Blue Sky Therapy Blog

Life in a Post PPS World:Why Therapy Matters More Than Ever Under PDPM

by Lisa Chambers, MS, CCC/SLP

If You Have Not Heard It Enough Already- Here’s The Difference Between PPS & PDPM

As we draw near to the second anniversary of PDPM, the lot of you reading this are acutely aware of the core differences we have come to familiarize ourselves with when discussing PDPM related to the preceding reimbursement system, RUG-IV. Without being long-winded or exhaustive there is one core mentality shift that sheds light upon many nuanced factors. With PDPM, there is a renewed focus on the entirety of the individual patient rather than volume of care rendered. One other goal was to improve SNF payment (and performance) without increasing total Medicare spend, but hindsight knows that was not quite the case.

The differences are bountiful, but by looking at aspects which play a role in how we operate with this renewed focus on the individual, we can infer and understand a wide variety of puzzle pieces which can help us become better operators and care givers. Our first example will be one that hits close to home. Rehab went from “driving the reimbursement boat” to becoming “just another cost center”. Well, as with many things in life, this is a double-edged sword. The perception of therapy might have changed, but not the importance- whether we are talking about the patient or the facility.


Reimbursement Shift- Beating A Dead Horse

Everyone should know the how and why we get reimbursed has changed. But how does that impact what we do? In short, it should not (if we were already doing right by the patient, that is!). While this shift in how we view the patient in a more wholistic fashion is welcomed, we haven seen new efforts unfold in how operators optimize the aspects of day to day care to become more effective and efficient from both a clinical outcome perspective as well as fiscally. A core example is the transition and other implications in the world of rehab. Very early into PDPM we heard reports of large layoffs, group and concurrent mandates, and anonymous Confessions of a Therapist, that shared candid, and sometimes disappointing insights into the minds of operators and third-party rehab providers. Because therapy is no longer driving that proverbial shift we mentioned previously, it can be easy to lose sight of the importance of this department and what a successful one can and will do for your facility.


Therapy Delivery & Focus- Has It Really Changed? (OR SHOULD it have?)
Service Delivery & Minutes

It was well noted that CMS would be paying attention to changes as we transitioned to PDPM. The Director of Regulatory Affairs for the APTA, Kara Gainer, said it best, ““I think it’s really short-sighted that these companies are doing this, because they know CMS is watching, and they know if they have a dip in outcomes or dip in utilization, CMS is probably going to audit them.” The perceived objective of this shift was not to disincentivize care, but rather to ensure reimbursement was justified based on the patient needs. PDPM has enabled and encouraged us to look for ways to do better. Our commitment to our patients did not change, and therefore, neither did our service delivery.



Some notable shifts have occurred in terms of what we pay attention to compared to under PPS. SLP interaction and knowledge is a strong example of this. Because of certain aspects of PDPM, we are more cognizant than ever of the dozen SLP-related comorbidities. While BIMS assessments were still standard practice prior to PDPM, those that may have had Social Workers or Case Managers administer those tests have hopefully learned what a licensed SLP can pick up on versus an untrained eye. Missing out on even one item can correlate to a CMI decrease nearly an entire point in some scenarios.  



This aspect of PDPM offers us new opportunity and gives us another option to provide care outside of the 1:1 model.                             Incorporating a mode of therapy that allows us to work more efficiently and improve workflows, best practices, and bolster                   clinical initiatives is exciting! And ultimately this benefit to the patient should be viewed as a win! Several studies have shown                 that appropriate Group Therapy improves outcomes for patients and elements to this practice, most specifically socialization,               can positively impact mood and cognition as well!


What Should You Be Focusing On- “I Saw the Sign. And it opened up my eyes!”

Quality Outcomes

Did you know? - A 5 Star Quality Rating will automagically add 1 star to your overall rating. Inversely, a 1-star Quality Rating will remove a star from your overall rating. While the health inspection is the driving force behind Overall Rating- consider this chart below. Even with a 1 star across the board, having a 5-star Quality Rating puts you in a Median Occupancy category 3 percentage points higher than the 1-star group.

Quality Rating is a very forward facing KPI. Those consumers that leverage online directories and tools may be skewed by a star rating, but deeper than that are all the elements that go into determining that rating, and even deeper, metrics that are monitored by referral sources and other providers.

Quality Outcomes can be viewed many ways by many folks, but one of our favorites to acknowledge is readmission/rehospitalization rates. Blue Sky is always seeking to better support our partners as we continue to emphasize the importance of quality rehab outcomes and how they drive overarching patient success so we invest in a variety of software and tools to help us help them!

Key Performance Indicators



First, let us define these terms for clarification.

Rehospitalization- SNF's patients were admitted to a short-term acute stay during a SNF services episode OR within 30 days of SNF discharge.

Readmission- patients came from an inpatient setting, were admitted to the SNF, and were subsequently readmitted to any hospital within 30 days of the first inpatient discharge.

These metrics are often looked at in a 30-60-90 day capacity and it is obvious that the numbers increase as time goes on, but just how much so is interesting.

For 956 SNFs analyzed in Ohio, the 30-day trended readmission rate is 12.70%. The 60-day window sees a jump up to 17.93%, over a 70% increase! The 90-day average comes in just under 21% at 20.97%.


Here is where the fun of number crunching kicks in!


Five-Star rated facilities are at 11.2%, 15.9%, and 18.5% respectively.

Inversely, 14.6%, 20.1%, and 24.0% are the trended 30-60-90 day rates for Ohio’s One-star facilities.


Huh, who would have thought that quality of care/readmissions could be linked to overall rating?!


What does this mean in the market? I bet your assumptions are correct…


The 166 One-star facilities have an average Medicare FFS annual count of 52.

The 187 Five-star facilities average 88 skilled referrals a year. An increase of nearly 60%!


Oh, and one last thing. If you recall the comment about Quality Rating boosting overall by a star…. The 182 Two-star homes averaged 69 skilled referrals per year. Quite an impact quality can make!

While we may have digressed from the ideology of PPS vs PDPM, it is relevant to point out that these data points are all aspects of our day-to-day operations, and we must remain aware of how we continue to look at these driving factors of our organizations and how our viewpoint may have shifted since Oct 1, 2019. Therapy plays such a critical role in driving quality outcomes for your residents we need not lose sight of what a strong rehab team and oversight can do for the overarching benefit of your facility or organization.


Discharge Destinations- The Continuum of Care: Consistency Breeds Excellence

The continued proliferation of Medicare Advantage plans has seen our skilled Average Length of Stay (ALOS) become more and more pared down over time. As we look to transition patients to the next level of care, it is important to consider what is being done at each step of the journey to successfully create plans and best practices that allow for safe and effective discharges. Whether it is SNF to Home or any other step of the journey, a level of consistency can go a long way to help impact the aforementioned readmission trends. Therapy’s role in this is of the utmost importance. Our upcoming blog will dive into great detail, but for now we will mention briefly that Blue Sky Therapy is an advocate for consistency and has pushed us to position ourselves where we are working with hospitals, SNFs, ALFs, Home Health Agencies, private duty agencies, in-home part B post skilled home health, and operating our own outpatient clinics. All of this is to assert ourselves across the entire continuum/patient episode and bring a new level of consistency not often realized outside of uber health systems.


Rehab- More Than Just a Piece of the Puzzle

Why Therapy Matters More Than Ever- Tying It All Together

Interdisciplinary Collaboration that is effective is the gold standard with a direct impact on the success of the patients and the facility. Organized and meaningful communication will enhance care and outcomes as well as maximize available reimbursement. The therapy team is a key component of this team as they have consistent daily interaction with the patient for extended periods of time often being aware of subtle changes in condition that should be communicated and addressed early. They also can provide insight into the coding required to reflect the patient’s unique characteristics so that is reflected in the MDS and in the patient’s plan of care.

Identification of Patient Characteristics: The Foundation of Your Reimbursement

is the foundation of your reimbursement. Capturing or not capturing all the components accurately under PDPM can impact your reimbursement significantly! NTA’s, cognition and speech comorbidities, GG scores along with mood and depression are areas that therapy can support to ensure accurate coding of patient characteristics.


Quality Outcomes- Where Therapy Helps

Therapy can help impact long and short measures as well as provide programing for patients to address a specific diagnosis, minimize declines through education and working with restorative programs as well as proactively addressing areas such as fall risk, cognitive declines, etc.


What’s Next for Long-Term Care?

While your guess may be as good as ours, it is safe to assume PDPM is not going away any time soon. PPS was around for two decades and some may say that was a decade too long. While COVID-19 created an environment where we could not dig our heels into the sand and get as intimately acquainted and engrained into the new system as we might have hoped, it also presented an opportunity to continue to think outside the box and prioritize the most important issues at hand. As COVID-19 restrictions ease and occupancy ticks back to where it once was, we will continue to refine and define the future of long-term care by how we react to change. Whether it is PDPM, COVID-19, or the gradual shift toward value-based care, the best quote to live by is this…


“Change is inevitable. Growth is optional.”

changes in healthcare

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