Listen to the episode:A New Payment System, Changes in SNFs
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Gray: Welcome to ASHA Voices, I’m James Gray.
On this show, we discuss the stories behind how we communicate and how that communication changes our lives.
Soon, we’ll see a change in how Medicare reimburses for services at Skilled Nursing Facilities, or SNFs. We’ve heard lots questions about these changes from speech-language pathologists working in SNFs. So, we’re dedicating our entire show to this topic today.
Coming up, we’ll hear from ASHA’s director of Health Care services and a panel of SLPs in leadership roles at rehab companies. We’ll discuss both challenges and opportunities they see in this time of change.
Melissa Collier: I think that a lot of SLPs who are suffering with maybe some symptoms of burnout in SNFs. I think that PDPM is gonna be refreshing in a sense. My hope is that SLP’S will feel more empowered under PDPM, which is going to help everybody involved.
Gray: Stay with us for this conversation about health care trends, patient outcomes, and the evolving role of speech language pathologists in SNFs.
This is ASHA Voices.
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Gray: Support for this episode of ASHA Voices is brought to you by the Office of Multicultural Affairs at ASHA. Celebrating 50 years of increasing diversity and cultural competence.
Additional support for ASHA Voices comes from the 2019 ASHA Convention. Join 15,000 of your fellow ASHA Imaginologists for ASHA’s largest in-person professional development and networking event. Registration is already open. Find out more at Convention dot ASHA dot org.
Gray: If you aren’t familiar with the world of SNFs, picture a place where clinicians help rehabilitate people with life-altering conditions, like stroke or traumatic brain injury. If you walked through the halls you might see SLPs working with residents on communication, or cognitive and swallowing skills.
A change is coming to these facilities on October 1. If you walk down the same hallways after that, you probably won’t notice much difference in what SLPs are doing. But you might see changes in how they’re doing it, and maybe in how patients are using their services. And people have big questions about that.
The driver behind all this is the Centers for Medicare and Medicaid
Services, or CMS, which is changing how it reimburses for services provided to patients covered under Medicare Part A.
So, whether you’re interested in the changing tides of patient care, you have a family member receiving long term care, or are working or looking to work in a SNF, listen up. We have a lot to talk about.
GRAY: Joining me now to break down just what’s changing and what’s not, is Monica Sampson. Monica’s an SLP with a clinical career in SNFs. She’s also the Director of Healthcare Services at ASHA. Monica, welcome to ASHA Voices, thanks for being here.
SAMPSON: Thanks for having me.
GRAY: The new Medicare payment model known as PDPM, or the Patient Driven Payment Model, goes into effect on October 1st. Tell me how we got here. Why did CMS decide to make these changes?
SAMPSON: The PDPM will replace the current model which is the RUG-IV. PDPM aims to reimburse for services based on patient outcomes, while the current model focuses on the amount of therapy provided. At the core of it, we’re not changing what we do, and the kind of skilled services we provide, but it’s a question of who’s on our caseload, and how we’re splitting the pie. So it’s the same amount of money, and considering we now have more players, uh, in the mix, how are we going to split the pot of money so that it is ultimately focused on moving the patient forward and improving their outcomes for discharge back into the community optimally.
GRAY: So this is a values question. It’s saying, we can’t judge a patient just by minutes, and quantities like that; instead we need to look at what’s changing with them. That true?
SAMPSON: Absolutely. And you asked me a question about the motivation for change. As I mentioned earlier, the current system is set up to maximize the amount of therapy provided to patients. It unfortunately created a system where there are some players who have… played to the financial incentives. e’ve seen this play out in investigations of rehab providers for fraud and abuse by the Office of Inspector general and the Department of Justice. At ASHA from, a… clinician perspective, we’ve constantly heard from many members about how the existing model has set up an environment which has in some ways undermined our clinicians, clinical judgment, and where they feel that their expert opinion and skilled services have not been valued, and sometimes been overruled by administrative mandates.
GRAY: So what I’m hearing you say is that this decision, it’s looking at how we can improve patients, and see their patient characteristics, but it’s also, an opportunity to help SLP’s because of some issues they’ve had. What kind of things have you heard from SLP’s?
SAMPSON: There is one call from a member that very early on in my days at ASHA, that has kind of struck with me. She was extremely frustrated that she was expected to meet a 90% productivity every day. She felt that her skilled services and her independent clinical judgment were not being exercised in this situation. So we chatted a lot about what is going on at the level of the facility. Part of her frustration was that you know, she really had never been taught to have these conversations with stakeholders. How do you plug into the business of healthcare? She had no context for coding and reimbursement, she didn’t know how her clinical services were fitting into the business needs of the facility and her employer. The stress from this was driving her to consider leaving the field.
GRAY: You’ve touched on a lot a things I wanna talk about in this conversation, which is issues of how SLP’s can advocate for themselves, and how their understanding of coding and comorbidities can get them more involved in their SNF. But also, I just wanna kinda bring this full circle real quick and say we’re looking back right now. We’re looking at the current system that will be replaced by PDPM on October 1st. Looking forward, will this new payment model, PDPM, resolve some of these issues?
SAMPSON: PDPM is not the pill to end all ills plaguing the SNF industry, and we all recognize that. But I think it’s a step in the right direction. It is putting the patient at the center of it. It is, it, therapy, is based on patient characteristics, and that is driving what we do. It is person centered care, it is inter-professional service delivery, and, the, new system gives us the opportunity to capitalize on best practices. It forces us as providers to rethink status quo, and kinda be creative in who we provide services to and how we deliver them.
GRAY To help us do some speculation and look at the future, I’m gonna bring in 2 guests now. Kelly Cooney is the Vice President of Clinical Compliance and Training, at Therapy Specialists, a company providing rehabilitative services in SNFs, including speech-language services in California. And she’s the President of NARA, the National Association of Rehabilitation Providers and Agencies. Kelly, welcome to the show.
COONEY: Thank you very much.
GRAY: And Melissa Collier is the Director of Audit Compliance at Rehab Synergies, LLC, a company that provides rehabilitation services including speech-language treatment in SNFs, located in Texas. Melissa also runs an active Facebook group about PDPM for SLPs Melissa, thanks for joining us.
COLLIER: Thank you for having me.
GRAY: And I wanna mention that you’re both SLP’s, (Right) ‘cause I think that’s an important part of this conversation.
COLLIER: Correct, yup
GRAY: We’ve talked about what’s changing , looking at quantity of minutes versus quality and patient characteristics, and I just kinda wanna talk about that idea of value over volume, and ask you, in your roles, how do you, where do you see that playing out?
COONEY: I’d be happy to start. This is Kelly . . .
COONEY: John Cane from CMS told a story that really resonated with me that I think explains a little bit this shift from volume to value. He said his own father was in a skilled nursing facility, and he walked into the gym, and he looked around and he said, “Huh, I could look around this gym and tell pretty quickly by just asking two simple questions, how much we at CMS are paying for each of the people that I see around me. I needed to ask how many minutes of therapy they got this last week, and I needed to ask a little bit about the level of assistance they needed from nursing. And he said it was, really resonated with him that we needed to know more about the people, to know more about what should be paid for their care. Because each one of those people has very unique needs. And so this new system is really set up to do just that. It’s set up to kinda determine the comorbidities that each person has, and to better reflect the care that they need. And it’s refreshing, I believe . . .
COLLIER: Yeah I, I totally agree. I do think that PDPM has the opportunity to put that clinical decision making back into the hands of the therapists, so that we as clinicians can guide and determine what each individual patient needs, based on their unique characteristics.
GRAY: I’m thinking about that, and I’m wondering, when we talk about value and patient characteristics, are you anticipating change in results for patients based on this different mindset?
COONEY: I certainly do actually. I think when I talk to clinicians. Because the new model that we’ll be entering into and getting good at, really focuses on all the comorbidities of the patient, and really helps identify some areas where we may have had facilities that didn’t recognize the value of speech pathology for cognition for example. I believe, and I’m seeing in practice in our facilities, that because that facility is now more aware, because they are having to report these different characteristics in order to receive payment, of those characteristics. And it’s creating a more interdisciplinary team approach . . .
GRAY: That’s interesting . . .
COONEY: That really allows the speech pathologist to have some impact. They’re bumpin’ into people on the team that maybe weren’t as interested in hearing from them before, and really havin’ an opportunity to, to create some change in outcome.
GRAY: I’m hearing you say Kelly, that you’ve seen more interdisciplinary work. Have you already, started to maybe pilot some changes or something?
COONEY: Absolutely. Some of the areas where we’re seeing some changes, and where our organization and a lot of our NARA members are… really focused is, for example the speech-language pathologist might be interacting with a person that fills out the section of the MDS that includes the cognitive impairment. They might be more involved in sharing information with that person. Before they operated a bit in isolation, now they’re operating more together. So we’ve developed some tools for communication so that those folks can hear from each other, and we’re creating a lot more opportunity for one to one dialogue between those folks as well.
GRAY: You mentioned specifically there are tools. I’d love to hear some of those if you could share ‘em.
COONEY: Sure. So our organization at Therapy Specialists, we created a worksheet that the speech pathologist fills out on evals that looks at some of these items that are gonna be important for reimbursement and shares what they found with the interdisciplinary team. And I think it goes back to Monica’s point about understanding the business side. The patient with aphasia takes more resources than someone without. And so CMS has allocated more resources for that person. So it’s kinda like the bill that we’re sending for our services to Medicare, and we need to make sure that we’ve got everything on it that, that will represent the care that this person requires.
SAMPSON: You know, a more medically complex patient clearly needs additional care from several different disciplines, (Right) and the system is ensuring that everybody who needs to be invested in the patient’s care is actually appropriately recognized and reimbursed for their services. That kind of leads me to a concern that many of our members raise, which is where some SLP’s are thinking guaranteed payments for minutes under RUG-IV can mean a guaranteed job. And if the number of billable minutes of treatment change, that could mean a change in how much I’m needed, and how many hours I get to stay at a facility, and would I continue to have a fulltime job. What would you say to SLP’s who clearly have some anxiety about these?
COLLIER: I think on my end, this is Melissa; in the Facebook group that I run, I get that question a lot, Monica. And my response is always that we have to remember that the requirements for a patient to participate under our Part A program in skilled nursing is not changing. That if a patient requires medically necessary speech-language pathology services under RUG-IV, they should require those under PDPM. The only thing that technically is changing is the way that we are paid. There may be some business decisions that swing one way or the other on the pendulum as people try to figure out PDPM, but ultimately if a patient requires medically necessary services, there should be no change in the way that we treat our patients.
GRAY: I find what you’re saying right now really interesting about that there won’t be any change. I know that some SLP’s are anxious that their services will be used less.
COONEY: I think it’s time of the, of innovation in the industry. People are really looking to say is what we were providing, Was it truly clinically everything that we were doing, providing the value that CMS is requiring of us now? And in many cases, absolutely. And in other cases, you know Monica talked about sometimes there were providers that were doing things for the wrong reasons. Those calls that ASHA was getting from people saying “I don’t think this is right”, right. Those providers may be taking a step back and reevaluating how they do things. So I think we as clinicians need to really focus on our outcomes. and we know exactly what we’re being measured on, right. So that’s another, kind of going back to knowing about your industry, and knowing about what CMS has helped determine brings value, and is going to be looking at your facility and, and providing or taking away payment; penalties perhaps, if your facility does not reach certain outcomes.
GRAY: We’re gonna take a quick break. When we come back, we’re gonna continue our conversation with Monica Sampson, Kelly Cooney, and Melissa Collier. We’ll talk about changes in group and concurrent treatment. This is ASHA Voices.
Support for this episode of ASHA Voices is brought to you by the Office of Multicultural Affairs at ASHA; celebrating its 50th anniversary. OMA is focused on helping ASHA members address cultural and linguistic diversity in the speech-language-hearing world. Find resources to increase your cultural competence by going to ASHA dot org and searching for multicultural
Additional support for ASHA Voices comes from the 2019 ASHA Convention. Learn about the latest research, expand your clinical skills, discover new products and earn continuing education credit. The ASHA Convention will take place in Orlando from November 21st to the 23rd. Registration is open. Find out more at Convention dot ASHA dot org.
We’re back with Monica Sampson who’s the Director of Health care Services at ASHA. We’re also joined by Kelly Cooney, the Vice President of Clinical Compliance and Training at Therapy Specialists. She’s the president of NARA. Also with us is Melissa Collier, Director of Audit Compliance at Rehab Synergies LLC.
I wanna talk about group and concurrent treatment now. PDDPM involves significant changes in what we might expect in group and concurrent treatment.
With changes coming to groups, some are anticipating that we’ll be seeing more group and concurrent treatment. So first I’ve seen members raise this question; I wanted to bring it up. What’s the difference between group and concurrent service? Melissa, maybe you can help us understand this.
COLLIER: Yeah absolutely. One of the great parts about PDPM as Kelly mentioned a little earlier, is that the group definition did change. Currently under RUG-IV, the definition of group is a treatment of 4 patients, regardless of payer, doing the same or similar activities. Beginning October 1st, that definition, removes the criterion of 4, and replaces that with 2 to 6 patients. So it does give SLP’s and other clinicians more leeway in clinical decision making as to the size of their group, which I appreciate. Concurrent on the other hand, definition of concurrent is treatment of 2 individuals that are either doing similar or un-similar activities. And so historically for group and concurrent, RUG-IV made some pretty large changes back in 2011 when we were, um, dis-incentivized, um, per say, uh, to provide group, because we were required to divide those minutes. And so a lot of clinicians felt that given the amount of time and work it takes to develop a group therapy session, that it might be better to just use that time in one to one. So currently we’re in a situation where under PDPM, those minutes are counted in full as coded on the MDS on the initial Medicare assessment and the discharge assessment, so we no longer have to worry about minutes. So I think that the opportunity for group and concurrent is going to be huge.
GRAY: would people be seeing if they’re watching group and concurrent services?
COLLIER: well you’d see a lot of laughter, (Laugh) and a lot a fun. one of our facilities has recently been doing a medication management group for those high functioning individuals who are preparing to go home. You know they have their medications, they’re doing it. It was almost kind of a race, to see who could put their medications in the right, pill box in the, on the right day, and who could finish first. So again, there, there comes that competitive kind of fun interactive socialization component that we’ve been missing in my opinion in skilled nursing.
GRAY: Social. That seems like one of the key words to me. Kelly, could you speak to a little bit bout, for you, if you see the social impact of group and concurrent treatment? And if you anticipate seeing more of it?
COONEY: you know life doesn’t happen in this sterile clinical treatment environment. We oftentimes as therapists try to help our patients be successful by… decreasing distractions and modifying the treatment environment so that they are most successful. But then we need to send them home, or to an assisted living facility, or to the skilled nursing facility long term, where life doesn’t happen that way. Right? So we need to look at neuroplasticity principles, and we need to get past quality and intensity and repetition and specificity, and move into things like transference. How is this person able to apply this skill to new tasks and new situations? And what happens when they get some environmental constraints that they haven’t had before? How do they perform? Because that’s what happens in real life. And so, we have a responsibility during the patient’s time with us there, to make sure that they’re able to carry that over in a way that they think, that we think they would. And so, providing treatment in that sort of group or concurrent, uh, manner is gonna help with that. Right? It’s gonna help us identify those problems before they go.
GRAY: what do you believe needs to be in place for successful implementation of group and concurrent treatment? And that is to say too, not just as far as time, but also as far as what activities are involved. Like, what are we gonna see if we’re looking at successful group and concurrent treatment?
COONEY: I think we definitely need some structure. I think we’ve all talked about some programs, you know. If not your company, are you, thinking about some ways, that you can have some replicable programs. So is it medication management where we have enough pill boxes for everybody to simulate a medication management regime, and follow those directions and be able to use thought organization and maybe OT’s involved with some fine motor skills as well. we’ve been working on this for the last several months, and, and really focusing on function, and getting some great ideas and tools from our communities, because our therapists are really creative. So we have a shopping task for example, where we, we have a people are gonna need to go home and go shopping, right. Can they safely reach things on high shelves, can they reach things on low shelves when they’re working with PT and OT? Can they transition a recipe to a shopping list? Can they talk to somebody while they’re shopping? So it integrates, and works with all the disciplines together, to get this person through a very functional task. So that’s now something we mi—we can have in a bin, you can pull that out every couple a weeks. You know our patients don’t stay all that long, so, gosh, time for the shopping task. Those patients that I have that are appropriate for that, that are gonna go home and maybe use that type of, need that type of, uh, to do, to perform that type of task can access that group.
GRAY: I wanna open this up more broadly and talk about say opportunities under PDPM. Opportunities for SLP’s and also for rehabilitation facilities like SNF’s and also opportunities for SNF’s. What kind of things do you think could be working well? Let’s, maybe we can speculate. If you’ve tried anything so far that you’ve found successful with, we’d love to hear about that now. And Kelly, can we start with you?
COONEY: Sure. I’d say the biggest opportunity that we have, and we touched on a little bit earlier, is.. collaboration. We have a, a huge opportunity, now that the whole patient is being looked at more clinically and with more critical thinking and forethought, to really work together with the interdisciplinary team to get best outcomes. So it’s really taking a look at how the fact that this person’s diabetic, how it might be impacting their whole plan of care, right? The fact that this person has a hip fracture, but also a diagnosis of Alzheimer’s, how that may impact their plan of care. And so, you know, where we’re finding great success is creating opportunities for that collaboration. I think sometimes we may have felt like we were shoutin’ into the wind a little bit about something we were concerned about for a patient, and it really matters to the whole of this patient’s care. And because of the changes in payment, and because of the changes in quality expectation, there’s more incentive for it to matter to everybody. And, while it maybe should have all along, it definitely will more now in most facilities. And so that’s where I see a tremendous amount of opportunity is that communication of need.
COLLIER: Yeah, I think that my hope is that PDPM brings the clinical decision making back to the clinician. I know that we talked briefly on this podcast about the business initiatives and the business prospects kind of outlining, you know you need to evaluate every patient upon admission and screen every patient. And you have to provide X or there will be, you know some sort of negative consequence. And so I think that there is some freedom for clinicians to innovate, and to get more creative, and to, um, again, bring their clinical decision making back. I think that you know, we just got finished talking about group and concurrent, but I think that a lot of SLP’s who are suffering with maybe some symptoms of burnout in SNF’s. I hear that from my Facebook members, or a lot of questions about oh, I just can’t, you know, I just can’t keep it up. Um, I think that PDPM is gonna be refreshing in a sense. Um, and so my hope is that SLP’S will feel more empowered under PDPM, um, which is going to help everybody involved.
GRAY: I wanna thank my guests. Monica Sampson is an SLP, and the Director of Healthcare Services at ASHA. Kelly Cooney is the Vice President of Clinical Compliance and training at Therapy Specialists, and she’s the President of NARA. And Melissa Collier is Director of Audit Compliance at Rehab Synergies LLC. Thank you all for joining me today.
KELLY: Thank you.
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Want to learn more about P–D–P–M and how to advocate for yourself as an employee? You can find webinars and many other resources on ASHA’s website. Just go to asha-dot-org and search P-D-P-M.
And see Monica and Kelly discuss PDPM at the 2019 ASHA Convention in Orlando this November. They will be participating in a seminar where you can ask questions about PDPM to rehab organization leaders. You can also attend a presentation by ASHA’s Sarah Warren on Medicare, SNFs and Home Health. A special thank you to Sarah for giving me background information on PDPM for this episode. Registration for the 2019 ASHA Convention is open now.
And I want to highlight one more resource from ASHA: check the pages of the ASHA Leader magazine in 2020 for more information about how SLPs can advocate for themselves inside SNFs. You can also follow online at leader dot pubs dot asha dot org.
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We want to hear from you. Do you work in a SNF? What have you done to prepare for PDPM. Do you have questions for us? We might answer them on a future episode of ASHA Voices.
Email us at email@example.com Or leave us a voicemail message at 301-296-5804. We might include your comment in an upcoming episode.
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ASHA Voices is produced by the American Speech-Language-Hearing Association and comes from the team behind the ASHA Leader magazine.
Support for this episode of ASHA Voices is brought to you by the Office of Multicultural Affairs at ASHA. Go to ASHA dot org and search for multicultural, to find ways to increase your cultural competence.
Additional support comes from the 2019 ASHA Convention. Registration is open now. Find out more at Convention dot ASHA dot org.
Production assistance comes from Pamela Lorence. I’m J.D. Gray, and this is ASHA Voices.
Next time, on ASHA Voices, we’re going to look at school-based issues. We’ll stop by ASHA Connect to learn about achieving big things while carrying a heavy workload. And, we’ll talk apps for speech-language sessions with Sean Sweeney of the Speech Techie blog. Back in two weeks!
I’m J.D. Gray. This is ASHA Voices.