Measurement of Success

October 1st ushered in the Patient-Driven Payment Model (PDPM).  Now that the transition has occurred and we are familiar with the day to day implementation, the question is: How do we measure success? Patient outcomes is the answer! It always has been and continues to be the mark by which success is measured in quality healthcare.

Success starts with interprofessional team collaborative care, which collectively includes the facility and therapy.  Therapy plans of care and facility care plans should correlate with an overarching focus on patient-centered goals and the discharge destination of choice.  Compare and contrast these plans to identify areas of improvement within the collaborative process to ensure positive patient outcomes.  A collaborative review of section GG for accurate coding and a unified approach toward identified goals is paramount.  

Other areas to closely monitor are quality measures and quality indicators for skilled nursing.  These measures impact all SNF residents.  Review reports and identify areas of strength and risk within your facility. While all measures are impacted by care in the facility, a few stand out as potential targets for CMS monitoring post PDPM:

  • Needs increased help with ADLs
  • Changes in mobility
  • Functional progress toward goals
  • New or worsened pressure ulcers
  • Experienced a fall
  • Discharges to the community
  • Readmit to the hospital within 30 days of discharge

As we continue to strive for success, our processes of collaboration will become more finely tuned.  Sometimes small adjustments make huge differences in the end results.  As we analyze and streamline processes, a maintained focus on the patient, quality of care, and the ultimate goal of improved outcomes will achieve success. 

September Breaches in the Healthcare Industry

The healthcare industry continues to be a target for hackers because patient information is highly valuable.  On February 14, 2019, CBS This Morning reported social security numbers sell for $1, credit card numbers sell for up to $110 and full medical records sell for up to $1000 as reported by Experian.   

In an article in the HIPAA Journal on October 21, 2019, there were 1,957,168 healthcare records compromised in breaches from a total of 36 breaches over 500 records. The breakdown of the causes of the breaches are below.

  • 24 – Hacking/IT incidents
  •   9 – Unauthorized Access/Disclosures
  •   2 – Theft
  •   1 – Loss

Almost half of all the national breaches in September involved phishing attacks.  Ransomware attacks are also troublesome for the healthcare industry.  One ransomware attack in September resulted in 528,188 records reported as potentially breached in an attack on an OB-GYN provider in Jacksonville, Florida. 

Avoid phishing attacks by:

  • limiting the amount of personal information you make public through sites such as LinkedIn, Facebook, etc.,
  • implementing multiple layers of approval for major transactions such as requiring two people to sign off on wire transfers,
  • taking part in your organization’s security awareness program,
  • exercising healthy skepticism,
  • verifying identity and not assuming someone is who they say they are,
  • deleting emails containing PHI as soon as they are no longer necessary to retain,
  • never sharing your password with anyone,
  • changing your password regularly, using strong passwords, and
  • before clicking any link – STOP. LOOK. THINK.

What Isn’t Changing Under PDPM: Skilled Care Requirements

The technical requirements for Medicare Part A coverage have not changed.

Physician Certification and Recertifications

The physician must certify that the skilled care is needed on a continuing basis because of the resident’s need for skilled nursing or rehabilitative care. 

Certifications must be obtained at the time of admission or as soon thereafter as is practical. The first recertification must be on or before day 14 of the Medicare stay, and each recertification after that must be at intervals not exceeding 30 days from the last recertification. The timing of 30 days is based on the physician’s signature for the designated recertification beyond the 14th day.

If a resident is admitted (or readmitted) directly to the SNF from a qualifying hospital stay, the resident can be considered to meet the level of care requirements, up to and including the ARD for the five-day assessment, when correctly assigned to one of the designated case-mix groups. Although the case-mix groups have been updated for PDPM, this provision remains in place.

In conclusion, if questions remain as to whether your new admission or readmission qualifies for skilled care, please reference the Medicare Benefit Policy Manual, Chapter 8, section 30.2.

Technical Requirements

  • The prospective resident must have Medicare Part A coverage with days available in their benefit period.
  • The individual must have been an inpatient of a hospital for a medically necessary stay for at least three consecutive calendar days (midnights). Days in observation or the emergency room do not count.
  • The beneficiary must be admitted to a Medicare-certified bed within 30 days of the qualifying Part A stay. The transfer and admission to the SNF can be from the beneficiary’s home, assisted living facility, or a non-skilled stay in a nursing facility. The day of discharge from the hospital is not counted in the 30 days.
  • The beneficiary must require skilled care for a condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF for treatment of a condition for which the beneficiary previously was treated in the hospital. Remember that the applicable hospital condition need not have been the principal diagnosis that precipitated the hospital admission, but any condition present during the qualifying hospital stay.

Additional factors needed to establish eligibility for skilled coverage remain in place. These include:

  • Services must be ordered by the physician;
  • The resident requires daily skilled services:
    • Five days or greater per week for rehabilitation services;
    • Seven days per week for nursing services; or
    • Six days per week for skilled restorative programming (with a word of caution that, when skilled services are based on a skilled restorative program, medical evidence documentation must justify the services, which generally are only a few weeks in duration);
  • The daily skilled services must be provided as an inpatient in a SNF; and
  • The services delivered must be reasonable and necessary for treatment of the resident’s illness or injury.