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CMDA Monthly MeetingSept 3, 2019 12n – 1:30 PMCDPHE Sabin RoomMINUTESIntroductionsAttendees present: Alexander Jacob, MD, Stanley Kerstein, MD, Sing Palat MD, Kristin Lipe MS3, Travis Neill CMDA Board, Allison Villegas CMDA Board, A. Lee Anneberg MD, David Bolshoun MD, Ann Kokish, Malcolm Frasier MD, Greg Gahm MD, Cari Levy MD, James Libbon MD, Margaret Mohan, Jo Tansey, Margaret Dominguez, Don Murphy MDOther attendees were present by Zoom. CDPHE update: seeking new medical director. Division medical director is still Jeff Beckman MD.CHCA update: preparing for fall conference, October. See agenda onlineUnderstanding the Provider’s Role in partnering for PDPM success: Kendra Coco MPT, NHA, RAC-CT, with VivagePDPM – taking away from therapist utilization model to nursing utilization model. Incentivizes us to take more high acuity pts in SNF. Applies only to Medicare A Currently RUG IV has 66 RUGs and heavily weighted on therapy. Medications, labs, respiratory therapy currently not considered in payment model. With PDPM, looks at base rate (room and board) plus therapy, nursing, and non-therapy ancillary needs. 28,800 combinations of per diem adjustments! Puts the patient as the focus. Higher needs will result in a higher case mix for each component, based on acuity.Dr. Kumar at AMDA explained the 5 different focuses of PDPM:1: Admission- Provider documentation is important for correct MDS assessment. Initial assessment is a 8 day lookback, including hospital interventions. Will need to work w/ hospitals to obtain info. Can use Change of Condition assessment after the initial assessment to capture changes in medical needsAdvantageous to have providers see patient within 24-48 hr of SNF admission because acute care hospital provider’s documentation may not apply or may be resolved in the SNF.2: Diagnosis accuracyReason for SNF Admission is key. Acute diagnoses may already be resolved ie. UTI may already be resolved, psych diagnoses that required prolonged hospitalization.) Typically SNF are providing “aftercare.” Non-therapy ancillaries (NTA ie not PT, OT, SLP, nursing) are paid 3x the NTA component rate in the first 3 days. Dr. Murphy: provider visits within 24-48 hrs not likely to happen. Dr. Kerstein: No increased reimbursement to providers. Note, many facilities will try to get their initial assessments withint the first 4-5 days and hence earlier visits are better but within the first 72 hours may work as well. The visit does not have to be the H+P, any initial visit with the needed documentation will be satisfactoryPrimary medical diagnosis should be specific (UTI with what organism). Include pertinent active comorbidities that have risk of complicating SNF stay or related to goals/ treatment. Dr. Anneberg: Can’t specify UTI organism right away, until cultures available – need to request records to complete SNF record and bill appropriately.Diagnosis must be documented by a provider within past 60 days and must relate to past 7 days. Must directly relate to current status of function/ cognition/ risk of death. A “strong code” can be identified by CMS Mapping Tool. “Return to provider” (RTP) will query providers if codes are not considered appropriate primary diagnoses for SNF stays. Not appropriate if diagnoses are too general or already resolved. 43% of current diagnoses would be RTP.Fracture coding: Lots of confusion. Last CMS call recommended specifically listing surgically repaired the fractures. Eg. List the exact fracture with ORIF/ Joint replacement, list if open/ closed, displaced/ nondisplaced, laterality, traumatic/ pathological. Dr. LaRocca: this is confusing, contradictory from other advice about not using diagnoses that have resolved. Dr. Frasier: CMS often re-clarifies, moving target of advice. Neill: diagnoses should be established upon admission, rather than wait for provider to sift through everything. Coco: It will be essential to have dialogue about the clinical scenarios. Gahm: Remember that PDPM is budget neutral – not about saving money. Coco: California currently over-reimburseed; Colorado under-reimbursed maybe. SLP neurological comorbidity diagnoses – will add to complexity of patients. Eber: should MDS items or mapped ICD-10 codes be documented? Coco: any are helpful. NTA items: may document from MDS or diagnoses – Based on point system that includes: active HIV complications, obesity, parental feedings, intermittent catheterization, wound care, shortness of breath with lying flat, fever, vomiting, ostomy, toileting program etc. Slide will be sent to Dr. Eber for distribution.Behaviors: must be documented, reproducible by other staff. Rejection of care is included. Dr. Bolshoun: does diagnosis have to be coded or just documented? Coco: Document it somewhere. Kokish: Reimbursement opportunities can be missed by not documenting. Surgical procedure: Higher acuity defined as having at least 1 inpatient day prior to SNF for surgery and if procedure carried risk to life/ disability. Dr Anneberg: some surgeries do not involve an inpatient stay. Dr LaRocca: some people need SNF without 3 midnight hospital staySwallowing/ nutrition: symptoms of a swallowing disorder will impact S.T. component. Mechanically altered diets, weight loss, IV/ tube feeding influences the case mix, document well. Dr. LaRocca: CMS rac/ mac can review billing and retrospectively deny if considered inappropriate. Dr. Kerstein: what is considered significant change in swallowing/ weight? Coco: Most facilities use 2 domains, doesn’t resolve in 14 days, use MDS criteria. Skin: List appropriate codes. Care plans and interventions need to match the diagnoses. Meds: important, continue to review Special treatment will affect acuity: chemo, dialysis, trach care, isolation precaution etc.3: Managing medically complx patients: Focus is on avoidable rehospitalizations, advance care planningGoal to reduce length of stay in SNF: PT/ OT will have a 2% reduction of payment every 7 days after day 20. Dr. Anneberg: lots of patients need more than 20 days for therapy. Dr. Levy: what if patient is delirious and can’t do well in their first few days in SNF? Coco: SNF will still get paid, just less for the PT/ OT component.4: Pharmacy cost containmentUnder NTAIncludes antibiotic stewardship5: Therapy services collaborationUse therapists to top of their licenseRisk audits: current PEPPER reports will need to be updatedPt qualifies for PT/OT even if therapy is not orderedZoom: Can we have the CMS tool for mapping codes; Coco: Link will be distributed by email. Dr. Kerstein: is there a limit to number of codes? Coco: yes, but the codes can be prioritized too.Dr. Frasier: will this apply to all patients in-house on Oct 1? Coco: yes, all Med A will switch everyone on Oct 1, require new assessments for all patients in-house. Dr. LaRocca: How many patients are involved? 5% bonus to medicare payments make it worth partnering with quality organizations that can help make PDPM effective. Review of Tools for Frailty, Sarcopenia, Nutrition and Rapid cognitive Screen from SLU – Dr Leslie EberInspired by talk at annual CMDA conference Rapid Geriatric Assessment from St Louis University, John Morley – has 4 screens and Advance directive questions – See handouts. Should be able to complete in 5 minutes. Frailty: syndrome marked by reduced physiologic function. Predicts poor outcomes. Can be viewed or described in different ways ie. How many things are wrong, how much reserve.Phenotypes in literature: cardiovascular, surgical risk10% older adults are frailMany tools to assess frailty – St. Louis uses the 5 questions tool:Fatigue, Resistance, Aerobic, Illness, Loss of weight (score 3 or more is frail)Pre-frail syndromeFRAIL-NH tool – 8 or more of 13 is Frail. Sarcopenia: loss of muscle mass, muscle strength and physical function. Predicts poor outcomesOver 40% of nursing home residentsMalnutrition may be an independent risk factor for developing sarcopenia.St Louis uses SARC-F screening tool – score 4 or more is Sarcopenia.Are you at risk of weight loss? Use the SNAQ. Self-reported responses, can apply even if patient has dementiaScore 14 or less is significant risk of weight lossRapid Cognitive Screen – Scores indicate normal, MCI or dementiaRapid Geriatric Assessment is demonstrated on YouTube by Dr. Little, takes less than 5 minutes totalOther toolsTreatable causes of Dementia: “DEMENTIAS” pneumonicWeight loss: Meals on Wheels pneumonicFatigue: list of common often overlooked reversible causesDr. Gahm: supplements and early interventions without evidence in some casesInfluenza update 2019-2020, Dr. Greg GahmWHO waited to announce this year’s predominant viruses, so full vaccine not available yet Both A strains are new. New strains often prevalent for 2 years before herd immunity develops.Dr. Anneberg: What about the expanded respiratory virus screening results on patients from hospitals. How do we know what should be isolated or treated, what do we do with it? The only serious one is influenza A. Dr Gahm: University study of respiratory cultures found sputum versus transtracheal versus lung cultures often do not match anyways. Apply common sense- if the patient isn’t coughing, personal protective equipment probably is not needed. Dr Levy: I.D specialist may be able to speak to this, from a facilities perspective. Dr Eber: the panels are often helpful for family. Dr. Libbon: respiratory panels often just part of standard order sets, ICU admissions. Dr. Bolshoun: Patient was taken off multiple antibiotics when metapneumovirus came back positive; testing can be very helpful. PDPM comments:Dr. Levy: if PDPM is driving you crazy, more education is available on the AMDA webinars. Dr. Eber: try to have physician H&P done within 3-4 days of admissionDr. Howe: improved documentation may lead to more triggers for quality measures. Frustrating from hospice standpoint, hospice versus nursing home repercussions for documentation. Do surveyors have response? Mohan: no. Dr. Levy: do the right thing. Most of the time it’s going to be OK. ................
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