Updates as of October These are updated and/or new slides that are not in the manual as of 10/2018 Includes new references

Transcription

1 Updates as of October 2018 These are updated and/or new slides that are not in the manual as of 10/2018 Includes new references

2 Lessons Learned If you re part of a bundled program, use those improvements you ve made across the board, even with MA contracts Even though the new program doesn t allow PA providers to be the lead, the hospitals and medical homes still need PA providers to refer to so be the best you can with cost and outcomes payment lessons

3 NEW SLIDE: Measure #5: Functional status, Cognitive function, and changes in both from admission to discharge This is section GG of MDS and new to Oasis Will discuss during payment change section

4 Section GG QRP Measure Beginnings of ensuring equal playing field across PA settings in terms of functional status Already reporting in SNF; will start reporting in HH Jan. 1, 2019 (CY 2019) Some additional items and/or changes for SNF reporting as of 10/1/18; HH as of 1/1/19 Resident can use assistive devices does not affect coding Based off of the CARE item set used in IRF settings

5 CMS Section GG Training Website Initiatives Patient Assessment Instruments/NursingHomeQualityInits/ggtraining Training sections for HH and SNF (as well as other PA provider types) Good for whoever will code section GG but does not include training on the newest GG items that began Oct 1, 2018

6 Key Points Admission and Discharge performance ratings are NOT based on staff assessment of potential ability (so cannot copy rehab goals) Assesses need for assistance and establishes d/c goals for self care and mobility Items focus on self care and mobility Admission performance Discharge performance Discharge goals

7 Key Points continued Review of Wheelchair coding Definition of helper Must be employed or contracted by facility Does not include students, hospice personnel, family, private caregiver, etc.. Cannot code using occurrences from these non staff personnel

8 Section GG Admission Coding Admission Coding: Look back day 1 3 and assess usual performance PRIOR TO improving from treatment Important to not just rely on therapy evaluations as we know patients often are different outside of therapy Requires TEAM to look at 3 full days and determine the persons usual performance, not the best or worst CMS expecting this Admission coding is CRITICAL to setting the stage for payment & outcomes Coding Tips: Stay away from use of Dash (means you have no information) Discern between 07/09/88/10 codes and have documentation to support choice

9 Section GG that will be the same for SNF and HH Item SNF MDS HH OASIS as of 1/1/2019 Eating Yes Yes Oral hygiene Yes Yes Toilet hygiene Yes Yes Sit to lying Yes Yes Lying to sitting at EOB Yes Yes Sit to stand Yes Yes To/from chair or bed Yes Yes transfer Toilet Transfer Yes Yes Walk 150 ft Yes Yes Wheel 150 ft Yes Yes Note type of w/c used Yes Yes Walk 50 ft with 2 turns Wheel 50 ft with 2 turns Yes Yes Yes Yes

10 Section GG additional items for SNF as of 10/1/18 Additional SNF MDS items to be assessed & collected beginning October 1, UE dressing 2. LE dressing 3. Shower/bathe self 4. Don/doff footwear 5. Roll L & R 6. Walk 10 ft in room, corridor or similar space (TUG!) 7. One step (curb) 8. 4 steps steps 10. Picking up an object from floor either standing or from a wheelchair 11. Car transfers These items are already collected in the Inpatient Rehab setting

11 New items as of 10/1/18 continued Admission coding only: Section in GG on prior level of function in everyday activities in 4 areas: GG0100 Self care including bathing, dressing, toileting, eating Indoor mobility Stairs Functional cognition New section on prior device use GG0110 which includes history of use of: wheelchairs/scooter, mechanical lift, walker & orthotics/prosthetics

12 Upcoming SNF changes (additional to the QRP & VBP) Final Rule changed the next few slides MDS changes Proposed October 2018: Designing a new alternative SNF case mix system to replace RUGS! Will be called RCS 1 Part of the Value Based Purchasing program Office of Inspector General and Med PAC recommended payment changes

13 NEW SLIDE Timeline for RCS 1 SNF Open door forum March 8, 2018 CMS stated they have no timeline for implementation of RCS 1 nor are they saying it will be exactly as proposed. April 2018 will release the proposed rule for FY 2019 effective Oct 1, 2018 so we ll know more then Fee for Service Payment/SNFPPS/therapyresearch.html We will go over the RCS 1 payment system now; we need to expect this or something similar to be put in place

14 Patient Driven Payment Model PDPM This will replace the proposed change called RCS 1 Effective October 1, 2019 (FY 2020) Huge shift away from volume (ie: therapy minutes setting the payment) to value and person centered care (diagnosis and co morbidity driven)

15 Website References SNF FY 2019 Final Rule: sheets/2018/ html and SNF VBP: Initiatives Patient Assessment Instruments/Value Based Programs/Other VBPs/SNF VBP.html SNF QRP: Initiatives Patient Assessment Instruments/NursingHomeQualityInits/Skilled Nursing Facility Quality Reporting Program/SNF Quality Reporting Program IMPACT Act 2014.html

16 Patient Driven Payment Model (PDPM) Final Rule August 2018 Will replace RUG s Compensates SNF s on medical complexity Will change MDS schedule and structure 5 day/admission; interim payment assessment (IPA) and discharge assessment with therapy minutes are only MDS s Single daily rate payment based on clinical characteristics in 5 areas: PT and OT with further emphasis on individual therapy (minimum 50%) but allows some group and concurrent (25% each) SLP Nursing Non therapy Ancillary (NTA) Non case mix rate (rural, urban)

17 PDPM PT/OT per diem components Each area will have a per diem amount based on patient primary diagnosis and we will add these up to get per diem rate for first 14 days PT/OT rate decreases every 3 days after day 14! PT & OT rate decreases by 2% every 7 days after day 20 SLP rate does not decrease NTA rate also decreases by 2/3rd after day 3 and stays at that level for remainder of stay in SNF Therapy can use concurrent and group treatment options but minutes in both of these are capped at 25% per patient, per discipline Minimum of 75% of therapy minutes must be individualized

18 PT/OT per diem payment components 3 areas make up the PT/OT components: 1. Clinical category 4 diagnosis groups: Medical management: includes cardiac, pulmonary, cancer, acute infections & medical management diagnoses Other Orthopedic: includes surgery (not elective or spinal) and Non surgical orthopedic or musculoskeletal Major joint replacement or spinal surgery Acute neurologic and Non orthopedic surgery 2. Functional level based on section GG scoring Payment will be based on classifying a patient in 1 of 16 case mix groups Case mix group = 1 of the dx groups combined with section GG function score range

19 SLP per diem payment components Patient will fall into 1 of 12 case mix groups combining these components Calculating SLP case mix: 2 Clinical categories: Acute neurologic Non neurologic Presence of either: Swallowing disorder Mechanical diet Presence of comorbidity or cognitive impairment

20 Determining Cognitive Level Cognitive Performance Scale CPS Cognitive level: Cognitive functional scale based on BIMS scoring: Cognitive BIMS score CPS score Level Intact Mildly impaired Moderately impaired Severely impaired

21 Presence of either: SLP related co morbidity 12 options: Aphasia CVA/TIA or Stroke Hemiplegia/hemiparesis TBI Tracheostomy (while a resident of SNF) Ventilator/respirator (while a resident) Laryngeal Cancer Apraxia Dysphagia ALS Oral cancers Speech and language deficits SLP comorbidity options

22 Interrupted stay Policy also Finalized If a resident is d/c d and returns to same SNF by 12 AM at the end of the 3 rd day, the stay will be treated as a continuation of the previous stay both in terms of resident classification and payment. Source of readmission is not relevant If the absence is greater than 3 days or the resident gets admitted to a different SNF, the readmission is considered a new stay. An Interim Payment Assessment (IPA) can be done if there is a triggering event that the facility believes needs to show a change in the resident. No payment change will occur because of the IPA, only care planning changes Essentially there is no way to change the payment once the 5 day is established, unless the resident meets criteria for a new stay

23 What CMS will monitor under PDPM Changes in payment that result from changes in coding or classification of patients vs actual changes in case mix Changes in volume and intensity of therapy services from RUG IV to PDPM Compliance with group and concurrent therapy limits Any increases in mechanically altered diet that may suggest residents are being prescribed such diet for financial considerations rather than for clinical need Andy overutilization of using cognitive impairment as a payment classifier for SLP component Facilities whose patients experience inappropriate early d/c or provision of fewer services Residents who experience frequent readmissions, especially if they occur outside of the 3 day window

24 Home Health Changes Bipartisan Budget Act of 2018 signed into law 2/9/18 will affect Home Health Agencies: Change from 60 day episode to 30 day unit of service effective 2020 Elimination of therapy thresholds in the case mix a new case mix system must be implemented by 2020 Must be budget neutral A Technical Expert Panel must have a say in the new system (APTA,AOTA,ASHA all involved) CMS must have a report to Congress by April 2019 with a plan

25 Home Health Proposed Rule CY 2019 (effective Jan. 1, 2020) Patient Driven Payment Model (PDGM) Episode will be 30 days Sections will make up payment: 1. Admission source Community or Institutional (Acute/LTCH/SNF etc.) within past 14 days Early episode 1 st 30 days; higher payment Late episode = anytime after 30 days; less payment 2. Clinical Groupings 6 based on Primary Diagnosis Musculoskeletal rehab Neuro/stroke rehab Wounds Behavioral Complex Nursing Medication management/teaching/assessment 3. Functional Level from section GG on Oasis Low/Medium/High based on scores Oasis items used to calculate: grooming, dressing UE/LE, bathing, toilet transfers, transfers, ambulation/locomotion, risk of hospitalization 4. Comorbidity adjustment from secondary diagnosis None/Low/High

26 Other changes in Proposed Rule Changes in certifying and recertifying patient eligibility for continued HH care Allowance for agencies to report the cost of remote patient monitoring Transition toward payment for home infusion therapy Budget neutral = prevents massive cuts However, there will be costs to implement changes and will affect therapy delivery

27 Webinar Resources for Home Health changes Type/Home Health Agency HHA Center.html AOTA and APTA will also provide updates as they occur also will have updates

28 Fall Plan of Care Establish for anyone at risk of falls or who has fallen Utilize multifactorial process to obtain data on fall risk Establish interventions based on evaluation findings of strengths and weaknesses combined with history, medications, home environment and level of function in community Incorporate patient s personal goals Utilize evidence based tests to establish goals and for retest reliability for outcomes

29 New Research on Fall Prevention, Fall Risk and Rate Yvonne A Johnston, Gwen Bergen, Michael Bauer, Erin M Parker, Leah Wentworth, Mary McFadden, Chelsea Reome, Matthew Garnett; Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome Evaluation, The Gerontologist,, gny101, Accessed September 25, Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD DOI: / CD pub3 Accessed September 18, 2018.

30 New Research continued Stevens, Judy A. et al. The Potential to Reduce Falls and Avert Costs by Clinically Managing Fall Risk. American Journal of Preventive Medicine, Volume 55, Issue 3, Lusardi MM, Fritz S, Middleton A, et al. Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Metaanalysis Using Posttest Probability. Journal of Geriatric Physical Therapy (2001). 2017;40(1):1 36. doi: /jpt

31 New York Times Jan 2, 2018 Afraid of a fall? The Dutch Have a Solution 7ppY Dual Task Training Research (cognitive motor exercise): de Boer C, Echlin H, V, Rogojin A, Baltaretu B, R, Sergio L, E: Thinking While Moving Exercises May Improve Cognition in Elderly with Mild Cognitive Deficits: A Proof of Principle Study. Dement Geriatr Cogn Disord Extra 2018;: doi: / Accessed August 5, 2018

32 OTAGO Program Evidence based PT program to reduce falls/improve function in community dwelling elders Ideal for those over 80 with high fall risk or who have fallen in past year; patient must be able to do exercises on own or have helper available PT must be certified $35 and about 4 5 hrs of an online course and exam; Must follow materials as given however can choose correct exercises based on eval findings and can progress as patient tolerates Follow patient for a year, but many months are phone calls Must get buy in from management because there is some non productive time but it is minimal and can result in reduced rehospitalizations program

33 Assessment of Language Related Functional Activities ALFA Good testing tool to determine both cognitive level and if someone can be taught medication management Costs about $200 to purchase Test time around minutes but can be broken up 10 subtests to assess different functional abilities Allows observation of multiple cognitive processes

34 Successful Hospital SNF collaboration Rahman, M., Gadbois, E. A., Tyler, D. A. and Mor, V. (2018), Hospital Skilled Nursing Facility Collaboration: A Mixed Methods Approach to Understanding the Effect of Linkage Strategies. Health Serv Res. doi: /

35 Maintenance Therapy Documentation Resources Medicare Learning Network: and Education/Medicare Learning Network MLN/MLNProducts/Downloads/MedQtrlyComp Newsletter ICN pdf Medicare Benefit Policy Manual: and Guidance/Guidance/Manuals/downloads/bp102c01.pdf Chapter 7 = Home Health Chapter 8= SNF Coverage for skilled therapy does not turn on the presence or absence of a beneficiary s potential for improvement from therapy services, but rather on the beneficiary s need for skilled care

36 Offsets for to pay for new bill (not in manual) Any time there is increased spending, Congress must attempt to balance it by creating offsets or takeaways The Permanent Fix created offsets that will affect us: Reduced SNF payments HHA will get a lower increase than initially planned in FY 2019 and beyond PTA/OTA payment differential beginning Jan 1, 2022 Will pay 85% of amount on claim for Part B treatment A modifier must be added to denote if OP services were furnished in whole or in part by a PTA or OTA This is similar to APRN and PA payment by Medicare This had been recommended by MedPAC in Feb 15,2018