Discussion: Problem state and research question

Walden University

 

 

 

Week 7

 

Assignment: Revised Doctoral Study Prospectus

 

 

 

The effect of Patient-Driven payment model (PDPM) on quality care in nursing homes.

 

 

 

 

Prepared By: Charmaine Maestrado

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problem Statement

 

The world’s population is rapidly aging and the number of elderly people is increasing

 

daily( Manav, Yeşilot, Demirci,&Öztunç, 2018).1.4  million Americans are living in a nursing

 

home. Unfortunately, thousands of them are evicted against their wishes simply because of their

 

eligibility status.It is a troubling trend statewide as the senior population is growing , nursing

 

home facilities are closing down.The primary contributor of these closures is the low Medicaid

 

reimbursement rate(s). Majority of the nursing homes are run by large corporate chains that

 

operate multiple facilities throughout the country.It is illegal to discriminate against residents’

 

based on payment source. Medicare and Medicaid subsidize different amounts. Medicare pays

 

more. However , Medicare is not for long term purposes since it will only cover certain days. Discussion: Problem state and research question

 

Medicare only covers short-term rehabilitation: up to 20 days for 100% after that you have to pay

 

for the copayment. As of 2017, long term Ombudsman received more than 10,000 complaints

 

about nursing home discharged and transfers.

 

Minimizing our costs as a business is always a challenge . Staffing plays a huge part in nursing

 

home operational costs. If we do not have enough resources to remain in business. We are most

 

likely going to cut our staff and this is going to impact the care and services we provide to our

 

patients. The new payment model , the patient-driven payment model (PDPM) is expected to

 

align reimbursement with shift from volume to value.This study will identify the significant gap

 

between the funding and the actual cost to providing the  care as well as the impact on staffing

 

levels in the nursing homes.

 

 

 

 

 

 

 

 

                                                          Purpose of the study

 

The purpose of this study is to  examine the impact of the new payment model on quality of care

 

in nursing homes.  Hettich and  Pivec (2018) noted that Under the RUG-IVpayment

 

system, SNFs are paid at a constant per diem rate, regardless of the length of a resident’s stay,

 

unless the resident is reclassified into a different  group during the stay . It has been three

 

months since we started the new case-mix model titled the Patient-Driven Payment Model

 

(PDPM) and replaced the Resourced Utilization Groups or the RUGs model.

 

 

                                                          Significance of this study

 

In healthcare, quality is a measure of success. We cannot improve what we cannot measure. The

 

resident’s health outcome will tell us how we are doing.  The study will help us determine how

 

effective the new model is and identify the impact of it in rehabilitation services and the overall

 

well being of the resident(s).The goal of Patient-Driven Payment Model is to provide patient-

 

centered care that treats the resident as a whole instead of reimbursing nursing facilities primarily

 

for rehabilitation services.The PDPM focuses on clinically relevant factor rather than codes and

 

other characteristics as  the basis for patient classification.  It will focus on critical conditions

 

,patient diagnosis, comorbidity and history of the most recent hospital stays for reimbursement

 

rates. Rehabilitation services will take a lesser role in reimbursement and PDPM will affect Part

 

A but not Medicare Advantage patients.  Discussion: Problem state and research question

 

 

 

                                                           Background

 

The keywords searched were online doctoral program completion, Elsevier, Emerald insight 

 

and CINAHL Plus.

 

1. Babbie, E. (2017). Briefly discussed the importance of deductive theory and social

 

change.

 

2. Elliot, A. E., &Barsness, S. (2016). Explained how Medicaid reimbursement started and

 

importance of staff engagement.

 

3. Hettich, D., &Pivec, A. (2018). Provided  information about Prospective payment

 

system which is under the previous model system. Briefly explained the purpose of Patient-

 

Driven Payment Model (PDPM).

 

4. Howard,L. (2014). Provided information about the role of the government in reimbursing

 

skilled nursing facilities.

 

5. Manay,A. Yesilot,S. ,Demirci,P. &Öztunç (2018). Provided information about the

 

cognitive function and quality of life of elderly people living in a nursing home.

 

6. Moick, S., Simon, J., &Hiesmayr, M. (2019). Nutrition care quality indicators in

 

hospitals and nursing homes: A systematic literature review and critical appraisal of

 

current evidence. Clinical Nutrition

 

https://doiorg.ezp.waldenulibrary.org/10.1016/j.clnu.2019.07.025

 

 

 

                                                          Framework

 

I will be using Donabedian Framework and  Andersen Behavioural Model. According to the

 

concept of Donabedian, quality of care is a multidimensional construct. In his framework he

 

distinguishes between structure, process and outcome indicators that all affect quality of care

 

(Moick,Simon,  &Hiesmayr 2019. I believe this can help me explore both clinical and

 

leadership aspect in healthcare . Evidence -based practice from previous scholars will be applied.

 

 

Under Andersen Model, I can do cost utilization. It can also let me identify important factors

 

such as measuring quality indicators. We want to be effective and cost-efficient.Since the

 

payment model just started, it may be too early to distinguish the impact of it but we will see a

 

combination of extensive services with non therapy ancillary services and with nursing services

 

to deliver a case mix that finally reimburses the facility for what the services they actually

 

provide. Our per diem  rate should be budget neutral where Rehabilitation therapy will no longer

 

drives payment. Patient characteristics and MDS coding will drive reimbursement .

 

 

 

Research Question(s)

 

 

RQ–Quantitative: What is the impact of Patient-Driven Payment Model on workforce and

 

reimbursement rate?

 

H01- 90% of post acute care are billed to rehabilitation services. The RUGs payment rates are

 

certainly not dependent on the clinical conditions except for depression as part of the

 

rehabilitation case-mix. As far as reimbursement , physical therapy (PT) and occupational

 

therapy (OT) reimbursement rates will decline by 2% every week after the 20th day of stay.

 

Non-therapy Ancillary services will decline by 66% after the 3rd day of stay. We can be able to

 

use our pharmacist to help us optimize drug therapy early in a resident’s day instead of having

 

the pharmacist quarterly for drug regimen review . We can provide admission medication review

 

to help us identify the barriers and adverse effects, medication errors upon transition and transfer

 

and to assure that the new admission has a successful stay in our facility while we maximize the

 

payment rate for them.

 

Annual federal and state government expenditures for the provision of nursing home care

 

services through the Medicaid program now exceed US$48 billion. Elderly recipients account for

 

nearly three-fourths of the total costs of nursing home care, and nursing home care services

 

comprise 15% of the total Medicaid program spending ( Howard 2014).We are in the crisis

 

situation. The biggest fear that we might face is that , providers will be forced to close

 

particularly those facilities in the rural or smaller communities who have a  higher percentage

 

rate of Medicaid.

 

H1- A study showed that each additional hour of therapy received per week was associated with

 

a 3.1 percentage point increase in the likelihood a SNF resident was discharged home.

 

 

                                                   Nature of this study

 

There is growing tension in long-term care based on an increasing focus on quality of life and

 

resident experience juxtaposed with reimbursement models shifting to an emphasis on quality of

 

care and measurable outcomes (Elliot&Barsness, 2016). This will be a quantitative research, we

 

will focus on data and metrics. Collecting and gathering consistent , valid and measurable data is

 

necessary in/ for this study. Organizations need to look at their financial planning systems , staff

 

management practices and ensure that those approaches will align with their business strategies.

 

The overall purpose of PDPM is to lower costs, improve patient outcomes , augment revenue

 

sources and optimize the reimbursement that facility is due. I think that PDPM will open new

 

opportunities for new admission and effective disease management. Discussion: Problem state and research question

 

 

 

Secondary Data Types and Sources of Information

 

Secondary data will be accessed from an online doctoral program. I will also be using previous

 

data and studies used by Centers of Medicare and Medicaid to look at factors such as RUGS IV,

 

PPS model, mix case model and implications of cost analysis for rate setting. The rehabilitation

 

department will play a significant role in this study.

 

 

Implications

 

 

Long term care organizations need to change their business approaches and strategies because of

 

the new payment model. The development of PDPM did not take outcomeswhen determining

 

therapy groups or payment. At this time, it is difficult to determine how the changes will

 

affect the bottom lines since we just started it. The sources may be also limited since everything

 

is highly regulated.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Babbie, E. (2017). Basics of social research (7th ed.). Boston, MA: Cengage Learning.

 

CohenMiller, A. S., & Pate, P. E. (2019). A Model for Developing Interdisciplinary Research

 

Theoretical Frameworks. Qualitative Report, 24(6), 1211–1226. Retrieved from https://search-ebscohost-

 

com.ezp.waldenulibrary.org/login.aspx?direct=true&db=a9h&AN=136871953&site=eds-

 

live&scope=site

 

Elliot, A. E., &Barsness, S. (2016). What’s in Your Bundle? Building a Communication Map of

 

Relational Coordination Practices to Engage Staff in Individualizing Care. Seniors Housing &

 

Care Journal, 24(1), 3–19. Retrieved from https://search-ebscohost-

 

com.ezp.waldenulibrary.org/login.aspx?direct=true&db=a9h&AN=120614537&site=eds-

 

live&scope=site

 

Hettich, D., &Pivec, A. (2018). Payment System to Change for Skilled Nursing Facilities:

 

CMS’s Patient-driven Payment Model revamps PPS for SNFs. (cover story). Dennis Barry’s

 

Reimbursement Advisor, 34(3), 1–12.

 

Howard, L. L. 1. larryhoward@fullerton. ed. (2014). Does Government Oversight Improve

 

Access to Nursing Home Care? Longitudinal Evidence From US Counties. Inquiry (00469580),

 

51, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1177/0046958014561634

 

Lo, T. K. T., Parkinson, L., Cunich, M., &Byles, J. (2016). Factors associated with the health

 

care cost in older Australian women with arthritis: an application of the Andersen’s Behavioural

 

Model of Health Services Use. Public Health, 134, 64–71.

 

https://doiorg.ezp.waldenulibrary.org/10.1016/j.puhe.2015.11.018

 

Manav, A. İ., Yeşilot, S. B., Demirci, P. Y., &Öztunç, G. (2018). An evaluation of cognitive

 

function, depression, and quality of life of elderly people living in a nursing home. Journal of

 

Psychiatric Nursing / PsikiyatriHemsireleriDernegi, 9(3), 153–160. https://doi-

 

org.ezp.waldenulibrary.org/10.14744/phd.2018.26817

 

 

Shirey, M. R. (2013). Strategic Leadership for Organizational Change. Lewin’s Theory of

 

Planned Change as a Strategic Resource. Journal of Nursing Administration, 43(2), 69–72.

 

https://doi-org.ezp.waldenulibrary.org/10.1097/NNA.0b013e31827f20a9