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Updated: Oct 9, 2019

Written by,

As the implementation date for PDPM draws near, SNFs need to assure that the IDT members have a firm understanding of how information gathering and sharing may need to change. Communication will remain a key focus for success but when and what we share will look somewhat different. Some questions to ask might include: How is the morning meeting structured? Are clinical discussions part of the daily communication? How do you track and communicate patient progress?

The Morning Meeting – This is the ideal time for all IDT members to share key data points and clinical updates on patients in the facility. Topics of discussion should include;

  • Admissions/discharges

  • Resident appointments

  • Falls

  • Clinical changes

  • Therapy progress

  • Concerns

This type of communication assures all clinical needs are being planned for and met, allowing us to maintain a patient-centered approach. It mitigates the risk of missing therapy due to being out of the facility. It helps identify any changes in condition and assures all key players are informed about the needed interventions.

Patients that fall under PDPM will require additional conversation during the morning meeting. It will be essential to discuss the ICD-10 codes, section GG scoring, the identification of all NTAs and any changes in condition that might warrant on IPA. We have developed a Morning Meeting Checklist to guide the conversations and to ensure the discussions are comprehensive and include all considerations for patients under PDPM.

Clinical Discussions – Under PDPM, clinical changes will impact reimbursement therefore the way we communicate this information should be a focus for the IDT. Looking at each patient as an IDT allows changes to be reported and potentially captured on the MDS (either on the initial 5-day or assessment or leading to the decision to complete an IPA). It assures all involved understand what changes have occurred and how to optimize the care plan accordingly. Having these daily discussions as part of the morning meeting allows for ongoing assessment of the possible need for an IPA.

MDS – This will remain a critical role under PDPM. But the IDT will all need to be involved in gathering and sharing information for the assessments. Discussion in the morning meeting should include the primary diagnosis and clinical category so that all IDT members are aware and in agreement. Collaboration on and confirmation of the GG score should be discussed and monitored after day three and ongoing to determine if any changes warrant an IPA.

With these types of detailed communication in place, the team will remain focused on the residents’ clinical pathways and successful discharge planning while removing barriers to success and mitigating risk of readmissions as they arise.

By changing the way we gather data and communicate it to the entire IDT, the patient remains our focus and we can better assure outcomes and accurate reimbursement in the new era of PDPM.



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