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Hi and welcome to today's webcast skilled nursing facility patient driven payment model a focus on clinical care delivery i'm McKnight's editor Jim Berlin and I'll be. Moderating today's event we're going to get a look at PD p.m. today in a way that is going to get down to some of its roots and explain it to you as you probably never heard it before the elements and strategies will be. Right there before us and taking us down this very educational path will be Todd King senior director of clinical services for long-term care and Nancy Laflin senior director of quality services both with Omni care a CVS health company. They'll jump in right away but first I'd like to tell you about some important things for today's presentation please get ready for some excellent note-taking opportunities the slides will not be available for download today but this presentation will be available for reviewing or viewing for first-timers shortly after it ends the session will be. Archived and available on demand by simply. Going to the registration page to enter this studio the URL is McKnight's comm slash January 29 webinar you'll see that again at the end if you are. Having audio problems with this broadcast please first check the volume control on your machine this is the most common cause of hearing problems you also have a Help. Button you can use if your own troubleshooting doesn't work also we will have time for a Q&A session near the end of Todd and Nancy's presentation if you have any questions please feel free to tap them out and submit them directly to us starting now in. Fact those we don't get to in real time will be answered afterward now regarding CES this educational offering has been reviewed by the National continuing education review service of the National Association of long-term care administrator boards and nab has approved this for one clock. Hour however you need to stay tuned to this event for its entirety during its original broadcast in order to receive a certificate note that since April 1st of last year all licensed long-term care administrators seeking. CES must provide their NAB CE eregistry ID number in there webinar registration form we cannot verify or report attendance to nab see eregistry without. This information you need more information regarding compliance with these new CEOs please go to nab web dot org slash C e registry and we'd also like to note this program is made possible by support from Omni care please visit your friends there at WWMT care comm now a little bit more about our presenters Todd King serves. As director of. Clinical services for Omni care he manages consultant pharmacists and clinical managers implementing clinical programs and managing managing facility formulary while providing education for staff and customers across a wide stretch of America Nancy Lachman is a consultant pharmacist and is the. Senior director of quality services for Omni care she holds a certificate in gerontology and has spoken on many long-term care related topics like Todd. She is also a fellow of the American Society of consultant pharmacists and has held many procedures posts with industry groups well Todd there's a lot to adapt to with all of this PD p.m. preparation no question but what. Do you think the most important. Thing providers really need to get up to speed on still. Regarding clinical aspects of PD p.m. well thanks Gianna. A big question and you know when Nancy and I started preparing and looking at PD p.m. we really saw some opportunities around what CMS has done around the reimbursement with clinically complex residents and clinically complex conditions so what we had to do today is kind. Of talk a little bit about that and get some some ideas and some opportunities on how facilities can really get the most out of their outcomes with this. New process already well it sounds like a great jumping-off point if you're ready why don't you take it away yeah once again thanks Jim and Nancy and I'd like. To first of all thank everybody for jumping on the call and the webinar today we're really excited about the opportunity because with this new case-mix reimbursement process P DPM as we all know. It by now there seems to be a lot of opportunity out there and many of you are probably wondering well why are two pharmacists here today talking to us about this new case-mix reimbursement model and you know as I mentioned previously when Jim asked the question we do really think there are some opportunities. For providers to dig. Into the clinical aspects of the reimbursement models and also look at the changing environment. And opportunities to provide the highest quality outcomes at the most appropriate cost for your residents so what we're going to do today is kind. Of go through some of the background information about PD p.m. talk a little bit about some of the nursing aspects non therapy ancillaries which is a hot term that you guys. Are probably familiar with we'll dig into those a little bit and talk specifically about. Some of the conditions that we're going to be dealing with more frequently in long-term care facilities and at the end we're going to tie it up with a. Couple case presentations of some actual potential residents and some of the opportunities that we see from using this model on some of these new types. Of reimbursement structures that we'll see so Nancy is going to go through predominantly the background information and talk a lot about the ways that some of the things are changing and some of the clinically complex. Opportunities that there will be out there and we're really looking forward to the opportunity and would appreciate your questions at the end as Jim mentioned so Nancy I'm going to turn it over to you and we'll be discussing a lot of things going forward and I'm really looking forward to the presentation and. Going through the questions well thanks Todd I appreciated. You well know by now the goal of PD p.m. is provide patient centered care and to treat the whole patient instead of reimbursing nursing facilities primarily for rehabilitation services we'll be looking at an October the 1st 2019 beginning of CMS's fiscal year rugs will. Be discontinued abruptly and the patient driven payment model places PDMP as it's called will force on focus us on critical conditions patient diagnosis comorbidities and history of the most recent hospital stays for reimbursement rates rehab services will take a lesser role in reimbursement and P DPM. Will affect Part A keep in mind but not Medicare Advantage patients I think that many of our administrators would consider the ratio of Part A. To Medicare managed care and determine if the Part C type of patient or Medicare managed care patient would be appropriate for your facility and the services that you provide or you're ready to jump right in and continue Medicare Part A patient services under the new reimbursement system so what we'll see. Is a shift from non - non therapy ancillary. Services and nursing services and less emphasis on services that were delivered through rehab or extensive. Services that you see what we'll see is a combination of extensive services with non therapy ancillary services and with nursing services to deliver a case mix that finally reimburses the facility for what the services they actually provide what we'll. See under this new system is that your per diem rate should be budget neutral where rehab therapy will. No longer drives payment patient characteristics MDS coding will drive reimbursement there the emphasis on those assessments and the skills and knowledge of your resident nurse assessment coordinators will weigh heavily on the reimbursement that you receive from CMS. For your part a patient the overall intent of P DPM is a multi-faceted for example to decrease the cost of rehab therapy by changing its delivery systems and considering group concurrent and one-on-one services. While separating physical and occupational therapy from one another as it is in rugs to increase patient outcomes facing care plans now on a patient's functional ability and goals augment your revenue sources for. Clinically complex residents and. Patients who might benefit from therapy but had not been recognized before on using the MDS. And to provide the payment the facility is really do by correctly classifying each resident using the MDS to document patient conditions and their characteristics to put them into a category of payment so the questions asked is why are rehab services so important and why did we focus on them for. Almost twenty years now right now ninety percent of Part A stays our bill for rehabilitation services the rugs payment rates are certainly not dependent on the clinical conditions except for depression as part of the rehab case mix and once rehab minutes were categorized. The assessment did not go further to consider any additional needs that our residents were needed to be provided by nursing services or non-therapeutic services so this is a real opportunity for not only the lesser focus on just rehab but. The ability to really use the skills that we have promote a disease. State management open more widely the opportunities for new admissions develop Mitch services and use the new payment model to develop strengths that you've never realized you had before and use them to improve and increase. Your senses as we compare the rugs categories to the. New PDP M we will be shifting from our 66 current categories of care to five distinct case-mix groups that stand alone but they all now include a casement. Patients or separate PT your physical therapy is separated from occupational therapy and speech and language pathology stands alone but it does take into consideration now the clinical services required by residents who may have for example suffered. A stroke or have dysplasia it will also consider the non therapy ancillary services and. As a nursing services which now have their own case mixed. Group PDMP won't redistribute payments to the clinically complex that you admit in. Your facilities for example conditions that will pay more under P BMP or things like IV therapy we'll see an increase in payment diabetes. And medications that are included and embedded into those payments scales for these disease states or conditions as with anything left new there always seems to be as long as there's dollars in cents involved some type of. Catch does is they're then built into the PDMP are some regressive payments what we'll see is the physical and occupational payment rates will decline by 2% every week after day 20 of each stay the non therapy ancillary services will decline 66% on the third day of a patient's day that means that pharmacist may need to help you optimize. Drug therapy early in a residents day such as providing admission medication regimen review to help you identify the barriers and. Adverse effects medication errors and upon transition to assure that the. New admission has a successful stay in your. Nursing facility while you maximize the payment rate for them so of course so that means that the initial MBS will be critical in its accuracy to leverage payment especially for. Your new admissions and these three categories that have some. Type of regressive payment today we are going to concentrate on nursing services that require clinical information ADL's extensive services the presence of depression and restorative nursing to take a look at where your reimbursement is going to come from and how you will begin to identify the. Residents accurately and build care plans for them the. Wonderful thing about nursing services is that it is not regressive in its. Payment so once you admit you submit. Your first MDS and you gather a payment rate for that individual and nursing services that payment rate will remain the same for the non therapy. Ancillary services we will be concentrating on the comorbidities and extensive services. Included in the care for these residents and your payment for those types of services keeping in mind that even infusion medications are embedded into these payment rates so of course you probably realize by now that the source of all a PBM patient characteristics and diagnosis will come directly from the minimum data set the facility will submit an admission MDS. And then the next mandatory MDS isn't until the discharge of the part a stay so the 14-day 30-day 60-day and 90-day MDS are eliminated the discharged MDS will be performed on the last day of the part a stay to capture the correct payment there are new. Additions and sections to the MDS including sections i J o and GG and new diagnoses have been added that include diseases of the colon to assure that you appropriately reimbursed however that reimbursement rate will hinge on the accuracy of the first MDS so you have. Until they eight to submit that initial admission MDS for a Part A stay and I think that everybody agrees to take their time assure that you have researched all diagnosis assess all conditions and assured that the. MDS is scored appropriately to assure you get those monies that are due to you based on the services you will be providing so in just a review the five-day MDS can be performed on day 1 through 8 there is an interim payment assessment MDS that has to be submitted no later than 14 days. After a change in classification or a change in status however if the resident even went out to the hospital it may. Not necessarily reset the day to day one for the tapering so that means if you do an interim MDS on the 21st or 22nd day of our reham stay you will still suffer the same regressive payment as it was for two percent after the 20th day then that PPS. Discharge assessment will be done on the last day of the port a stay keeping in mind that as mbss or to be compared quarter to quarter CMS will be comparing your initial MDS to your last and. Discharge MDS to see how the resident progressed and what their functional capabilities are and then determine the type of payment that you will be receiving for that individual new to. The MDS is information about the quality a qualifying hospital stay this part of section J is going to be modified to collect data on the patient's surgical history while they were in the hospital and there are 29 different surgical history codes and we have listed just. A few of them accessing the hospital information therefore will be an imperative to enter these items correctly on the new MDS these 29 codes will help set the primary reason for the nursing facility stay and begin to classify the new admission into a. Clinical category for payment so facility nurse assessment coordinators will have to capture all of the appropriate. Icd-10 codes used in the new section I. Neff primary diagnosis to assure that the diagnosis is reported as the primary reason for admission swallowing disorders aphasia and special treatments and procedures have always been on the MDS but now finally they will. Count towards payment in addition to diseases including ulcerative colitis Crohn's disease and inflammatory bowel disease it's been said that as we shift from. The cost of rehab the cost of medications will go higher as you probably recognize from a number of commercials on television for ulcerative colitis and for current disease these are all treated by medications and they will be the center of the cost for this individual there will be very important. To capture all of the patients other conditions as well as their functional. Abilities to assure that they fall into the best case mix within the category to assure you have the best payment rate while functional status or ADL's has been used for years to score as a case-mix Section G G of the MDS functional abilities and goals. Will now assist in CMS's identification of. Assistance and self-care Section G G will be asked on the admission MDS and on the discharge MDS to calculate not only the functional status or improvement of the resident during their stay but will actually also be used in calculating the quality measures for functional abilities the functional abilities that will. Be assessed in this. Section that will count torpe Minh will be the. Residents ability to roll left and right to sit and go to a lying position to move from a lying to a sitting position on the side of the bed chair and bed transfer to a chair toileting transferring walking fifty feet with two turns or walking 150 feet you're already familiar with section G G but after October the first. Disease will count in your payment rate so as you can see from this very simple gray grid finally occupational physical and speech therapy as well as nursing services and non sorry the ancillary services will all have a. Case mix index assigned to them that means that many many questions on the MDS will help improve the reimbursement for these residents based on their characteristics and. Their needs however keep in mind that physical therapy occupational therapy and non therapy ancillary services will. Be regressive in their payment so before we had four major categories in run today we have a breakdown of five major categories with the non case mix actually based on your rate in October 18 for your cost so that we can come up with a base per diem rate for your facility so let's talk briefly about non. Therapy and Fleury services this. Is where your cost is going to. Shift and it is one of the most important changes coming our way October the 18th non therapy ancillary services will account. For about 43 percent of your nursing rate as CMS has calculated it from October 2018 but as I said before it tapers after the third day of stay it does include the cost of medications which has been embedded into it each of the residents has. Points allocated based on the number of conditions the average resident has about six diagnoses or conditions that that we see on any average patient these all have the ability to now be captured in the MDS and assigned a point value to determine payment for that. Individual there are 15 conditions that have greater than one point that may be where you find your niche service while there are 30 conditions that have one point but when you add to them all up with these concomitant conditions you will see that there is great value and taking the complex resident into your facility and treating them because finally. Will be reimbursed for those services your attention to be brought to hiv/aids which. Now has eight points assigned to it which is the very highest. Diagnosis that you will be paid for in the ninth era P ancillary services but again how do we manage hiv/aids well it's the cocktails with medications and antiviral therapy nutritional support it can be vitamins at times it could be. Two feedings and. Appetite stimulants so all of these items are captured on the MDS but again I cannot overemphasize the accuracy of the resident nurse assessment coordinator. In capturing all of these services for which you will be reimbursed when you just take a look at their reimbursement non therapy ancillary services who would have ever thought 20 years ago that long-term care facilities will finally be reimbursed based on the age of the resident and it appears that the younger the resident is the more. You will get paid and in terms of cognition for example there are some very granular detail to the science that went behind approving or estimating the cost here for example we know that as you assess cognition we find residents who are not impaired a slightly cognitively impaired moderately impaired and. Severely impaired but each one of these has a different case mix to be. Added to the non therapy ancillary services and count for payment so when you see all of these such as cancer or infections taking someone into the facility with arthritis or swallowing disorders or after a stroke or sepsis before we as we were handling sepsis we would stop with extensive therapy and that the resident was probably. On an infusion medication today. These services will be higher reimbursed and we. Expect to see an increase of 25% just in IV medications alone so love behoove us as we go through. This learning process over the next several months to understand your cost today and where they will be in the future there is a lot of minutia in understanding the technicalities. That went in to identify each of these different services and conditions but quite frankly what I see here are a lot. Of niche services and we must get over the fear of taking residents with HIV or taking a residents who have a tray or need ventilator or respiratory services as a matter of fact I anticipate that there will be some facilities in dealing with things like respiratory infection respiratory failure ventilator services respiratory services that we might. Even see the return of the respiratory therapists back into our building the conditions that are included in non therapy ancillary services are HIV AIDS IV feedings or total parenteral nutrition IV medications. And respirators so HIV scores 8 points while. IV feedings or TPN scores 7 points IV medications or antibiotics used to treat let's say osteomyelitis gains 5 points and ventilator and respiratory services provide 4 points all the rest have 2 points but take a look at the ability to do or. Transfusions in long-term care understand taking a person with a lung transplant or a major organ transplant requires you to have the medications immediately available for example one missed dose or one day of doses missed on. A medication that avoids rejection can cause the resident to reject within 24 hours so we need to bone up on our skills understand what we need to have available understand the. Types of medications such as specialty drugs that are used today to treat and manage multiple sclerosis asthma COPD and chronic lung disease and take a look at the bone and joint infections some of these really need assistance and the hospitals are driving them out of. Their setting and right into ours certainly with the assistance of your medical director and your pharmacist as well as your dietitian there. Are a lot of opportunities here to take the type of residents that we were a little shy of. Taking before but it does mean that. We'll need to really lean on one another. To deliver holistic clinical services that are multidisciplinary in addition there. Are many many conditions that will provide one point however you know you'll be getting credit for someone you've got a tube feeding or someone with an ostomy or someone who is on ms+ they have an intermittent. Catheterization or someone who has end-stage liver disease or chronic. Pancreatitis you'll finally get paid for malnutrition these things become very important and as you can see if someone. Has malnutrition and they're on. TPN and they may have an IV medication with that you're. Finally looking at someone who might be four or five points to the. Advantage when it comes to payment so non therapy ancillary utilization was calculated by taking a look at data for Medicare Part C and Medicare Part D prescription claims to risk adjust the conditions that were decided upon to be included in non therapy ancillary services these conditions were also not. To diagnosis from discharged patients to the long-term care facilities that were discovered on the 5-day MDS and included the primary diagnosis for admission they use Medicare Part C to estimate the. Utilization of Part A and Part B services and they use Medicare Part D medication claims to adjust the drug cost prediction for these types of conditions or disease states for. Which they are you will now be paid they use both of these to define the conditions and include them in the non therapy ancillary services so I was happy to see things like COPD which we know we have residents. That go into the hospital several times during the year in spite of the fact that we've given them their vaccines and immunizations and their inhalers but when you treat someone with Pete COPD that inhalation therapy or the inhalers that course is embedded into these non therapy ancillary services and the score that. Is assigned to the resident let's take a brief look at nursing services nursing services like everything else will depend on your MDS data some of the data will affect case mix of other categories and payment such as depression so while we may seem mundane and they may be components of the MDS that we've. Always answered right now they have far more meaning and that they determine the payment rate for which you will receive from CMS most interesting. You can see here that insulin dependent diabetes is one of those that will you will be paid for but what is your diabetes management program in the nursing facility do you want to have a sliding scale for the entire Part A stay how will you move your resident from being having. Multiple doses of insulin over the course of the day to being managed to maybe two three or only four injections over the course of the day you will finally be paid for patients who are using radiation or at two dialysis or have as I. Said before cognitive deficits and even it recognizes in PD p.m. that behavior management is part of nursing services it's what we do providing both the drug and non drug therapy to. Manage behaviors and while there are some shifts away in some of the categories of behaviors you will see that they finally do recognize that for the chronic care patient even IV p. IV feedings or TPN will be reimbursed under the nursing conditions in a PD p.m. this is all very exciting and really allows us to take a look at disease states management management and the services we provide but there are also excelled services and it really will require a great are not sufficient staff and qualified staff to deliver the quality. Of care we anticipate the last thing that we would want to do is submit a discharge from Part A with declining ADL's or scores based on some of the case-mix indexed for those patients so what we need to do is understand that icd-10 coding will be the primary basis for the MDS 9 therapy ancillary services as well as. Nursing you've got to recognize that medication will be the primary mode of treatment for these higher cost predicted icd-10 pays based diagnoses and conditions that are going to be reimbursed there is a shifting cost away from rehab and he expected to fall into pharmacy services and that really means that you need. Someone new not only understands their business but you need a provider that understands your business to help you manage those costs let's say for the non therapy ancillary services in the first three days of care how good or your pharmacist. For example in recommending an IV medication that. We took that could be converted by the third day of stay to an oral medication so that you can decrease the cost that coincide with the regressive payment for non therapy ancillary services one of the things that will be a big change for all of us is how depression and cognition will be assessed there will be a new. Measure called the cognitive functions scale and this combines the brief interview for mental status or the bim's and it combines the cognitive performance scale or CPS into a single scale that places our resident into one of four categories for cognition so again new learning techniques and understanding of hel. The MDS will be upgraded to accommodate all of the diseases that have been identified by CMS as being served and long term care routine but certainly not reimbursed routinely when you take a look at all of the 16 classifications for physical therapy and occupational therapy. The twelve classifications for patients with speech or language pathology needs including things like stroke disclosure and some of the other conditions that go along with speech therapy. Including depression the. Six non therapy ancillary services classifications and all as this case mixes and the 25 nursing classifications that you'll be in reimbursed for it. Is possible that you can have 28,000 different combinations for clinical care from the MDS mother MDS. Will be the document of all documents but remember it must be supported by an appropriate care plan and the appropriate documentation to survive an audit of. The information under sure that you have coded imprecisely to get the reimbursement that you are entitled to and at this point I'm going to hand it off to Todd to briefly review the advantages. RPD p.m. and to discuss at least two disease states where your consideration so you can understand how the drug costs will start to shift into your day to day costs for the Part A stay patient Todd thanks Nancy and great job there on reviewing the background of PD p.m. and how we're going to be faced. With some changes and I think I'm one of those people in Nancy's the same way with we. See changes opportunity and I think as we go through these next. Few slides you'll see where we think some of the advantages and opportunities are we touched on briefly. As we went through the presentation some. Of the advantages of P DPM it does review remove therapy minutes as the basis of payment it establishes a component of non therapy ancillary services and we'll touch on that just a little bit. As we go through the the last two cases I'd also improve services to the clinically complex by increasing reimbursement for those residents and the two cases that. We do have one ms and one on HIV we'll just give you some basic background information of some of the multitudes of opportunities that are there for these residents it reimburses for clinical characteristics rather than a physical function better treatment for vulnerable example ventilator residents infected isolation in stage renal disease and others if they're listed here as Nancy. Did a great job and going through those specific conditions and where and how they'll be reimbursed based on the point system I do think there are situations where based on some of the. While Nancy was speaking I was able to look at some of the questions and I think there is some good information in the Federal Register under the section that looks at the resident and facility characteristics and shows the specific changes from previous reimbursement to the new. Model and I think it would be good for everyone to. Take a look at that just because it will give you a little bit better insight on the subtleties between some of the things that Nancy was talking about with characterizing behavioral problems and cognition issues and. That type of thing it pays for each component of care variable per diem adjustments we based the resident classification of objective clinical information which is next as Nancy mentioned several. Times is really going to be a key factor when we categorize those residents at admission. With all of their their information also in. The Federal Register you can see based on some of those characteristics that. Yes urban homes will be reimbursed at a higher rate there are some other facility characteristics that will change some of the reimbursement rates so once again I think it's a good opportunity to go out and look at the areas where. Some of those changes will occur so managing PD p.m. I think it's important to remember that unlike rug 4 which incentivizes therapy to capture the payment PD p.m. will require the facility to carefully manage how the Smith facility delivers services in order to provide. The right level of care for each resident so that's kind of. What we feel. Is an opportunity to manage this condition moving forward in making sure that we're able to get the reimbursement that's needed and also provide the level of care that's needed CMS and Medicare does feel that P DPM is designated to be budget neutral if you go in and look at the federal register. In the facility and resident characteristics section that I mentioned a couple times now you'll see how some of the calculations were done. And where the changes in reimbursement are going to be some give and take based on conditions and resident type etc so that is the plan is to have this to be budget neutral we'll see how. That goes I. Think it does give an opportunity for us to look at different types of residents in making sure that we do look at the clinically complex and. Treat those residents accordingly so one of the last couple things that Nancy and I wanted to do before we close out here was just kind of look at. A couple specific opportunities and conditions and I think as the kind of the recurring theme that we've talked about today is a lot around medications and some of the potential issues around medications and then Nancy mentioned the drop in reimbursement of non therapy ancillary after day 3 we. Really do think that is an opportunity for facilities to partner with their clinical pharmacists and consultant pharmacists to make sure where those transitions and reimbursement occur that we're making sure we either optimize therapy look at therapies that are current and standards look for alternative therapies where cost opportunities might be look at adding therapies medications where there may be opportunities. To treat chronic conditions effectively so lastly here we're going. To take a look just real quick and I I kind of meet them that we put this in here just to kind of give you an idea of some of the complex nature that happens with a resident that has MS or multiple sclerosis and looking at the different types of medications. That might be used looking at some of the other types of areas where this PD p.m. reimbursement system will allow the facility if they categorize the resident correctly to make sure that we're the reimbursement there and then also the cares there you know these residents they. Do take corticosteroids which are medications. That have a lot of side effects and need to be managed accordingly immunomodulators to prevent disability these are infusion medications that. Are high-dollar medications medications to treat specificity antidepressants medications used to treat neuropathic pain bladder dysfunction those categories if you look at the number of medications just right there for a typical MS resident making sure that you have that pharmacist there to help. Make sure those drugs are appropriate for that resident and for their condition to make. Sure that they're functioning at the level that they should function also for these residents exercise and vitamins prevention of pressure ulcers and urinary tract infections self catheterization a lot of these other items that are. Nursing type of services that are things that really need to make sure that when we look at this system we're able to categorize. And move those forward accordingly and then lastly we'll look quickly at a resident who has a 10 HIV infection and Nancy touched on this several times there may. Be medications chemo prophylaxis antibiotics to treat opportunistic infections and there may be there traditionally will be antiretroviral therapy or a. RTS and there's a variety of medications in this class that need closed management there are honestly some opportunities now out there with generic medications in this market space where there can be alternative therapies or look at Aric utilization to help with. Cost while maintaining the clinical effectiveness of these medications other medications in an HIV resident could. Be antivirals for herpes zoster infections anti diarrheal antipyretics anti microbials to treat all candidiasis and fungal infections these are opportunistic type infections that come along with the progression of HIV analgesics and then antibiotics to treat sepsis and making sure we with all these categories that when we are in the. PD p.m. reimbursement model that we are engaging that pharmacist to make sure that that pharmacist is there with us to to help make sure that the drug therapy as appropriate as possible so just the kind of wrap up here I. Just I kind of wanted to first of all thank Nancy for her participation she did a really great job at going through the background of PD p.m. and we're looking at looking forward to taking some of your questions I do think that this is an. Opportunity for us when I say us facilities and providers and long-term care pharmacists to partner in a way that probably we hadn't thought about for up. Until this point I know that out there is there are some anecdotal things has been happening in some small pockets of areas where pharmacists are getting closer to that admission process but historically the consultant pharmacist has been more of a retrospective look at. The residents record I really think this is an opportunity for us to get in front of that. Resident and that Kim that that multidisciplinary team righted. Admission to help with this new reimbursement model and also. We think that that will provide a higher more positive outcome because you know we could talk all day about the transitions of care that happen and the issues that happen during transitions of care from acute care to. Long-term care facility and then from long-term care facility to home. You know making sure that we do infuse those opportunities to have pharmacists in in areas where they can help with those so I. Just wanted to say thank you again for taking the time today and I think I'm going to turn it back over to Jim for some questions and Nancy and I'll be available here for a few minutes well thank you very much Todd I want to thank. Both of you for it's just really incredible information as we can see the questions are pouring in we'll give you a chance to catch your breath there Todd Nancy as well obviously but we want to jump right in and let you folks know that well first of. All this we've had so many questions the slides are not available for download but the presentation will be available as you can see right where if you go to that URL on the slide right then and you can view again and these things will be there for viewing and. If somebody wants do it for the first time so let's get to the. Questions right away we have quite. A few good ones and if we don't get to them all we will get you some answers afterwards so Kim asked how where and when is a comorbid diagnosis such as Alzheimer's or related dementia accounted for or factored in the PD p.m. is that easily enough answered it's tricky while the overall reimbursement for dementia appears to be lower. Signifying that it truly is Alzheimer's dementia on the MDS one food reimbursement but you also have to capture all of the conditions that coincide with Alzheimer's disease so if they need assistance in feeding or daring Continent they need assistance in ambulation if they are. Prone to pressure ulcers or excoriation of the skin those are the types of things that have to be well documented on the MDS so that you can capture all of those nursing services that feed into. Of the reimbursement so for example taking a look at. Assessing a residence of cognition scores and. Then making sure that if they've improved or declined on that last MDS report a stay will be incredibly in Courtin as type said for example medications used to treat Alzheimer's or to treat cognitive problems may have a lot of side effects or adverse reactions what we don't want to see is a loss and those. Functional capabilities like being able to walk or transferring over the course of their parte stay some of those medications. With their side effects such as lethargy or sleepiness or could actually impede and lower that functional ability score and that's where your pharmacist can help you not only. In just the array of drugs that treat Alzheimer's but also prevent negative conditions associated with the drugs they may be causing a client a decline in those ADL I think the greatest opportunity here is finding someone who's got a slight cognitive decline and yet being able. To identify hey this is someone who can really use some rehab therapy let's get them into speech therapy and help them today with their swallowing. While it is not a tremendous burden to them and. See if we can't improve their skills this is where it becomes exciting where. These earlier interventions can be grabbed and used successfully and you'll get. Reimbursed for them okay great let's try to get to a couple more here and this next one is so important but I know we could probably do another webinar on it let's get a few responses perhaps on. Your thoughts as Michael asses I know we're going to get this. As you are well aware most facilities struggle with nursing documentation especially. As it relates to nursing nurses accurately identifying diagnoses to justify medication administration with that said do you have any suggestions as to what methods and/or strategies to implement that would help facilities capture the correct diagnosis to ensure proper reimbursement rates are received again we'll. Try to get to a couple more questions but what are your thoughts on that this is Nancy a great question and thank you for it. First of all you will start with the hospital summary and your relationship with your referral source and access to the hospital records will be critical and not just establishing and documenting the primary reason for admission but also all of the problem list and the diagnosis that the resident or the patient came into. The hospital with and is being discharged with keep in mind however that a lot of times that hospitals are so focused on the acute care diagnosis that they fail to understand all of the others reaching out to the primary physician that a resident had at home and understand what medications they took before they went to the. Hospital and his or her list of diagnoses for that patient would be very. Beneficial to capturing the documentation even if that doctors not the attending in the nursing home in addition to that your your. Medical records vendor should be improving icd-10 codes helping you code these diagnoses associate medications that are that have diagnosis codes that we understand and know for example non influence of diabetic diabetes mellitus would be one of them however keeping in mind that nurses can't diagnose pharmacists can diagnose it's not within our licensure so we have to capture. The information from anywhere we can get it and that means you need an on the ball attending physician at admission. To do that first thorough physical and examination with a thorough history to get all of the conditions and array of conditions that each resident who's a senior usually has including arthritis osteoarthritis for example to make sure you can maximize the conditions and get credit for them in payment. Alright Jim I'll just add to that real quick if you and a great answer Nancy and that was exactly where I was going to go the only thing I was just kind of out. There with the group that's out there today is how many of you admission people out there see medications come in without a. Diagnosis and historically what we would do is we'll say yeah we this is an admission we don't have time to get that we'll get it later those days are gone in this new system that's. Wise Nancy mentioned working with your attending physician your consultant pharmacist to help identify medications that may not have a diagnosis get it to that primary care provider find out exactly what it's being used for and you may have another non therapy ancillary service that you can code in your system thank you all right very good I want. To get to one more and then I want to get the final thoughts before we do some sign-off so I'm going to put you on like a 30-second clock here. Because I think this will go back over something we had Janet asked what about reimbursement for expensive cancer meds we've had a lot of cancer questions can you quickly summarize that well if this is Nancy of course and yes this this will be an issue in. The fact that if it is a non therapy ancillary service there will be a decline in your reimbursement by 66% assuming that you're doing. Infusion of antineoplastic that will keep the resident in extensive services so that plus the cancer will increase your score for that individual so you've got to capture all of that that goes that goes with cancer treatment or if they had surgery for the cancer or stolen radiation you have to capture everything that's going along with that resident. In their cancer diagnosis and all the related conditions to ensure that you Cubs are not information to actually pay for that for that type of medication now some of the oral therapies that we are using today for example metastatic breast cancer they are expensive and you are going to have to find your niche and learn. To to balance the clinical err with the type of resident you're accepting so your due diligence has to be at. Admission more than it ever has been. Before you decide to take a resident and understand this skillset your staff needs and ask your pharmacist to help you identify those. Types of drugs including specialty medication and their cost and if there are alternative therapies. Okay now the final payoff for the listeners that's why we always like them to stick around is after all of these great points and all of so much information what is the one thing if you have to emphasize one thing that listeners have to take away from this presentation I'll go with you first Nancy I think the thing. That that really is we're just all in the beginning of learning this and every day as we examine this we will learn something new attend what you can do as types of just download. The information spend a few minutes each day understanding its development and how it will pay understand that the shift of your rehab services you may be paying 43% less in your rehab bill and that's where you're going to find the money for. Your medication bill so learn to balance most of us learn how to read a balance sheet go back to 2018 and October understand where your costs were then you can calculate your budget for 2019 2020 very good and Todd what would you like I think Jim and to look at look at. Places you might not looked at before and kind of this is going to shift some of the things that we've done in the past a. Lot of things as a matter of fact and I hope today we kind of gave a little bit of insight on how partnering with your your providers and partnering with your consultant pharmacists and other your your electronic health record there's going to be a lot of technology come out to help facilities comply with this new process so look. At the look to those areas because those people are going to be there to help you and and want to partner with you because we're all in this together outcome and our goal is to. Provide the highest care that we can to our residents and I. Think that partnership will help make this happen so thanks again excellent very very good and again we need to thank Todd and Nancy for their outstanding insight on this and I want to reiterate that this will be viewable again at McKnight's comm slash January 29 webinar we also want to. Thank our session sponsor Omni care check it out at Omni care calm and of course we always think our listeners have been a big part of success today and we look forward to seeing you again at future McKnight's webcast keep up to date on all our offerings by checking the events tab at McKnight's comm once again thank. You. For.


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