A Clinician's Guide to Skilled Rehabilitation Documentation
Lynda Jennings, OTR, RAC-CT, CDP
Includes all course content in digital format
Prerequisites Required
Description
On October 1st, 2019, the new Patient Driven PaymentModel (PDPM) replaced the Resource Utilization Group, Version IV for Skilled Nursing Facilities (SNF). PDPM improves the accuracy and appropriateness of payments for classifying patients into payment groups based on specific, data-driven patient characteristics, while simultaneously reducing administrative burden. As a result, therapy minutes no longer are utilized to classify SNF residents into Resource Utilization Groups (RUGs). Therapy services no longer are the primary driver of reimbursement. In its place is a new model where the focus is not on the number of minutes of service provided, but on classifying the resident on patient characteristics, outcomes, and quality versus quantity of rehab services.
What has not changed is the importance of skilled therapy documentation to support the services provided to our patients. This relevant 1-day course will educate the clinician on the basics of PDPM, the key components of documentation and the importance of utilizing evidence-based tools to support skilled care. In addition, this workshop will review the importance of the interdisciplinary process of consistently painting a picture of the clinical needs of the patient as well as providing documentation that supports the content of the Minimum Data Set (MDS)tool.
*Hands on lab will be modified for Web based delivery formats into recorded demonstrations
Highlights
- Immediately improve your knowledge of the new reimbursement model PDPM
- Effective, evidence-based tools to incorporate in your clinical documentation
- Hands-on lab to practice your documentation skills with a focus on demonstrating skilled services and measurable goal writing
- Provide clarity into the role of the MDS and what components drive reimbursement
- Best practices for multidisciplinary and discipline specific documentation
Learning Objectives
- Discuss key components related to documentation under the new PDPM reimbursement model.
- Evaluate the importance of IDT collaboration and communication for MDS completion.
- Describe the key components of skilled clinical documentation.
- Distinguish how to provide a clear chronological record of the patient's status, the need for services, the patients response, and outcomes.
- Demonstrate how to incorporate evidence-based assessments into clinical documentation.
- Classify discipline specific defensible documentation best practices.
- Examine the specifics of the various types of reviews and how to best prepare for an audit.
Course Content
| A Clinician's Guide to Skilled Rehabilitation Documentation | SCORM Package | ||
| Next Steps Copy 0zuth | Module |
- Changes Made via the Patient Driven Payment Model(PDPM)
- PDPM basics
- Role of the MDS
- Supportive documentation
- Medicare meeting
- Modes of therapy treatment (individual, concurrent, group, cotreatment)
- Restorative nursing programs
- Multidisciplinary Approach: Nursing and Therapy Collaboration
- RAI process
- Care Assessment Areas (CAAs)
- Care plan development
- Care plan implementation
- Best Practices for Effective Documentation
- Purpose of documentation
- Key components
- Screening (evaluation/plan of care, measurable goals, certification/recertification, daily/weekly/monthly documentation, therapy grid/billing, patient/caregiver education, discharge summary)
- Regulatory requirements (Medicare beneficiary part A, Medicare beneficiary part B, managed care/other payers)
- EHR/EMR (point of service documentation)
- Justifying Skilled Services
- Supportive documents
- Medical necessity
- Justifying intensity of service
- Evidence-based assessments
- Jimmo versus Sebellius
- Hands-On Lab
- Discipline Specific Guidance
- Physical therapy (mobility, ROM/strength/balance, wound care)
- Occupational therapy (self-care, ROM/strength/balance, cognition)
- Speech Therapy (swallowing, diets, cognition)
- Modalities
- Handling Audits and Remaining Compliance
- Triple check
- Denials and appeal management
- Target audits, probe, and educate
- Therapy specific audits (ZPICS)
- PDPM compliance areas
*Hands on lab will be modified for Web based delivery formats into recorded demonstrations
Lynda Jennings, OTR, RAC-CT, CDP, is the Vice President of Clinical Services and Compliance at The Village at Incarnate Word. She is a seasoned clinician and operations manager whose healthcare experience spans 30 years with expertise in PDPM, Medicare/Medicaid policy, compliance, documentation, and clinical programming. Prior to joining the team at The Village, she served as Chief Operating Officer at Touchstone Rehabilitation, overseeing the clinical and financial operations of twenty-three skilled nursing rehabilitation centers across Texas.
Lynda is a member of Texas Occupational Therapy Association serving on the board in various capacities including past state association president. Currently, she serves as the State Parliamentarian and CEU content reviewer. In addition, she is a member of the AOTA, Leading Age and American Association of Nurse Assessment Coordinators. She received her certification as a Resident Assessment Coordinator in 2019. Lynda is an adjunct clinical instructor at the University of Texas Health Science Center, a member of the OT Advisory Board and Alumni Council. She is a recognized expert in her field and has been a guest lecturer on various topics.
DISCLOSURES
FINANCIAL: Lynda Jennings is compensated by Summit as an instructor. She is the VP of Clinical Services and Compliance at The Village at Incarnate Word for which she receives a salary. She receives a salary as adjunct faculty at UTHSC (University of Texas Health Science Center). As Managing partner/president of Jennings Therapy Solutions, PLLC Lynda receives consulting fees. She is also compensated for creating blog content/speaking for Relias.
NONFINANCIAL: Lynda Jennings volunteers as an Advisory Board member for UTHSC-OT Department. She serves as a volunteer and member of the Alumni Advisory Council with UTHSC-San Antonio. She is also a volunteer Parliamentarian and Speaker/Presenter at the State Conference for the TX OT Association.
Summit receives financial support for this course from Physitrack
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