The Patient-Driven Payment Model (PDPM) has transformed the landscape of skilled nursing facilities (SNFs), placing greater emphasis on individual residents overall needs and outcomes. As reimbursement under PDPM is tied to a variety of clinical factors, it’s essential that facilities leverage every tool available to optimize care and reimbursement. Among these tools, the Minimum Data Set (MDS) and Restorative Nursing Programs play a critical role. When these two elements work together, they can unlock tremendous success for SNFs, improving resident outcomes, quality of care, and ultimately, financial performance.
Understanding the PDPM
The Patient Driven Payment Model (PDPM) categorizes residents into payment groups based on their clinical characteristics, including diagnoses, functional status, comorbidities, and therapy needs. This system aims to shift away from therapy minutes as the primary driver for reimbursement, focusing instead on resident-specific factors that more accurately reflect the care needs of each individual. The PDPM requires SNFs to capture detailed and accurate data through the MDS, which is used to assess the resident’s functional status, medical conditions, and care requirements.
The Role of the MDS in PDPM
The MDS serves as the foundation for PDPM classification. It collects comprehensive data on the resident’s health status, functional abilities, medical diagnoses, cognitive status, and other factors that influence the level of care required. Accurate MDS assessments are critical because they directly affect the PDPM reimbursement. The MDS is completed upon admission, quarterly, and annually, and is used to assess the resident’s progress, making it an essential tool for capturing the right information to maximize reimbursement depending on what other nursing care the resident requires.
How Restorative Nursing Programs Impact PDPM
Restorative nursing is a person-centered approach aimed at helping patients maintain or improve their functional abilities. These programs are focused on activities that help residents retain mobility, manage daily tasks, and improve quality of life, rather than just treating illness or injury. Restorative nurses work with residents to implement individualized care plans that promote independence and prevent functional decline.
Under PDPM, restorative nursing plays a pivotal role because it focuses on maintaining and improving functional status. The Functional Score Component in PDPM is highly influenced by the patient’s mobility and ability to perform activities of daily living (ADLs), which are directly impacted by restorative nursing programs. Restorative programs can include walking, range of motion exercises, ambulation, and other therapies aimed at improving independence and physical function.
How MDS & Restorative Programs Work Together
To unlock the full potential of PDPM, the MDS and restorative nursing programs must work in tandem. Here’s how:
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Accurate MDS Data for Reimbursement: The MDS collects critical information on functional status, cognitive function, and medical conditions. This data is used to classify patients into specific PDPM categories, determining the level of reimbursement. Accurate MDS assessments ensure that the care needs of residents are fully captured, aligning with the restorative nursing program’s goals.
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Documenting Functional Improvements: Restorative nursing programs focus on maintaining and improving a resident’s functional status. This is vital under PDPM, as functional scores significantly influence reimbursement. By documenting improvements in mobility and daily function, restorative nurses can provide tangible evidence that supports PDPM reimbursement categories. Be sure to complete an assessment at the start of restorative program and when of if therapy ends according to you local state and federal guidelines/
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Comprehensive Care Plans: Both MDS assessments and restorative nursing programs rely on comprehensive, individualized care plans. The MDS helps to identify the patient’s needs, while restorative nursing programs focus on strategies to address those needs. Together, they create a unified approach to care that supports both quality outcomes and accurate billing.
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Collaboration for Optimal Outcomes: Continuous collaboration between MDS coordinators and restorative nursing staff ensures that both the clinical needs and functional abilities of residents are addressed. For instance, if a resident’s MDS assessment indicates a decline in mobility, restorative nurses can target this area with appropriate interventions, and the MDS team can track progress over time.
Benefits of Integrating MDS & Restorative Nursing Programs
The integration of MDS and restorative nursing programs offers several benefits for SNFs:
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Improved Quality of Care: By focusing on functional outcomes and supporting residents in maintaining their independence, restorative nursing programs help improve overall care quality. This is not only beneficial for residents but also ensures that SNFs meet the expectations set forth by PDPM.
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Maximized Reimbursement: When both the MDS and restorative nursing programs are aligned, SNFs can accurately report functional status and improvements, leading to higher reimbursement rates under PDPM. This ensures that the facility is compensated appropriately for the level of care provided.
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Better Resident Outcomes: By addressing functional decline proactively through restorative nursing, residents experience improved mobility, independence, and quality of life, contributing to better overall outcomes.
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Compliance and Risk Management: Accurate documentation and collaboration between MDS and restorative nursing teams ensure compliance with PDPM requirements, reducing the risk of audits or denials.
MDS & Restorative Program Collaboration Table
| MDS Data | Restorative Nursing Program | Impact on PDPM |
|---|---|---|
| Functional status (mobility, ADLs) | Range of motion, ambulation, bed mobility, transfers, ect | Captures functional score |
| Cognitive status | Cognitive stimulation activities, behavioral support | Supports accurate classification, can affect reimbursement rates |
| Medical diagnoses | Person-centered care planning | Ensures the care plan aligns with the resident’s condition and needs |
| Therapy needs | Maintenance therapy to prevent functional decline | Supports accurate therapy billing, ensuring appropriate classification under PDPM |
Overall
When MDS assessments and restorative nursing programs work together, they can create a synergy that enhances both the care provided to residents and the financial health of the facility. The combination of accurate data through MDS and targeted interventions through restorative nursing can lead to improved patient outcomes, higher reimbursement under PDPM, and a strong, sustainable approach to care management. This integrated approach is the key to unlocking success in the new PDPM era for skilled nursing facilities.