use a primary care physician as a gatekeeper to manage access to specialists and services. Exclusive Provider Organizations (EPOs) are similar but don’t require a primary care physician for referrals. PPOs allow out-of-network care but at a higher cost to the patient, while Point-of-Service (POS) plans blend features of HMOs and PPOs, often requiring prior authorizations for out-of-network care.

One managed care variation that deserves particular attention is the Institutional Special Needs Plan (ISNP), tailored for individuals living in long-term care facilities for 90 days or more. The true ISNP model operates on a capitated basis, where facilities receive a fixed payment to cover all medical needs for a resident, regardless of the level of care required. This creates financial constraints that can significantly limit the resources available for therapy and other skilled services. Facilities may need to rely heavily on restorative nursing, wellness programs run by non-clinicians, or minimal skilled therapy focused on maintaining and preventing hospitalizations.

From a therapy perspective, managed care presents unique challenges. These plans often require pre-authorizations and extensive paperwork, creating significant administrative burdens that can delay access to care and lower reimbursement rates. A recent APTA survey revealed that about 75% of physical therapists reported delays in care from three days to two weeks due to pre-authorization. Additionally, eight in ten therapists noted that the administrative burdens of managed care contribute to burnout, with an average of ten minutes lost per patient for authorizations and 30 minutes or more for appeals.

Value-based care is another area to watch. While long-term care facilities aren’t yet reimbursed directly based on outcomes, measures like the Discharge Function Score and rehospitalization rates are becoming increasingly important. These metrics are tied to quality initiatives like QRP and value-based purchasing, which reflect a shift toward performance-based reimbursement. Improving outcomes in these areas will position facilities—and therapy teams—for success in the evolving value-based care landscape.

Managed care and value-based care are not without their burdens, but they are integral to the future of healthcare delivery. Understanding their nuances and adapting practices to meet their demands will be key to navigating the challenges ahead. By focusing on efficient, high-quality care and staying informed about these systems, therapy teams can better meet the needs of their patients while thriving within this complex framework.

SNF Quality Reporting Program

Let’s examine the SNF Quality Reporting Program (QRP) closer to clarify its purpose and how it works. QRP is a pay-for-reporting program that all skilled nursing facilities must participate in. Unlike pay-for-performance programs, QRP doesn’t tie payment directly to care outcomes but instead to the facility’s compliance in submitting required data.

To meet the program requirements, SNFs must submit data through the MDS. As of recently, 90% of their submitted MDS assessments must be 100% complete—meaning no dashes or blank fields. This is an increase from the previous threshold of 80%. If a facility falls below this threshold or fails to rectify incomplete submissions, it faces a 2% reduction in its annual payment update. Such a penalty can have a significant financial impact on the facility.

This underscores the critical role of the MDS coordinator. An effective MDS coordinator must be skilled in gathering and interpreting information from various sources and have adequate time and resources to ensure compliance. A lack of support in this area can lead to incomplete or inaccurate submissions, jeopardizing reimbursement and potentially affecting the facility’s overall financial stability. In short, QRP compliance is essential, and its requirements highlight the importance of accuracy and thoroughness in MDS data collection.

SNF Value-Based Purchasing Program

The SNF Value-Based Purchasing (VBP) program is a fascinating and impactful initiative because it represents true value-based care, with facilities being paid directly based on their performance. Here’s how it works: CMS withholds 2% of all Medicare payments, approximately $450 million. Of that amount, 60% is redistributed to top-performing facilities based on specific performance metrics.

Currently, the only active measure influencing repayment is the All-Cause Rehospitalization Rate. This is a critical metric as it addresses one of the biggest drivers of healthcare costs. Facilities that excel in reducing rehospitalizations not only improve patient outcomes but also stand to gain significantly from the redistributed funds.

While rehospitalization is the sole metric now, additional measures are set to be included in the coming years. These new metrics will have important implications for therapy teams. Some of the key measures to focus on include:

• Discharge Function Score: This metric reflects performance in subacute rehab, making it a metric over which therapy teams have the most direct and immediate control. Improving functional outcomes at discharge is already a cornerstone of therapy practice, and tying it to reimbursement emphasizes its importance.

• Long-Stay Residents Who Have Falls with Major Injury: Falls are a critical area of focus in long-term care, and therapy teams are often at the forefront of fall prevention efforts. Knowing that this measure directly impacts reimbursement raises its priority further.

The calculation for VBP payouts considers performance and improvement over the prior year. Facilities are ranked on their rehospitalization rates and their progress in reducing them. This dual emphasis on performance and improvement allows facilities at all levels to compete for redistributed funds, regardless of their starting point.

These metrics offer significant opportunities for therapy to contribute to facility success. By implementing programs targeting rehospitalization reduction, improving discharge functional outcomes, and enhancing fall prevention strategies, therapy teams can, directly and indirectly, impact patient care and financial outcomes under the VBP program.

5-Star Quality Rating System

The Five-Star Rating System is a critical tool that Medicare uses to help beneficiaries and their families make informed decisions about long-term care and subacute rehab facilities. If you’ve never visited Care Compare, it’s worth taking the time to look up your facility and see how you’re performing. This publicly available star rating system is designed to reward high-performing facilities and penalize those that do not meet standards, encouraging transparency and accountability.

Medicare encourages individuals to use the Five-Star Rating System when choosing a facility for themselves or their loved ones. The rating combines three primary factors: health inspection results, staffing measures, and quality measures.

Health inspections carry the most weight in determining the initial star rating. Facilities are grouped based on their inspection performance, with the top 10% receiving five stars, the bottom 20% receiving one star, and the middle 70% assigned two, three, or four stars based on their ranking. This initial health inspection score sets the baseline for the overall rating.

Staffing measures are then factored in, focusing exclusively on nursing hours, including RNs, LPNs, and CNAs. While therapy hours are reported on Care Compare, they don’t currently influence the staffing rating. Facilities with a four- or five-star staffing rating can add one star to their health inspection score, while those with a one-star rating may lose a star.

Quality measures are also included, with many derived from the Casper Report and other metrics. A five-star quality measure rating can add a star to the overall score, while a one-star rating can subtract one. The facility’s final rating is capped at five stars. Facilities with a one-star health inspection rating cannot be upgraded beyond two stars, even if they excel in staffing or quality measures. Similarly, facilities designated as Special Focus Facilities due to persistent quality issues cannot exceed three stars until they address their deficiencies.

For example, if a facility starts with a three-star health inspection rating, has a four-star staffing rating, and a three-star quality measure rating, it would add one star for staffing, resulting in a final four-star rating. If the quality measure rating were five stars, another star could be added, but the facility would still cap at five stars.

Understanding this system is essential for clinicians, as it directly impacts public perception of the facility and, potentially, patient referrals. Additionally, clinicians should ensure familiarity with tools like Section GG and resources like the RAI manual to contribute accurate and meaningful data that aligns with the facility’s goals and quality improvement initiatives.

Focus on Section GG

The RAI Manual is an extensive resource, clocking in at around 1,000 pages, but the Section GG component is much more manageable—roughly 40 pages. Reviewing this section lets you get clear, detailed explanations for coding each GG item. This understanding is critical for ensuring that GG data is accurate, as it influences various downstream outcomes and metrics.

Getting GG coding right starts with a solid understanding of its requirements, but it also demands processes to maintain accuracy over time. A strong recommendation is for the rehab director or someone in a similar role to perform regular audits. This helps identify and address errors early, ensuring the data submitted is as accurate as possible. These audits are vital because inaccuracies in GG coding can ripple through to other key metrics, such as the discharge function score, which is increasingly important for value-based care.

If your discharge function scores are lower than expected, it’s worth revisiting your GG data to identify any discrepancies. Accurate GG data ensures compliance and provides valuable insights for guiding clinical decisions. For instance, if the scores indicate areas of underperformance, you can adjust intervention strategies, reallocate therapy minutes, or focus on specific aspects of care to improve outcomes. Using GG as both a reporting tool and a decision-making guide allows therapy teams to optimize patient care while aligning with facility performance goals.

Documentation Strategies

Documentation strategies are increasingly critical in therapy practice, especially as managed care models continue to evolve. Therapists are pulled in three directions: delivering excellent clinical care, being as efficient as possible, and maintaining high-quality documentation. While patient care should always take priority, poor or incomplete documentation can undermine even the best clinical outcomes. If it’s not documented, it didn’t happen—and this opens the door for denials, regardless of the actual care provided.

To address this, therapists must improve documentation practices while balancing time and efficiency. One powerful strategy is incorporating well-supported outcome measures into routine practice. Outcome measures demonstrate progress and provide objective data points that justify the need for continued care. For example, if you’re working with a patient at risk of falls, the Timed Up and Go (TUG) test can show improvement and remaining risk. If a patient progresses from a score of 18 to 15, you’ve documented progress while showing they’re still above the fall risk threshold of 14, reinforcing the need for ongoing therapy.

Additionally, documentation should clearly reflect the clinical reasoning and skilled techniques used in treatment. For instance, the note "patient walked 200 feet" indicates no therapeutic value or skill. Instead, detail the interventions that required your expertise: "Patient ambulated 200 feet with verbal cues for foot placement and weight shift to improve gait symmetry and reduce fall risk." This approach demonstrates the skilled care provided and its alignment with the patient’s functional goals.

Another critical element is being intentional about dosing, cueing, and techniques and ensuring this is reflected in the documentation. Notes should highlight how therapy interventions address deficits and promote functional improvements. Similarly, progress must be clearly documented, focusing on functional outcomes. For example, showing how patients can perform transfers independently has improved ties directly to their quality of life and discharge readiness.

Effective documentation requires a dual focus: capturing the therapeutic value of care and demonstrating measurable progress. By combining these elements with objective measures and a functional framework, therapists can ensure their documentation supports reimbursement and accurately reflects the quality and impact of their clinical care.

Merging of Best Practices

Best practice is a complex balancing act. It involves standardization—using consistent outcome measures, adhering to clinical practice guidelines, leveraging data points, and conducting risk stratification—but also requires individualization. A cookie-cutter approach simply doesn’t work. Care plans must be tailored to the unique characteristics of each patient, including their presentation, goals, and beliefs. Even if a therapist identifies a clinically important goal, if it doesn’t align with the patient’s priorities, best practice dictates that the focus must shift to what matters most to the patient. Merging these two components—standardized approaches and individualized care—is no small task.

A crucial element of best practice is ensuring that all clinicians understand the "why" behind what they do. This requires translating broader clinical knowledge into practical, actionable approaches for staff. Success in this area depends on fostering an environment where clinicians adopt best practices and evolve with them.

A good starting point for incorporating best practice knowledge into clinical care is utilizing resources provided by accrediting bodies like the APTA. Clinical practice guidelines are an especially accessible tool, offering evidence-based recommendations for treating specific diagnoses. Beyond guidelines, many resources can help clinicians incorporate well-supported practices into their care.

It’s important to recognize that best practice isn’t static—it evolves as research advances. What was considered best practice when many of us graduated may no longer hold today, and it will undoubtedly continue to change. This means clinicians must have a process to update their knowledge and continually adapt their practices. Knowledge translation is an ongoing challenge but an essential one. For example, structured processes for integrating new research findings into clinical workflows can ensure that practice remains aligned with the latest evidence.

Finally, therapists must advocate for the profession and demonstrate their value. Resources for therapy are unlikely to expand without clear evidence of the impact we provide. As a profession, we must be prepared to fight for our role and show why our work is essential—for patient outcomes and the broader healthcare system. Advocacy and the ability to translate knowledge into meaningful action are critical to advancing best practices and sustaining the field.

Standardization and Individualization

As I mentioned, the key to effective care is merging the two essential elements of best practice: standardization and individualization. Standardization involves understanding and applying what best practice says about clinical care for specific conditions and scenarios. This includes accounting for the patient’s comorbidities, diagnoses, polypharmacy, and other factors influencing outcomes on paper. The best practice offers clear guidelines for these areas, providing a foundation to ensure care is evidence-based and consistent.

However, it’s equally important to balance that with the individualized aspects of care. This means tailoring your approach based on the patient’s unique presentation, preferences, and personal goals. The patient’s voice must guide the plan of care, ensuring it reflects not only what is clinically important but also what is meaningful to them. Merging these two components—standardized best practices and individualized care—creates a comprehensive and patient-centered approach.

Big-picture clinical tools play a crucial role in achieving this balance. These tools include outcome measures to track progress objectively, risk stratification models to identify potential complications and structured frameworks for care planning. Clinical guidelines provide a roadmap, but tools like patient-reported outcomes, functional assessments, and even shared decision-making frameworks help bring the patient’s individuality into focus.

The key is to use these tools not as rigid checklists but as adaptable resources that allow you to respond dynamically to evidence and the patient’s evolving needs. Clinicians can provide effective and deeply personalized care by thoughtfully integrating standardized best practices with the unique factors that define each patient’s situation.

Big Picture Clinical Tools

Everyone working in long-term care needs to have big-picture clinical tools. From a clinical standpoint, one of the most valuable tools is understanding and utilizing quality measures, such as the CASPER report. This report contains many key indicators, and if you’re a clinician who hasn’t reviewed it yet, I highly recommend asking your rehab director or MDS coordinator for access. The CASPER report can provide a clear view of how your facility is performing on critical quality measures, including discharge function scores, which directly reflect the work being done on the ground.

If you’re not currently involved in your facility’s QAPI (Quality Assurance and Performance Improvement) meetings, that’s another area to explore. These monthly meetings allow clinicians to bring their expertise to the table. Rehospitalization rates, for example, are a key focus in these discussions, and your input could make a significant impact.

On the reimbursement and regulatory side, it’s important to stay informed about managed care corporations, their policies, and how they affect your work. Additionally, keeping up with changes in CMS programming, such as QRP, VBP, and five-star rating systems, is essential. While you don’t need to monitor these programs daily, understanding their evolving impact on your practice and the field is crucial for staying ahead.

How Can It Be Done?

All of this can feel overwhelming—because it is. No single clinician can manage all these areas effectively on their own. Success in long-term care relies heavily on an interdisciplinary team (IDT) approach. If you haven’t encountered this terminology before, it’s surprising because an IDT approach is essential for addressing the complexities of care and ensuring all components are met effectively. The team can leverage diverse skill sets to navigate these challenges and deliver high-quality care by working collaboratively.

Interdisciplinary teams (IDT) have become the new buzzword, and while the term is thrown around so often that it sometimes loses its significance, the concept remains critically important. Historically, long-term care facilities have operated in silos, with each department working largely independently. However, if you want to be effective in delivering quality care, breaking down these silos and building strong interdisciplinary processes is essential.

True collaboration requires structured processes that involve all relevant team members in every aspect of care. This includes everything from completing the MDS and accurately coding Section GG to creating and implementing care plans. When these processes are approached through an IDT framework, you can ensure that care is comprehensive, consistent, and reflective of best practices. Without this level of collaboration, it’s difficult to achieve outcomes that benefit both patients and the facility.

Future of Value Based Care

The future of value-based care is difficult to predict with certainty, but several trends are already taking shape. The expansion of managed care models is among the most significant. We’re seeing a proliferation of managed care organizations, Medicare Advantage plans, and new variations like ISNPs. Each state has its own plans and policies, making the landscape increasingly complex. Traditional Medicare is on its way out, with Medicare’s stated goal of transitioning all payments to managed care programs by 2030. The aim is to offload direct payment responsibilities, instead providing funds to entities that manage how and where they are allocated. This shift means clinicians and facilities must adapt to the evolving managed care framework.

Interdisciplinary team (IDT) processes are not just recommended but are becoming a formalized requirement in some areas. Medicare has highlighted the necessity of IDT collaboration for certain components, with expectations likely to expand. For example, Section GG on the MDS must be completed as part of an IDT process, with input from various team members to determine the usual performance level for patients. It’s not intended to be a unilateral decision by a single department. Facilities that fail to demonstrate IDT processes face increasing Part A denials, underscoring the importance of collaboration in care planning and documentation.

Best practice, as discussed, is the integration of standardized protocols with individualized care. Another emerging focus in this area is the consideration of social determinants of health. These factors include economic stability, access to education, community resources, and social dynamics that influence a patient’s ability to access, receive, and benefit from healthcare. CMS is collecting more data on these determinants through the MDS, expecting they will increasingly shape how care is delivered. This will include the types of questions we ask, the interventions we provide, and how we plan transitions and discharges.

Understanding the social determinants of health and their role in healthcare delivery is becoming essential for clinicians. Medicare’s growing emphasis in this area suggests it will significantly shape future care models. If you’re unfamiliar with this concept, it’s worth exploring how it aligns with CMS initiatives and the broader goals of value-based care. Adapting to these trends will be critical as the industry continues its transformation.

Wrap-up

I have a couple of other topics I could expound upon since we have a little time. We’ll review the exam first, and I’ll explain the questions and answers. After that, we’ll move into some Q&A. After addressing the questions, I may briefly cover additional topics if we still have time.

Exam Review

Here’s the breakdown of the exam:

Question 1: What is the limit on group and concurrent therapy provision under PDPM?
Options:

• 20 minutes per day
• 25% of minutes per day
• 25% of minutes provided combined per discipline per patient in a coverage day
• 200 minutes provided combined per discipline per patient in a coverage day

The correct answer is C: 25% of minutes provided combined per discipline per patient in a coverage day.

Question 2: Which of the following are the correct five case mix-adjusted components of PDPM? Remember, there are six total, but five are case mix-adjusted.
Options:

• PTA, OT, SLP, NTA, nursing
• PT, OT, SLP, NTA, nursing
• PT, OT, SLP, restorative, nursing
• PT, OT, SLP, NTA, activities

The correct answer is B: PT, OT, SLP, NTA, nursing.
While restorative information is recorded on the MDS, it does not directly factor into PDPM payment, though it can impact Medicaid CMI in certain states. Activities are a regulatory component but not payment-determining.

Question 3: The PT/OT variable per diem begins to reduce after which day of a PDPM stay?
Options:

• Day 10
• Day 20
• Day 50
• Day 100

The correct answer is Day 20. The reduction starts after this day.

Question 4: Which of the following were seen in therapy delivery and SNF rehab post-PDPM implementation?
Options:

• An increase in group usage
• A decrease in group and concurrent usage
• An increase in therapy minutes provided
• An increase in group and concurrent use and a decrease in therapy minutes provided

The correct answer is D: An increase in group and concurrent use and a decrease in therapy minutes provided.

Question 5: Which of the following is included in the changes to PDPM effective 10/1/24?
Options:

• Removal of the column two discharge goal from Section GG
• Removal of Section G
• Removal of Section GG completely
• Removal of Section GGG

The correct answer is A: Removal of the goal column from Section GG.
Section G was removed last year, Section GG remains active, and there is no Section GGG.

Questions and Answers

How significant is a patient’s prior level of function when determining scoring and the improvement made during their stay?
The patient’s prior function level is significant when calculating the discharge function score. For example, if your subacute rehab consists of high-acuity patients or long-term residents with minimal progress, such as going from supervision to modified independence, the discharge function score accounts for these expected progress limitations. The system evaluates improvement relative to realistic expectations based on the patient’s condition, prior level, and other factors. As such, it allows facilities to achieve a high discharge function score even if GG averages are low, provided progress aligns with expected outcomes.

Does rehospitalization include emergency department (ED) visits?
Yes, rehospitalization encompasses trips to the emergency department. However, there are exceptions. For example, standalone facilities not officially classified as hospitals might not count toward rehospitalization rates provided the patient is not formally discharged. Generally, though, we refer to hospital-related emergency department visits when discussing rehospitalization rates.

How is "prior level of function" defined, and how far back should clinicians consider?
This can be nuanced. Some may wonder whether they should consider a patient’s function before their most recent hospitalization or a prolonged decline. The RAI manual provides detailed guidance for coding the prior level of function and outlines specific recommendations for this scenario. While the manual provides clarity, some gray areas may persist, emphasizing the need for thorough understanding and reference to official documentation.

Additional Topics

Skilled Maintenance Therapy

Skilled maintenance therapy refers to therapy provided without the intention to improve but to maintain or slow the decline in a patient’s function. This type of therapy gained recognition following the Jimmo vs. Sebelius lawsuit, which clarified that skilled care eligibility is not contingent on a patient’s ability to progress. Skilled maintenance can involve developing and training others in maintenance programs or directly providing the care if only a skilled therapist can ensure safety and effectiveness. While documentation and implementation differ from traditional restorative therapy, skilled maintenance can benefit long-term care patients who require ongoing support.

Enhanced Barrier Precautions

The CDC’s enhanced barrier precautions require gown and glove use during high-contact activities with patients potentially colonized with multidrug-resistant organisms (MDROs). This precaution applies to individuals with catheters, chronic wounds, PICC lines, PEG tubes, and similar conditions. Facilities are responsible for identifying these patients and maintaining precautions, even in therapy settings. For example, providing high-contact care in a therapy gym may also necessitate gowning and gloving. The enhanced barrier precaution guidance, updated in April, emphasizes compliance during state surveys.

Facility Assessment Updates

The facility assessment requirement ensures that facilities evaluate their resident population’s needs, including obesity or trach/ventilator dependency. These assessments guide staffing, equipment, and training decisions. Recent updates stress individualized facility assessments and include therapy staff in required training. This expanded regulatory focus went into effect last month and underscores the importance of tailoring facility resources to resident needs.

Thanks for attending!

References

Please refer to the additional handout.