Key Components of the Nursing Component in PDPM for Skilled Nursing Facilities

The Nursing component within the Patient-Driven Payment Model (PDPM) is designed with a focus on patient characteristics rather than the volume of services provided. This component has seen the least change from the RUG-IV system but introduces a shift towards a more detailed assessment of the patient's clinical and functional status to determine reimbursement rates.

Under PDPM, the Nursing component encompasses several categories, such as Extensive Services, Special Care High, Special Care Low, and Clinically Complex, each with specific criteria that impact the case-mix index (CMI) and, consequently, the reimbursement. For example, the Extensive Services category, which includes tracheostomy care, invasive mechanical ventilation, and infection isolation, carries some of the highest CMI multipliers, highlighting the importance of accurate MDS coding​​.

The Clinically Complex category is broader and considers a range of clinical conditions and treatments, emphasizing the need for a comprehensive understanding of what qualifies a resident for this category. It's essential for Nurse Assessment Coordinators (NACs) and the interdisciplinary team (IDT) to accurately identify clinical conditions and functional scores, ensuring that all relevant data is captured and correctly coded in the MDS​​.

One significant difference between the former RUG-IV system and PDPM is the method for capturing functional performance. Under PDPM, Section GG of the MDS replaces Section G for determining functional scores, focusing on seven specific functional tasks. This change underscores the necessity for precise documentation and understanding of the resident's usual performance to accurately reflect their care needs​​.

For successful implementation of the Nursing component under PDPM, facilities must ensure that nursing documentation thoroughly supports the need for skilled care. This involves daily documentation that reflects the patient's condition and the skilled nursing care provided, based on active patient characteristics​​.

In summary, the Nursing component under PDPM requires a detailed assessment of the patient's clinical and functional status, accurate MDS coding, and comprehensive nursing documentation to ensure appropriate reimbursement. This approach emphasizes the importance of patient characteristics in determining care needs and reimbursement levels, aligning with the overall goal of PDPM to foster a more patient-centered care model.