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Restorative Nursing Under PDPM: Looking for Answers?

We can all agree: the value of a solid, efficient Restorative Nursing Program for SNFs should not be underestimated!

There’s a lot of BUZZ in the industry about increasing restorative programming in preparation for PDPM. Many SNFs have Restorative Nursing programs. Many do not. Some have a program, but it doesn’t function the way it should.

Here’s the stone cold truth…
Restorative Nursing may (or may not) make sense for your organization. Hear us out. 
Yes, Restorative Nursing is valuable and necessary! But only if executed correctly.  

According to the state operations manual, Restorative Nursing is important for maintaining the “highest practical physical, mental, and psychosocial well-being” for long-stay patients. No argument there. In fact, with the rising penetration of ACOs and bundled payment initiatives (BPCIs) in recent years, HealthPRO Heritage can attest to the trend that more partners in the SNF world are building restorative care programs for their skilled residents who intend to go home. The ultimate goal: to provide more efficient care -- in order to maintain higher functional levels -- within a shorter length of stay.

Wondering whether investing in Restorative Nursing will help your community under PDPM?
First, let’s clarify some basic background RE: Restorative Nursing and PDPM: 

Under PDPM, nursing will be separate from therapy and have its own component. The lowest two nursing categories are Reduced Physical Function* and Behavioral Cognitive Symptoms. Once the initial assessment is completed, these two nursing categories will split into different case mix indices (CMIs) based on:

  • Functional scoring under Section GG of the MDS, and
  • Whether two or more programs of Restorative Nursing are present for the initial assessment and/or the interim payment assessment (IPA).

The case mix increases (NOTE: only in the two lowest nursing categories) if a resident has two or more restorative programs at least six days in that seven-day look back for at least 15 minutes each.

*Interesting to note that more than 50% of the days reported in the CMS provider impact file for PDPM (FY 2017 Medicare FFS data) fell into the lowest nursing category: Reduced Physical Function. This is simply because the incentive under RUGs is tied to therapy minutes. Crazy, but true. It’s the way the system works today. Under PDPM, however, SNFs must focus instead on nursing skilled services (pre-admission-to-discharge) and redesigned documentation practices.  HealthPRO Heritage projects SNFs that successfully adopt/capture best practices for PDPM success will see (perhaps a significant?) reduced % of days in Reduced Physical Function.

Let’s do the math.
Next, let’s lay it out in terms of dollars and cents RE: Restorative Nursing under PDPM. Consider some examples to illustrate: 

A resident falls under the Reduced Physical Function category (i.e.: no real skilled nursing needs are present for the initial assessment, only assist in ADLs and mobility required). Restorative Nursing would be initiated by Day 2 of the stay so that at least two programs (and therefore a higher case mix index) are captured by an assessment reference date, or ARD of Day 8. (Using Day 8 may impact some other items from the hospital stay and other components, so be mindful!) 



Case Mix Group

Case Mix

For these examples,
base rate = $106.64

Calculate the Nursing Component

A resident scores a 5 on Section GG for nursing (i.e.: he/she
is more dependent, and requires more nursing care.)

 Two (or more) restorative programs



PDE2 = $106.64 X 1.57


A resident scores a 5 on Section GG for nursing (i.e.: he/she
is more dependent, and requires more nursing care.)

Only one
(or zero) restorative programs



PDE1 = $106.64 X 1.47


A clinically complex resident (e.g.: receiving oxygen therapy) also scores a 5 on Section GG.

No depression



CDE1 = $106.64 X 1.62


See where we’re going here? 

The delta (between Restorative Nursing vs. not utilizing Restorative Nursing) in this conservative example = $10.66/day. Consider the significance if more than 50% of the days landed in the Reduced Physical Function category for nursing. Is that considered lowering the bar? We think so! A clinically complex resident (without the restorative expense, because it does not impact this category) would be $5.34/day more.

Beware Tactical Pitfalls
In an effort to mitigate expense, some providers may be inclined to minimize therapy utilization under PDPM and instead rely on Restorative Nursing (or even Activities).

HealthPRO Heritage advises: providers and therapists alike must continue to prioritize residents’ needs – above all else! After all, it’s more important than ever before that we work together as a team to deliver on high quality, efficient care so as to optimize outcomes and help residents safely transition to the next level of care. Likewise, pressure continues to maintain AND IMPROVE quality outcomes in order to maintain strategic partnerships (as with ACOs and referral networks) and keep pace with expectations defined by other value-based purchasing initiatives (e.g.: Quality Measures, Five Star Ratings, Bundled Payments, Medicare Advantage, etc.) 

The compliance pundits warn: CMS will monitor for underutilization of therapy services – pre vs. post PDPM – and SNFs that rely on Restorative Nursing programs could be at risk. 

Still Looking for Answers?
HealthPRO Heritage offers the following guidance for SNF leaders asking questions about Restorative Nursing:

  • Do what’s right CLINICALLY for every short-term and long-term resident.
  • If you can, you should. Provide Restorative Nursing if your community has the capacity to do so. Yes, an investment (in both resources and staff) is required, so SNF leaders must do their due diligence to understand the inherent financial implications and ROI.
  • Already have a Restorative Nursing program in place? Assess the reasons for nursing skill for all admissions (e.g.: assessment, clinical meetings, and utilization review/discharge planning meetings, etc.). Evaluate clinical nursing and rehab capabilities to confirm whether your community indeed has the ability to care for a higher acuity resident more effectively.
  • Still unsure if Restorative Nursing will help your SNF under PDPM? The answer is clear:  Restorative Nursing will support reimbursement if your community has absolutely no skilled nursing needs for the resident population. After all, SNFs are seeing more residents go home with home health or outpatient services. CMS is setting the standard for SNFs to take more clinically complex residents -- which means higher nursing skill. 

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Tags: Patient-Driven Payment Model, PDPM, CMI, Case Mix Index, Restorative Nursing, Restorative Nursing Program