Journey to PDPM, Stage 5: Operationalize

July 12, 2019 Stephanie Mancini

You’re almost there! The 5th and final stage to achieving success on your PDPM journey is to Operationalize. So, what does that mean? This stage is about maintaining the changes that you have implemented throughout the first 4 stages of the journey. The goal is to remain compliant with PDPM beyond 2019 and to master these new processes in preparation for the eventual retirement of RUGS III and IV.

Let us be clear though – completing stage 5 does not mean that your journey ends October 1, 2019. By completing this journey, and having all the right tools and technology in place to support your people, the path to future payment changes will become easier to navigate.  

Here are some guidelines for completing Stage 5:

1. Transition Successfully to PDPM
The most important part of this journey is the successful transition of payment assessments from RUGs to PDPM. Each resident needs a PDPM assessment after September 30th, 2019 so reimbursement will not be interrupted.  The transition process will require some significant planning to make sure all the required documentation is in place for each assessment.  Homes will need to remember that lookbacks for assessments start prior to October 1st since the ARDs need to be between October 1st and 7th.  All Med A residents in the home on September 30th and October 1st, 2019 will need an assessment. Resources and staffing will need to be carefully considered to ensure the work gets managed appropriately. 

2. Monitor and Audit MDS With the New PDPM Rules
Once PDPM is in full effect, make sure coding processes and any tools are supporting PDPM as intended. Make sure your MDS coordinators are comfortable with any new or changed processes and any new tools that were implemented for PDPM. Their buy-in and feedback will be invaluable to your success.

3. Monitor Care Delivery
Your whole team must continue to follow the standardized processes and use the tools appropriately in order for predictive outcomes and improved resident experience to be achieved. Standardization improves quality of care which in turn improves the quality of life for your residents.  You worked hard to improve systems to improve the resident experience; make sure your hard work is maintained by putting the right monitoring activities in place. 

4. Ensure You Can Survive an Audit Without Claw Backs
Again, getting through PDPM doesn’t end on October 1st.  With every significant change to reimbursement, there is a period of increased auditing by CMS after implementation. They will be targeting homes with significant gains in reimbursement, with noticeable drops in the use of therapy amongst your resident population, and issues with reimbursement compliance (i.e. assessment dates and submission timeframes are not being met successfully). The key to not losing money will be in your concise and easy-to-find supportive documentation within the resident’s records. Make sure monitoring of processes also includes the documentation required to support care and services delivered.

5. Scale Approaches for All Payers
Don’t forget to ensure that staff are made aware when additional changes occur to the different state and insurance payment models. There may be technology setup changes required to address modifications to reimbursement methodologies by payers (rates and assessment schedules.) Keep in mind, other process changes may need to be made to avoid disruptions in reimbursement.

Want to review what you’ve learned throughout your journey to PDPM? Watch the webinars associated with each of the 5 stages:

Stage 1
Stage 2
Stage 3
Stage 4
Stage 5 – need to add link

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