Steven Littlehale on PDPM

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We, the caregivers, are also suffering when we complain about

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the negative rap we have. I honestly believe it's attributed

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to these really ill conceived models of reimbursement.

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What I love so much about PDPM is there is

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no difference between financial success and clinical

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success.

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Welcome to the nursing home podcast. Your goto

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source for professional insights in the longterm care industry.

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Hear from leaders and experts as they share current and practical

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insights to help make the most of your day. I'm the Longterm care financial specialist.

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What that means is I help people plan for the inevitable.

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Nobody wants to think about getting old, but it's possible that someday

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we might need a little bit of care. Here's your host. Nursing home Administrator Turnpodcaster

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Schmoel, Septimashptimash.

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Welcome to this episode of the nursing home Podcast.

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The podcast which is geared to the nursing home professional

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to bring you the very latest and the very greatest

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in the nursing home industry, where we speak to professionals,

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operators, vendors, and anyone else who can

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shed light and make your professional journey that much more successful.

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Today we have the opportunity of speaking with the

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Chief Innovation Officer of Zimmer Healthcare.

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For those who recall, we had Mark Zimmer of Zimmer Healthcare on the podcast

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a couple of episodes ago, and he was able to convince coerce

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Stephen Littlehal for coming on the show with us today.

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So, Steven, welcome to the nursing home podcast.

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Thank you. I'm really excited to be here this morning.

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I appreciate the opportunity. Thank you for taking some time and

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for coming on the Nursing Home Podcast. Really excited to have you here.

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Now, there are listeners who are very familiar with who you are.

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There are listeners who don't yet know you. So if you don't mind,

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for our audience, can you briefly describe your professional

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journey from where you are to how you evolved and are now

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part of the Zimbab team? Absolutely. I think I'm one of

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those rare people who knew all along what I wanted

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to do with my life. In high school, actually a junior in

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high school, I decided that I wanted to be a nurse. And as a freshman

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in my undergrad program, I decided I wanted to focus in

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on elder care. And I really attribute that to having amazing

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relationships with four grandparents and two great

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grandmothers, all while growing up. It was just extraordinary.

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So I have a graduate degree, I'm a clinical nurse specialist

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in gerontology, and for the first ten years of

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my nursing career, it was direct clinical care,

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Hebrew senior life in Boston. There I transitioned

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into their research and training institute and was part of

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the MDS 2.0 development team along

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with other projects. And there I really developed

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a very deep sense of what standardized clinical assessment

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was all about, the importance of reliability and validity

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and the power of what you could do with these standardized

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clinical data sets. I was then recruited to

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pointwright, then ltcq as

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their Chief Clinical officer and then later their Executive Vice President.

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And pointwright takes. All of this data clinical data,

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regulatory staffing, financial,

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basically any data that we can get our hands on

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and creates proprietary algorithms to really

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help give great insight into variants,

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to help operators, nurses,

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clinicians, lenders, attorneys have

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deep, data driven insights into what

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is most important to them to help answer

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very key questions that are most pertinent to

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their work. In most instances, that means providing

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MBS coordinators, clinicians,

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administrators, directors of nursing therapists and

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their stakeholders, nursing home stakeholders with

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realtime actionable, data driven insights.

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So after being at pointwriter for 21 years,

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I decided and some people refer to this as my midlife

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crisis. Maybe it was, but I decided that I

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really wanted to, one, get a little bit

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closer to providers. One step back to

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my roots and also really fill in

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a gap that I was well aware existed within

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my own learning and experience. And that is reimbursement

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and the financial aspects of providing clinical outcome

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care. Honestly, that insight became really

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more paramount since healthcare reform was

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signed into law. When we see that those two worlds

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are coming together, clinical outcomes and quality

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is in fact coming together with financial outcomes

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and financial success, and I delight in that, I think

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it's fantastic. So, you know, suddenly a clinician like

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me has a different audience. So that's really exciting

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for me. So I joined them at Healthcare services group.

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I've known those folks for Gosh almost the

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whole time that I've done that point right. I've been really excited

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with their deep analytical thinking around

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reimbursement models and how to support their clients

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and achieving success, which again today means how

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do you achieve success? It's through providing excellent clinical

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care. And I joined that team, that extraordinary

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team, as their Chief Innovation officer,

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to think about new ways in which we could support providers

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and other stakeholders in the space.

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So that brings me to today. Well, thank you for that

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complete background.

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Before we jump into some of the other questions,

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I will just tell you that being the host of the Love Your Nine to

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Five show podcast as well, which you may or may not be aware of,

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which is a career podcast. It is astoundingly unique and

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refreshing to hear someone who knew so clearly,

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so early on and you were able to exactly what

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you wanted to do and you further narrowed it down and

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you had the luxury of being at that stage in

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your life and continuing down the path further and further and

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further to accomplish what you have already accomplished.

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It's just so exciting to hear that. I can tell you how many conversations

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I've had with potential candidates for various

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positions where a big piece of their struggles is that

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their midlife crisis was finally figuring out what they really wanted to do and having

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the courage to do it. So I had someone who

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was in finance, but not clinical finance like regular working

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in a bank or whatever for 25 years, wrecked a marriage and

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a lot of other relationships, and financially broke, and finally said,

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oh, I always knew in high school I wanted to become a nurse.

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And finally she became a nurse, I think NLTN in mid forty

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s, or maybe even later, finally became a nursing

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home nurse, starting at that level. And I asked her, why didn't you

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start as a nurse? Then imagine where you would be. Your name would

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have changed to Stephen Littlehel at this point, as in that example.

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But I said, you could have been so much further down. She said, well,

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my dad wasn't financed. My mom was what was expected. And she didn't

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have the opportunity to think for herself, or she

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didn't allow herself the opportunity to think for herself and to open

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that up. So that is one piece that's very exciting. But getting

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back to the nursing home podcast, I remember hearing this point

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being made, I forget right now from home. That when

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the clinical results and the clinical product has a direct

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financial impact, that's when everybody wins. That's when the residents

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win. That's when the operators win.

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That's when all of the various partners that we all have win.

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Because at the end of the day, we're providing excellent care and

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we're getting reimbursed, hopefully appropriately, based on the care

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that we're giving. So before we jump into PDPM,

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let's discuss a little bit about the current payment model and what the

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challenges is in this system and what is

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the push to move to this new payment driven payment model?

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Oh, sure, absolutely. Just to kind of start,

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I cannot wait for this transition. This is going to be

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one of the happiest days in my professional career come October

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1. And that's a really bold statement.

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But for 20 years plus,

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many of us have been swallowing down the

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whole idea that the current model

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is motivating the wrong care, the wrong kind of care,

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and who suffers? Our nation's elders. What we

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don't realize is that we, the caregivers, are also suffering.

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When we complain about the negative rap we have in our

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industry. I honestly believe it's attributed to these really

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ill conceived models of reimbursement. Wow. So let me

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be more specific. Let me be more specific.

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From looking at clinical data, I'm able

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to look at the numbers of people, elders,

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residents, who are actively dying and

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who do not have that identified on their care plan and

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yet get sent back to hospital. Because we

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don't we, the clinical leadership in the facilities,

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don't recognize that they're actively dying. We don't know what's going on.

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We haven't prepared them or their family, and we

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send them back to the hospital. And sometimes,

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many times, unfortunately, they actually die in the hospital. Well,

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how could it be that an industry that is created

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to care for elders. How can we be so bad

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at identifying someone at end of life? How can

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we struggle so much with identifying people who are in

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pain? It's because our system doesn't reward

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that. It doesn't motivate folks to

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think about how can you systematically assess

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for end of life? For over 20 years now,

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there has been an existence in MDS based model for identifying people

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at end of life. And I say that to folks, and people on this

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podcast are probably shocked to learn that it's been in the literature.

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It was updated with MDS 3.0, it's in the academic

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literature, and it's been commercialized as well by not

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only pointwrite who has its own scale, but others.

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And yet we still have when you

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look at the stats and you look at the number of people who

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are properly identified at end of life, on palliative care,

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on hospice care, it's tiny. It's tiny.

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But yet when you look at the number of people who are getting therapy

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minutes, no problem there. We see that there's

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a tremendous amount of people who are getting three different types

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of therapy in minutes every single day.

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So the current system is motivating the

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wrong behavior. Again, it's a dramatic statement. I didn't have

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that clarity 20 years ago, but I sure have

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had it for the last ten years. Congress has had it for the last ten

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years. Med Pack has had it for the last ten years. Many of

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the people listening on this call today are all nodding their head, saying,

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we know what the right thing to do is. We have excellent clinicians.

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Maybe their skill set to identify

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these things is a little rusty because it hasn't been

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valued in our system. But many folks on this call

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are nodding their head and they're saying yes.

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One other quick example of this I was a

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co author of a research study which looked at

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the use of tube feedings in

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people with end stage dementia. And we looked at

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the impact of being in a state whose

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Medicaid system rewarded the use of tube feeding.

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And we just asked a simple question. In this population

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where there is no clinical justification to be using a tube

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feeding, if you happen to be in a state that

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pays off a tube feeding, is the prevalence of tube feedings

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in this population greater? Is anyone

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surprised to hear that it was? So if you're in a

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case mixed state or a state that motivates financially, rewards financially

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for the use of two feeding, sure enough, there they were. They were

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being used more in this end stage population

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with dementia. How sad is that?

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Now, I don't think that clinicians are sinister. I don't think administrators

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are sinister. And they're rubbing their hands together thinking,

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how can we figure the system out and provide inappropriate care

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for financial gains? But a great example

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to bring it to transition to PDPM, a great example

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is today you can get PDPM

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training in any number of places around

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the country. Some of it's good, some of it's bad.

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Some of it is saying, let's actually just focus on the

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financial drivers and teach you about the financial drivers,

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the PDPM, some of the education is

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saying, isn't it wonderful that depression is now being financially

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rewarded in PDPM? Let's teach you how to do a depression

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assessment, how to capture the data appropriate and provide

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the right kind of care. So two different extremes,

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but that's how we've ended up where we are today. Okay,

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just to jump in there for a minute, for providers, for operators,

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and for people who are focusing on, just on the financial side,

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they're panicking because we know that what we've done in the

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past is no longer going to reward us financially the same way that it has.

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So we must get ahead of this financial piece

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in order to survive and be able to be a provider,

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period. At the same time, like we mentioned earlier,

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at this point when the financial and clinical

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measurements and the way that the success

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markers are kind of leveling out,

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this is a time when clinicians come to a financial meeting,

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the financial people don't put their fingers in their ears and say geek talk.

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They actually care because what the clinicians are saying are

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going to impact how we're going to operate. And that impacts directly

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the financial results. So tell me if this makes sense.

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Both parts are true. If someone's a CFO,

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specifically of a large nursing home chain,

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he's got to make sure that when it comes year one, that they are

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at least surviving. Not necessarily. Again,

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probably part of it is a transitioning or maybe transmitting

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the same culture into the PDPM, meaning that

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we must make sure that we're financially viable

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in order to continue in the future. And then we'll figure out the clinical part

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and figure out we'll have our clinicians and we'll have our point,

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right? Partners. And Zimmer Healthcare Partners will show us

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how we can balance it out and make sure we're also providing

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for the the residents highest level of care. Which you're calling a bad

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model. Which is true. But that's probably where it's coming from. It's the same bad

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rap that people had for the old model of care.

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And they're going to be operators who are going to probably just focus on that.

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And again, the system is rigged in a way, so to speak,

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where they're going to have to provide great clinical outcomes in order

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to get that their focus may be financial, but the

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healthier approach again, I'm thinking this through and you're going to tell me

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if this makes sense or maybe adjust it a little bit. But the healthier

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approach is, you know what, there's a reason why these changes are happening.

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Let's embrace the fact that our

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goal is equal not just financial viability

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and profitability, but great clinical outcomes,

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which have always been important, as we mentioned earlier, for every operator.

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But that should be all the way up there on the pedestal. When we have

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financial meetings, we now will be able to for the first time,

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we'll be able to financially afford to provide the care we

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always wanted to get. Does that make sense? Yes, it does make sense.

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It does make sense. I would say what I love so much about

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PDPM is there is no difference between financial

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success and clinical success. They're one and

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the same in PDPM. I think the model is brilliant.

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If you set out on the journey of how can I figure out how to

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financially gain the system? Frankly, it's near impossible.

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If you push on one part of the model, the other part of

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the model gives way. Someone that I can't remember who uses

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analogy of a waterbed, you push on one side

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of the water bed and the other side comes up and I see that in

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the model. And that's the first time I actually read the proposed rule.

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I was geeking out. I was all excited and I'm like, oh my God,

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this is amazing. As a clinician, it's amazing,

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like how incredible it is for the facility to be able

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to do the right thing and get financially rewarded.

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And nursing is more front and center before

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they were relegated to the back of the bus and it was all about therapy

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and therapy minute. It's not to turn therapist into a villain.

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Our industry is so regulated that we have become

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rule followers. So we follow rules.

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Behaviors change, just like behaviors will change with PDPM.

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But these behaviors that are going to change are going to be

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so much the behaviors we want, the behaviors,

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the behaviors that I learned about in graduate

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studies and excellent elder care and studied Hebrews

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in your life in Boston. This feels so right

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for nurses. And I would say the greatest

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challenge we're going to have right now with PDPM transition is

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changing how we think, changing our framework

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for thinking about care. And let me be very specific.

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I go and I teach about PDPM quite a bit.

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And one of the coolest things for me is in the audience, I can

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have a lender from a commercial

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bank. I can have a hug lender. I can have a REIT sitting next to

19:14.965 --> 19:18.597
the director of nursing, the quality improvement nurse,

19:18.717 --> 19:22.122
the owner, the administrator, the ambulance coordinator.

19:22.242 --> 19:25.647
It has never failed. Each and every time I've done a PDPM

19:25.692 --> 19:28.852
class, that the mix of people and they're all hearing the

19:28.870 --> 19:32.752
same information. I have to be careful with the jargon I use as

19:32.770 --> 19:35.917
a clinician, but we're hearing the same information, we're getting

19:35.965 --> 19:39.982
the same goals. So the alignment is there. But anyway,

19:40.060 --> 19:43.567
to the point I was making, people will ask me about,

19:43.690 --> 19:47.487
for example, therapy, whether the role of therapy

19:47.562 --> 19:51.725
or even therapy contracts and what they should look like and

19:52.087 --> 19:55.552
here's a great example of taking the old world of

19:55.570 --> 19:59.322
thinking about care and applying and trying to apply it to PDPM

19:59.367 --> 20:02.150
and how it doesn't work. So folks will say,

20:02.887 --> 20:06.342
I will reimburse my therapist if it's a contract therapy,

20:06.402 --> 20:10.267
for example, I'll reimburse them based on my

20:10.390 --> 20:14.047
Ptot and speech therapy components and that's it.

20:14.080 --> 20:17.647
So they'll get a proportion of whatever that is. And I

20:17.680 --> 20:20.647
look to them in a very tactful, diplomatic way,

20:20.680 --> 20:24.097
say, you know, that's just keeping sister in the box. That is

20:24.130 --> 20:28.117
basically saying, I value therapy for a minute and that's it.

20:28.315 --> 20:32.077
And my point is that take the box away.

20:32.245 --> 20:35.677
Therapists are often the most skilled person

20:35.770 --> 20:39.117
in the building at any given time next to the physician.

20:39.252 --> 20:42.472
And how often is the physician there? They are the most skilled, they are most

20:42.505 --> 20:46.072
often doctorately prepared. And they not

20:46.105 --> 20:49.192
only can they provide rehabilitation services,

20:49.390 --> 20:52.677
but they're fantastic at cognitive assessments,

20:52.857 --> 20:56.622
they're excellent at wounds care and wound assessment.

20:56.817 --> 21:00.502
There's just so much that they can do that we don't bring

21:00.520 --> 21:03.622
them to the table. I've studied this in the past and I can

21:03.655 --> 21:07.272
see facilities that have higher proportion of physical therapists

21:07.317 --> 21:10.187
in the building have lower rates of rehabilitation.

21:10.687 --> 21:14.002
So we don't need to just value them for the

21:14.020 --> 21:17.247
minutes of therapy, bring them to the interdisciplinary

21:17.367 --> 21:20.557
team and have them as equal players. So what I

21:20.560 --> 21:23.967
was going to say is that famously, there's this friction

21:24.027 --> 21:27.427
between the nursing staff and the therapy staff. Part of it is

21:27.445 --> 21:30.957
because, like you mentioned a lot of times, the therapy staff are technically

21:31.047 --> 21:34.057
part of a different company. And as much as they try to bring everyone together,

21:34.135 --> 21:37.537
that doesn't always work. But there's also the nursing staff are there

21:37.600 --> 21:41.452
24/7, they work very hard, very long hours, and sometimes

21:41.545 --> 21:44.722
double. And we can't say it out loud, but we know sometimes people may even

21:44.755 --> 21:48.997
do triple shifts, which they can't do, but in a way they feel very

21:49.180 --> 21:52.602
devoted and they feel like almost in a way, like the mothers

21:52.632 --> 21:56.202
or parents of the residents, and these are our residents.

21:56.232 --> 22:00.097
And then you come in here, the therapist, with your expertise and your

22:00.130 --> 22:03.022
skills, then you're telling us to do this and to do that.

22:03.130 --> 22:06.517
And instead of embracing the skill that they bring to the

22:06.565 --> 22:10.197
table, sometimes you have that friction.

22:10.317 --> 22:13.627
But again, this is probably another example of where we

22:13.645 --> 22:17.682
can include the dietitian, like you started mentioning,

22:17.772 --> 22:21.277
and the therapists and really cash in, so to

22:21.295 --> 22:25.462
speak, on their skills, their expertise, their experience and work

22:25.525 --> 22:29.317
together, because now the goal is to provide that level

22:29.365 --> 22:32.387
of care for the residents and we're not competing.

22:32.812 --> 22:36.217
And again, the therapists don't have, oh, well, I need the resident for minutes.

22:36.265 --> 22:40.137
So you'll do meds later. And everybody knows

22:40.287 --> 22:43.417
the holy minutes, that's our bread and butter. So,

22:43.465 --> 22:46.677
yeah, okay. Even within the vessel, like you said, when you speak to the crowd

22:46.707 --> 22:49.977
of such a diverse group of people who are receiving

22:50.007 --> 22:54.072
the same information from a clinician. But from a clinician standpoint,

22:54.117 --> 22:57.867
and truth be told, from anyone who really cares about residents,

22:57.927 --> 23:00.922
that is such an exciting concept that they all need and care about the same

23:00.955 --> 23:04.257
information. But I think it goes again, this is the administrator

23:04.272 --> 23:07.687
and me speaking that within each facility there's also

23:07.750 --> 23:11.707
different stakeholders, so to speak. You have the banker in the facility, maybe the

23:11.710 --> 23:15.457
business office manager. Yes. And you have the owner in

23:15.460 --> 23:19.047
the facility, which might be the administrator. You have the clinician

23:19.092 --> 23:22.752
team and you have therapy team. This kind of even within the facility

23:22.857 --> 23:25.897
brings everyone closer to the same page because you don't have the people who are

23:25.930 --> 23:29.817
just ensuring that let's maximize therapy benefits and let's

23:29.877 --> 23:33.412
maximize the things that used to be the biggest payment drivers, but now

23:33.475 --> 23:37.422
we're kind of shifting that out. Yes. I love in your description,

23:37.542 --> 23:41.817
I love with what you just said, pardon me was use the term cashing

23:41.877 --> 23:45.922
in on the therapist skill and whether

23:45.955 --> 23:48.982
you intended to or not, that's exactly my point,

23:49.135 --> 23:52.702
is in PDPM, you are cashing in on

23:52.720 --> 23:56.847
the therapist skills. OK, so now I'm taking off my nurses

23:56.892 --> 24:00.067
cap and I'm putting on I'm opening up my

24:00.115 --> 24:03.877
accounting ledger and yes, it is cashing in on

24:03.895 --> 24:07.357
the therapist skill, but now the financial people

24:07.435 --> 24:10.672
can delight in that and so can the clinical team.

24:10.705 --> 24:14.337
And there doesn't need to be the tension that you so rightly described.

24:14.412 --> 24:17.842
The tension exists because we created it. They don't teach you

24:17.890 --> 24:21.502
to be at odds with in nursing school. They don't teach you

24:21.520 --> 24:24.642
to be at odds with physical therapists and vice versa.

24:24.777 --> 24:28.122
We taught that. We brought that in our current rug

24:28.167 --> 24:31.242
system, we created that. So unless

24:31.302 --> 24:35.427
you would like to go in a different direction, there are some things that although

24:35.457 --> 24:38.287
I delight over PDPM, there's a couple of things,

24:38.425 --> 24:41.302
probably more than a couple of things that I'm a little concerned about.

24:41.395 --> 24:45.297
And I want to kind of share the cautionary tale with listeners

24:45.342 --> 24:48.822
on this call, if I may, please. So in PDPM,

24:48.867 --> 24:52.777
as I mentioned, it's all about the patient characteristics and

24:52.795 --> 24:56.157
CMS is very clear to call the person the patient.

24:56.247 --> 24:59.797
And we should all delight in that. It's really the first time it's ever

24:59.830 --> 25:03.552
been acknowledged that we are caring for patients in our residents.

25:03.657 --> 25:07.297
So what's going to happen is, come October 1,

25:07.405 --> 25:10.777
behaviors are going to change. I've worked for companies where

25:10.795 --> 25:14.077
we were trained and educated not to refer to them as

25:14.095 --> 25:17.487
patients, partially because some of them are long term residents.

25:17.562 --> 25:21.217
This is where they live and this is their house, homelike environment and all that.

25:21.265 --> 25:24.042
So why is it that you delight that we refer to them as patients?

25:24.177 --> 25:27.592
Well, I think what you're referring to is the

25:27.640 --> 25:31.042
nursing home of yesteryear. I think that

25:31.090 --> 25:34.812
we care for both patients and residents in the same setting,

25:34.887 --> 25:38.272
for better or worse, richer or poorer. We're caring for

25:38.305 --> 25:41.662
patients who have absolutely no intentions of staying in our building

25:41.725 --> 25:45.492
and are going home. And they are as acute as the patients

25:45.552 --> 25:49.177
that are in an altar or an earth. Sometimes there is acute as

25:49.195 --> 25:53.427
the person in the hospital, as some of us are admitting people directly

25:53.457 --> 25:57.087
from the Er. To call them residence is inappropriate.

25:57.162 --> 26:00.292
They don't like it. And it doesn't really do

26:00.340 --> 26:04.197
us well when you look at just their data. And we start commingling

26:04.242 --> 26:07.822
it with our long stay people who

26:07.855 --> 26:11.422
are residents and who are with us for the duration. Got it.

26:11.605 --> 26:15.147
So words are important. You can have a person come in as a patient

26:15.192 --> 26:18.652
and transition to a resident. And why don't we just draw that line

26:18.745 --> 26:22.087
at 100 days? Or why don't we draw that line when their

26:22.150 --> 26:25.597
source of payment changes if we want to? Got it.

26:25.705 --> 26:28.947
Okay, thanks for clarifying. Yes, my pleasure,

26:28.992 --> 26:32.577
my pleasure. Words are important. So here we are with PDPM

26:32.682 --> 26:36.922
and October. Behaviors change and in

26:36.955 --> 26:40.902
some instances here is going to change as well. But behaviors

26:40.932 --> 26:45.267
change. So the behaviors, I mean, are documentation predominantly.

26:45.402 --> 26:49.662
I know for a fact from my time at Point Ride and more recently

26:49.737 --> 26:53.362
at Zimmer Healthcare Services Group, I know for a fact that

26:53.425 --> 26:57.372
certain care is being provided, but it's not being documented in their medical

26:57.417 --> 27:01.687
record. Let me give you an example, okay? So if you look today

27:01.825 --> 27:05.392
in 2018, all right? So last year

27:05.515 --> 27:09.492
and you looked at five day assessments, Medicare assessments,

27:09.627 --> 27:13.707
and you look at the nation, we're providing mechanically altered

27:13.722 --> 27:16.492
diets about 24% of the time.

27:16.690 --> 27:19.912
OK, so why is that important? Well, when you actually

27:19.975 --> 27:24.042
go in the building and you start looking at trees as they're being delivered,

27:24.177 --> 27:28.025
or you start looking at care plans, you see that no,

27:28.387 --> 27:32.457
24% is ridiculously low. Mechanically altered

27:32.472 --> 27:36.297
diet is chopped foods. It's softened foods, it's pureed

27:36.342 --> 27:39.307
foods. It means many, many things.

27:39.385 --> 27:42.852
It's not 24% of the time, it's closer. Maybe it's triple

27:42.882 --> 27:46.147
that. If you talk to the speech therapist in the building and you

27:46.180 --> 27:50.122
say, what proportion of your patients are people in this

27:50.155 --> 27:54.027
building getting mechanically altered? She'll say recently,

27:54.057 --> 27:57.157
I tested this out, and she did say, oh,

27:57.235 --> 28:00.877
you know, it's probably a couple of dozen people in

28:00.895 --> 28:04.312
the building, but frankly, it's closer to 70% of the building

28:04.375 --> 28:07.462
actually get it. So why is that? Well,

28:07.600 --> 28:10.572
there was no motivation to document it. Who cares?

28:10.617 --> 28:14.857
It was in the care plan. It never made it to the MDS. So now

28:15.010 --> 28:18.672
mechanically altered diet is going to increase your case mix

28:18.717 --> 28:22.467
index in the speech and language pathology component.

28:22.527 --> 28:26.017
So basically you're going to get paid for it. And why shouldn't you? You're doing

28:26.065 --> 28:30.222
it. You're assessing someone's swallowing disorder. You're putting an intervention

28:30.267 --> 28:33.877
in place. So damn, you do it. So what

28:33.895 --> 28:37.117
is that going to look like? What's that going to look like? Let's take those

28:37.165 --> 28:40.522
two components swallowing disorders and

28:40.555 --> 28:43.712
mechanically altered diet. Swallowing disorders,

28:44.212 --> 28:47.797
the nation's at a rate of about 3.7%.

28:47.980 --> 28:52.227
But if you look at the literature, in the literature that talks

28:52.257 --> 28:56.272
about studies in our population that we're talking about,

28:56.455 --> 29:00.357
they will talk about Dysphagia or swallowing difficulties

29:00.447 --> 29:04.012
being anything from 40% to 68%.

29:04.150 --> 29:07.627
But today, according to NDS, it's 3.7% from

29:07.645 --> 29:11.212
the analysis we did at the point right, a few months ago. So,

29:11.350 --> 29:13.777
wow, what's real here? 3%,

29:13.870 --> 29:17.352
40%, they're both real. So what's going to happen October

29:17.382 --> 29:21.552
1 is we're going to start saying, well, now I documented,

29:21.657 --> 29:24.742
there's a motivation for me to document it. So I start

29:24.790 --> 29:28.197
documenting this. And we go from 3% swallowing disorders

29:28.242 --> 29:31.902
up to 40. We go from 24% mechanically altered

29:31.932 --> 29:35.397
diet up to 50% mechanically altered diet.

29:35.517 --> 29:39.232
And we're doing the right thing and we're documenting it

29:39.310 --> 29:43.117
and we're getting reimbursed for it and we're evaluating our care

29:43.165 --> 29:47.137
plans constantly. Everything is great. Then someone comes by

29:47.275 --> 29:51.437
and that someone usually has initials such as Oog

29:51.787 --> 29:54.922
or CMS or fill in the blank and they

29:54.955 --> 29:58.827
say, oh, look at these providers, look at them gaming

29:58.857 --> 30:02.287
the system. And it's we're not gaming the system,

30:02.425 --> 30:05.632
we're playing by the rules. And so what do

30:05.635 --> 30:08.887
you do with that dilemma? We have some providers that are saying,

30:09.025 --> 30:12.322
I get it, and so therefore I'm going to slowly change my

30:12.355 --> 30:15.397
behavior. And then other people that are saying,

30:15.580 --> 30:18.742
I'm going for it, I'm going to do it right from the beginning on day

30:18.790 --> 30:22.282
one. I'm not going to say one way is better than the

30:22.285 --> 30:26.262
other, although I have to say the sort of insipid changing of behavior

30:26.412 --> 30:29.692
is really easy to identify when you're looking at data

30:29.740 --> 30:32.997
and analytics, so it doesn't provide protection.

30:33.117 --> 30:36.472
But anyway, we're in a dilemma. We're going to have all

30:36.505 --> 30:39.822
of our nation's nursing homes changing their coding

30:39.867 --> 30:43.272
practices and documenting care differently.

30:43.392 --> 30:47.017
I strongly believe the care has been given all along,

30:47.140 --> 30:50.602
but we're documenting it for the first time. So CMS is

30:50.620 --> 30:53.797
aware of this. CMS knows that.

30:53.905 --> 30:57.507
I guess this is a question. The reason the push

30:57.597 --> 31:00.742
for the change, as we already discussed, is to

31:00.790 --> 31:04.327
balance out the care in a way that is in the best interest of

31:04.345 --> 31:07.792
the residents and make that also in the best interest of

31:07.840 --> 31:12.087
the facility. It should be that much financially reward.

31:12.237 --> 31:15.877
There should be an expected outcome. OK, I think

31:15.895 --> 31:19.887
I'm getting it. Now, in other words, CMS is going to assume, or whichever

31:20.037 --> 31:24.297
initials walks in the building or analyzes the data from afar

31:24.417 --> 31:27.922
is going to assume that we're documenting everything.

31:28.105 --> 31:32.532
We always have been documenting everything. So if you're now increasing,

31:32.697 --> 31:36.472
assuming that what the data will say is that, you know, we used to not

31:36.505 --> 31:39.622
have so many mechanically altered diets and now

31:39.730 --> 31:43.197
we started giving everybody pureed food and because we're

31:43.242 --> 31:46.732
being financially incentivized to do so, that is

31:46.810 --> 31:50.302
a problem. And really, the truth is there's a lot

31:50.320 --> 31:53.662
of things that we. Always do. But the people who

31:53.725 --> 31:58.302
push for the accurate documentation, and not just accurate versus inaccurate,

31:58.332 --> 32:02.322
but complete documentation is when the rubber hits the road in the financial

32:02.367 --> 32:06.097
office, they see a problem. They're going to go back to the clinicians and

32:06.130 --> 32:08.797
say, you better make sure you do this. When you're doing it anyway, you better

32:08.830 --> 32:12.762
make sure you document. So that is a problem. Oh my gosh.

32:12.837 --> 32:16.602
So what's going to happen with that? Yeah, so CMS believes PDTM

32:16.632 --> 32:20.067
will be budget neutral and there's no way it's going to be budget neutral.

32:20.127 --> 32:23.292
These changes are never budget neutral because behaviors

32:23.352 --> 32:26.817
change. We play by the rules. We change our behaviors.

32:26.952 --> 32:30.367
We start documenting things we never documented before.

32:30.565 --> 32:34.542
And someone from afar who's looking at macro

32:34.602 --> 32:38.622
data sets, they're going to see the shift in coding

32:38.667 --> 32:42.652
practices. They've never worked a day in their life in

32:42.670 --> 32:45.697
a nursing home. They've never been in a nursing home. They don't listen to your

32:45.730 --> 32:49.357
podcast. They don't follow my blog on McKnight. And they are

32:49.360 --> 32:53.197
going to say they're clearly gaming the system and

32:53.230 --> 32:56.527
changing their behaviors. And they'll also say, look what they did

32:56.545 --> 32:59.847
in the past. Look at all the providers who went up to ultra

32:59.892 --> 33:03.847
high providing 720 minutes, but never 721

33:03.880 --> 33:08.017
minutes. And I'm being overly dramatic because there

33:08.065 --> 33:11.472
was tremendous variation in the therapy

33:11.517 --> 33:15.575
minute provision. There were some bad actors out there who

33:16.012 --> 33:19.687
got caught and others who didn't. But by and large,

33:19.750 --> 33:22.972
the majority of the industry was doing the right thing. And I think that will

33:23.005 --> 33:27.622
happen now. But PDPM is so profoundly different

33:27.805 --> 33:31.342
that unless you are looking through the change with the right

33:31.390 --> 33:35.932
lens, I'm afraid the conclusions you'll draw will

33:36.010 --> 33:39.517
not be flattering. And that's what we as

33:39.565 --> 33:43.827
providers and investors and REITs and attorneys

33:44.007 --> 33:46.972
and caregivers need to be prepared for.

33:47.155 --> 33:51.187
Awesome. So tell me another concern that you have

33:51.325 --> 33:54.972
with this new change of PDPM. Another concern?

33:55.092 --> 33:58.850
I alluded to it before, and that is

33:59.512 --> 34:02.827
we take the rules of the past and we try to apply them to the

34:02.845 --> 34:06.247
future. I'll give a different example and stop using

34:06.280 --> 34:10.047
the therapy example. So we look at the MDS coordinator

34:10.167 --> 34:14.247
and we look at his or her job description

34:14.442 --> 34:18.800
and we don't change it. We say, this person is amazing,

34:19.312 --> 34:23.262
she's been crushing it all these years, et cetera, et cetera.

34:23.412 --> 34:26.675
And we don't say, well actually,

34:27.112 --> 34:30.217
the job description does need to change. It needs

34:30.265 --> 34:33.747
to change because the MDS schedule has changed,

34:33.867 --> 34:38.022
the values have changed. So the MDS coordinator

34:38.142 --> 34:41.542
job description should be less about

34:41.740 --> 34:45.132
timing and documentation and scheduling

34:45.222 --> 34:48.802
and making sure everything is done in the right time and submitted, which is

34:48.820 --> 34:52.152
incredibly important today, capturing acuity.

34:52.332 --> 34:56.172
They should now in PDPM, they should be care managers.

34:56.292 --> 34:59.947
They should be very astute clinicians who are

35:00.055 --> 35:04.477
able to look at very obtuse clinical information

35:04.645 --> 35:08.352
about the patient that comes with them from the hospital.

35:08.532 --> 35:11.347
And they have to be able to look at that and kind of spec it

35:11.380 --> 35:15.292
out and say to themselves, well, this is odd, why are they getting

35:15.340 --> 35:19.252
this medication or have this equipment in place or

35:19.345 --> 35:22.902
have this behavior? But they don't seem

35:22.932 --> 35:26.137
to have an appropriate diagnosis that lines up with that.

35:26.200 --> 35:29.692
And to be able to stop and say, oh well,

35:29.815 --> 35:33.412
what are their diagnoses? And then advocate for

35:33.550 --> 35:37.417
with the physician, a more appropriate diagnosis that

35:37.465 --> 35:41.772
really captures why the person does have the characteristics

35:41.817 --> 35:45.232
that they have got it. And that's a very different skill set.

35:45.385 --> 35:49.077
That's really, like I said, a very astute clinician,

35:49.257 --> 35:52.627
not necessarily a different skill set. So then I was

35:52.645 --> 35:55.927
the person who's been there gathering the data from all the

35:55.945 --> 35:59.572
various departments and inputting everything into the MDS and

35:59.605 --> 36:03.622
making sure, as you said, make sure everything is submitted on time, which kind of

36:03.655 --> 36:07.252
has been the role and the focus of putting in

36:07.270 --> 36:10.497
all those hours of getting it in. Now that's changed.

36:10.542 --> 36:14.542
And the good part is, I guess, that they have the

36:14.665 --> 36:18.412
luxury to think broadly, like you mentioned,

36:18.550 --> 36:22.447
because the schedule has changed and because it's more about the

36:22.480 --> 36:25.957
bigger picture. But someone who's great at sitting in front of a

36:25.960 --> 36:29.197
computer all day and getting the MDS is in

36:29.230 --> 36:32.722
on time and complete and accepted, may not

36:32.755 --> 36:36.427
be the person who can sit there and look at the complete picture and like

36:36.445 --> 36:39.552
you said, and pick up on those things that are so important. I kept

36:39.582 --> 36:43.182
your hairway past, I should have. I'm just noticing the time. And it's

36:43.197 --> 36:46.552
a good thing because providing all of this service,

36:46.645 --> 36:50.697
all of this material which is so timely and you're so uniquely

36:50.742 --> 36:54.292
qualified to share this with the listeners, do you have any

36:54.340 --> 36:57.757
final thoughts regarding PDPM and these changes that

36:57.760 --> 37:00.172
you would want to share with our listeners before we let you go to your

37:00.205 --> 37:03.432
busy day? Thank you very much and I've really enjoyed spending

37:03.447 --> 37:07.372
the time with you and I hope my excitement and passion about this

37:07.555 --> 37:10.942
change comes across. I just think that we are in

37:10.990 --> 37:14.757
such an unbelievable inflection point in our industry.

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PDPM is setting our thoughts for success.

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PDPM is here for five years. It will be

37:21.295 --> 37:24.727
replaced by another system, and that other system

37:24.895 --> 37:28.672
is already foretold. You don't have to

37:28.705 --> 37:31.612
be in Oracle to know that. You just have to be able to read the

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Impact Act and understand where we're going to in

37:34.960 --> 37:38.997
this nation. We are going to site neutral reimbursement

37:39.117 --> 37:42.522
where all post institutional, post acute

37:42.567 --> 37:45.217
settings will get reimbursed the same rate. Now,

37:45.265 --> 37:48.322
traditionally, skilled nursing is less expensive than

37:48.355 --> 37:52.827
some of our counterparts, LTC and IRFs. So PDPM

37:52.932 --> 37:56.122
and the data that we're now collecting off

37:56.155 --> 37:59.562
of MDS is really going to demonstrate

37:59.637 --> 38:03.252
that we are the best game in town. We're providing

38:03.282 --> 38:06.592
the best outcomes at the lowest cost. So this

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is just a simple stepping stone. If we crush this, we're going

38:10.030 --> 38:13.722
to do exceedingly well in the future. Wow. How encouraging

38:13.767 --> 38:17.812
that is for operators. I can just say from my personal experience,

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that resonates with me so deeply because it's always been so frustrating.

38:21.747 --> 38:24.687
And I hear from the residents, you hear from the families,

38:24.837 --> 38:28.287
they knew that the level of care that we provide with the resources

38:28.362 --> 38:31.912
that are extremely limited compared to some of our

38:32.050 --> 38:35.547
professional clinical partners, and some of the results are beyond

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astounding. We don't have to go to specific examples, especially because it's

38:39.432 --> 38:43.017
late, but people come in completely paralyzed and walk out the front door.

38:43.077 --> 38:47.002
There are so many examples, and you're right, and we do

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it. We get the trimmest, leanest reimbursement

38:51.642 --> 38:55.017
for providing many, many times. Again, there are bad apples,

38:55.077 --> 38:58.422
of course, as well, but many, many times, outstanding results.

38:58.467 --> 39:01.132
And if that is the wave of the future,

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then that is really amazing news

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for providers who have always been doing this for other providers to

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get on the bandwagon. And like I said earlier, everybody went this way.

39:12.430 --> 39:15.637
Absolutely. Thank you so much for the time. I really

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appreciate it. All right, thank you for coming on. If our listeners want

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to hear more about some of your writing stories you're teaching,

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where's the best place for us to send them? Is there one place for for

39:26.431 --> 39:29.707
us us to send them? Well, I would say in terms of email,

39:29.785 --> 39:33.457
the best way to reach me is Stephen with a V@zhealthcare.com.

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A simple

39:38.035 --> 39:41.652
Google search will reveal many presentations that I've

39:41.682 --> 39:44.827
done, as well as writings, and I

39:44.845 --> 39:48.412
have a monthly blog in Ignites. Okay, awesome.

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Thank you so much, Steven. This is really enjoyable,

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and we're going to share this enjoyment with everybody

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else. Fantastic. Okay, thanks. Bye bye.

39:59.157 --> 40:01.275
All right, bye bye. Thanks. Have a great day.