MDS Alert

Published on Thu Sep 05, 2019 PDF

Revamping a respiratory therapy program could be a wise investment in care — and reimbursement.

It’s no surprise, considering the name, that the Patient-Driven Payment Model (PDPM) organizes payment around the care that residents receive. With the decision to tie reimbursement to the care that residents actually receive every day instead of the therapy they receive to try and change their condition, everything is shaking up in nursing facilities.

Documenting care, knowing how to navigate ICD-10 codes — diagnoses are crucial information in PDPM, because CMS wants to know why a resident ends up in a nursing facility — and really focusing on nursing are key means of surviving the transition to PDPM with your reimbursement intact.

With this in mind, some facilities are hoping to cater to residents whose nursing needs are more intensive, figuring that they have the staff skill and presence to deliver appropriate care for people whose medical needs are greater. One area of focus? Respiratory therapy.

With the changes to reimbursement beginning Oct. 1, it’s wise to consider how such a program may offer clinical, operational, and financial benefits for your facility, says Kris Mastrangelo, president and CEO of Harmony Healthcare International in Topsfield, Massachusetts.

Know What Qualifies

The Resident Assessment Instrument (RAI) Manual defines respiratory therapy as specific services related to pulmonary function, noting that they must be provided by a “qualified” professional, such as a respiratory therapist or a respiratory nurse.

Definition: “Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, nebulizer treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws,” the RAI Manual says in Appendix A.

If you don’t currently have a specialized, formal respiratory therapy program in your facility but see deficiencies in your delivery of care that could be alleviated by such services, PDPM may be the nudge you need.

Combat Hospital Readmissions

Many facilities are trying to figure out how to reduce or eliminate hospital readmissions, especially because the Center for Medicare & Medicaid Services (CMS) hits facilities with a financial penalty if they exceed a predetermined benchmark. With certain pulmonary conditions ranking high on the list of reasons residents are readmitted, being able to provide more intensive and specialized care for those conditions right there in the facility should, theoretically, curb some readmissions.

Once residents end up in a nursing facility, their conditions are generally at a point where they need to be “managed” — there’s a necessary continuum of care, but individuals generally aren’t in medical crisis. With a respiratory therapy program and expertise, nursing facility staff can more effectively rehabilitate residents with pulmonary issues, Mastrangelo says. This expertise, backed up with continual assessments and documentation, can continue to ensure that the resident is receiving appropriate care for her respective pulmonary or respiratory condition.

Secure Earned Payment

It makes sense that providing more care is more costly, and PDPM is designed to acknowledge that reality.
A Medicare Part A resident who receives respiratory therapy in a skilled nursing facility may be eligible for more than $100 more per day than a similarly situated resident who does not receive respiratory therapy, Mastrangelo says.

Of course, earning more money is not the driver for many who work in long-term care, and money should not distract from the compassionate necessity for providing care to people who need it. But having the knowledge, skill, and expertise to manage complex medical conditions should earn due compensation. Plus, facilities that can offer this level of care may be keeping people in more comfortable conditions than a hospital could provide — providing potential residents with healthcare options is always important.

Important: If your facility offers a formal respiratory therapy program or chooses to implement one, make sure that your designated respiratory therapists have documentation of their specialized education. Your state may require particular credentials or have specific continuing education demands. However, skilled nursing facilities may already be providing care that qualifies as respiratory therapy and can now get paid for those efforts.