Industry Voices—3 milestones senior care providers should meet to be successful through PDPM

Skilled nursing facility
With the new Patient-Driven Payment Model approaching quickly, it’s critical that senior care providers look forward and craft a sustainable plan to be implemented between now and October. (Getty/Rawpixel)

With the new Patient-Driven Payment Model (PDPM) approaching quickly, it’s critical that senior care providers look forward and craft a sustainable plan to be implemented between now and October. PDPM is not just a payment shift; it requires a cultural change in care delivery, care delivery models and a clear understanding of how your technology will support your journey. 

By breaking your journey down into three key change management milestones, this transformation can be made approachable, effective and even a positive development for the overall vitality of your facility and the people you serve. 

How to get started

Review the most recent CMS Impact File for the fiscal year along with the Facility Assessment for the types of clients you serve. Review your referral sources. Decide whether these sources will provide optimal reimbursement moving forward to support revenue goals. 


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  • Next, connect with partners to educate them on the referrals that are important to you, and whether they can help you achieve case mix goals. Begin to reframe resident care in terms of the clinically complex patients PDPM incentivizes.

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  • Understand the impact of accurate and comprehensive diagnosis coding. Start with auditing ICD-10 codes to see whether each primary diagnosis maps to a clinical category under PDPM. Also, take a look at how current coding practices need to change with PDPM given the primary diagnosis’ impact on therapies, including a review of the chart, with a focus on the NTA and SLP co-morbidities that drive reimbursement. Is there adequate supportive documentation for the primary and all other diagnoses in the record?
  • Analyze the accuracy and completeness of current medical data system (MDS) data capture processes by auditing five-day AND 14-day PPS MDS assessments. How often are five-day MDS modified for missing or incorrect information currently?
  • Review the information hospitals are giving you, and when you are receiving it. Learn what data are available on admission to code the five-day, and if you will receive the right surgical information to code the section-J questions.


Standardization levels the playing field for staff; when each person has a solid foundation and concrete baseline from which to work, the ability to care confidently is built into the system, and success is almost guaranteed.

  • Standardize processes to get the right information as soon as possible. This includes pre-admissions screenings to get the information on the record ASAP, and new interview tools designed to gain better insights from families and caregivers.
  • Further, standardize evidence-based protocols and best practice workflows to support care delivery. Ramp up care planning and supportive documentation capture to emphasize good clinical practices, and reduce survey and audit risks to ensure staff have the right information to provide care to a more clinically complex resident. Establishing consistent approaches promotes staff competence and makes it easier to identify performance issues.
  • One of the most important steps of standardization is evaluating your technology. Do you get the right actionable insights in real time so you can understand which critical tasks have been completed, and what still needs to be done? If not, it may be time to implement new technology and programming.


The Analyze phase helps you understand the effect standardization has on outcomes, and offers the opportunity to review how these changes have impacted potential revenue from PDPM.

  • Review the data generated and determine how they have impacted your quality mix and the potential revenue mix during PDPM.
  • Review processes to determine gaps that still need to be closed. Take a look at how the collection of data has improved, and whether more changes need to be made.
  • Compare projection with MDS to identify inconsistency of data, and audit MDS to see how process changes have improved accuracy.


The next step is to take what has been learned through analyzing the data from previous changes and look for additional ways to build in efficiencies. Close any identified gaps, train staff to the redefined processes and start to roll out any new processes across the facility.

  • Implement QAPI programs to close identified gaps and update your facility assessment with what you have learned.
  • Consider shifting business models to enhance reimbursement options. Take this time to look into specialized services provisions to close the gap between occupancy and revenue, and get to know your network. There may be opportunities as consolidation occurs and homes reduce the number of Medicare beds, or close completely.

Operating after Oct. 1 and beyond

Now, the focus is to remain compliant with PDPM in 2019, and to master these new processes in preparation for the retirement of RUGS III and IV in 2020 when more payers will be affected by this process.

This is the opportunity to right these changes and scale them across your organization to achieve the ideal fit and patient outcomes. Transition to PDPM, and complete an Interim Payment Assessment on all Medicare A clients in the building on Sept. 30 with an Assessment Reference Date (or ARD, the health care financial assessment) between Oct. 1 and Oct. 7. 

Russ DePriest is a general manager and senior vice president of skilled nursing at PointClickCare.

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