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In Our Evolving PDPM/PDGM World, Could Adding a Specialty Be a Game Changer?

Know Your Organization, Know Your Patients, Know Your Staff

As if there isn’t enough to do keeping quality, care and reimbursement plates spinning, the PDGM and PDPM requirements are fundamentally changing the game. A bit of angst – and for some, more than a bit – is completely understandable. But angst only gets you so far. At some point providers shift from understanding the change to maximizing performance within the change and beyond.

Adding a specialty to your repertoire in order to have more control, provide better outcomes and work within the playbook you’ve been given will be the matter at hand.

Think about it: in the skilled world, therapy minutes will no longer be the primary driver of reimbursement. The shift to clinical care for the whole patient has arrived.

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).

That’s quite a mouthful there. There are lots of ways to accomplish what is in that very loaded passage of the CMS Federal Register Final Rule.

For home health providers, on the other hand, the location from which patients originate impacts reimbursement directly. There is some anxiety around this provision in that the final rule provides a reimbursement bump for institutional referrals over the more common community referrals.

The upshot for both these provider types is that they may not thrive in a “business as usual” mode.

Pile on to this the new Medicare Advantage ruling that will allow more home health services to be covered by Medicare. This will bring in more competition in a setting that already suffers from turnover and retention challenges.

If you are a home health provider and have not been recruiting a large number of institutional referrals in the past, or a nursing home administrator struggling with how to broaden your market, one way to go about that is to take a hard look at your case mix and decide if you need to add a specialty.

It could be adding a specialty such as wound care, as noted in Home Health Care News, or incorporating dementia care, as Cypress Home Health has done. Behavioral health services are also seeing a resurgence in skilled nursing, as noted in Skilled Nursing News.

The Ohio Health Care Association recently published a study that ties improved outcomes to having wound care certified staff. The study enlisted 46 nursing homes in Ohio and used funds from CMS to send nearly 200 nurses through the wound care courses with the Wound Care Education Institute. Then the nurses took the certifying exam to receive the National Alliance of Wound Care and Ostomy WCC credential. Both the clinical and financial results were impressive.

Whatever case mix you target, plan time for analyzing what your market needs, bringing in a new specialty, recruiting patients/residents that fit that specialty, and most important, tracking and advertising your results. Insurance providers, hospitals and other care settings can’t refer to you if you don’t detail for them what you do and how you do it better than the organization setting up camp down the street.

Contemplating a Case Mix Change?

Here are a few quick pointers that apply with any case mix change you might be contemplating:

  1. Tie any new competencies to your mission – do you have a fit?
  2. Involve key people and ask for input.
  3. Analyze what is needed in your market.
  4. Can your people perform in this arena? If they can’t, consider the price and effort of training versus hiring for skills.
  5. Review current policies and procedures and develop any that are missing.
  6. Create the competencies you will need from the procedures in your policies.
  7. Develop a process for assessing initial and documenting ongoing competencies (upon hire, annually, and so on).
  8. Link competencies to resident population, acuity and diagnosis, and make them job and team specific.
  9. Build on experience, certification and education.
  10. Don’t forget contract staff.

After a change initiative is underway, don’t forget to measure and share results.

  • Get comfortable analyzing, understanding and communicating data and value to referral entities.
  • Seek out new referral entities, using the data to support your marketability.
  • Tell your story – both internally and externally. During any change initiative, it is important that your work force understands what you are doing and where you are going.

Someone wise once said, “This too shall pass.”  The trick will be not to let it flatten you while it’s doing so.


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