The Patient Driven Payment Model (PDPM), effective October 1, 2019, offers a unique opportunity for skilled nursing facilities (SNFs) to move beyond minutes and provide value-driven care to Medicare beneficiaries. PDPM reinforces the value of speech-language pathology in three important ways:
The Centers for Medicare & Medicaid Services (CMS) has clarified that the definition of skilled therapy is not changing under the PDPM. Patients from a variety of clinical backgrounds can benefit from speech-language pathology services and must receive these services when medically necessary, regardless of diagnosis.
SLPs play a critical role in identifying patients for treatment and determining their plan of care. Comprehensive coding that recognizes all diagnoses and comorbidities/complexities is critical.
The International Classification of Diseases (ICD) is a list of diagnosis codes that trigger speech-language pathology payment and the speech-language pathology comorbidity payment (when an applicable comorbidity is present) is available on the CMS website (see “PDPM ICD-10 Mappings”). This list will be modified over time, as CMS refines the payment system. It is important for SLPs and SNFs to accurately and comprehensively include the specific treating diagnosis (in addition the medical diagnoses) to describe cognitive, communication, and swallowing disorders on claims even when those codes are not yet included in the CMS list. In order for more conditions to be included in the list in the future, there must be accurate and comprehensive data submitted to CMS on the treatment conditions addressed by clinicians.
Therapists play an imperative part in quality improvement and helping to avoid payment adjustments under the value-based purchasing program (VBP), the quality reporting program (QRP), and Nursing Home Compare.
Engaging SLPs in the completion of relevant sections of the minimum data set (MDS) helps identify patients who need speech-language pathology services, ensures accuracy of the data, and facilitates interprofessional practice. SLPs should contribute to this process directly or in consultation with the MDS coordinator.
SLPs play a valuable role in managing:
SLPs engage in professional practice in the areas of communication, swallowing, and cognition across the lifespan. Communication and swallowing are broad terms encompassing many facets of function. Communication includes speech production and fluency, language, cognition, voice, resonance, and hearing. Swallowing includes all aspects of swallowing, including related feeding behaviors. Cognition includes memory, attention, problem solving, and executive functioning.
PDPM recognizes the impact of swallowing and cognitive disorders, in particular, on patients in SNFs. For cognition, SLPs address attention, memory, problem solving, and executive functioning. CMS reinforced the role of SLPs in providing cognitive treatment as outlined in a response to ASHA that clarified billing for cognitive treatment.
For swallowing disorders, SLPs address oral phase, pharyngeal phase, esophageal phase, and atypical eating (e.g., food selectivity/refusal, negative physiologic response).
SLPs treat patients with a wide variety of conditions including, but not limited to:
SNFs assess its quality on a variety of externally (e.g., payer-developed) and internally developed measures. A recent analysis of publicly reported Medicare quality reporting program (QRP) data [PDF] provides an interesting snapshot of areas where SNFs have the opportunity to achieve additional gains. Such opportunities include avoiding the payment penalties associated with the QRP, improving patient quality and experience of care, and potentially achieving efficiency and reduced costs. SLPs stand ready to assist in achieving these shared goals.
|Measure||# of SNFs (sample)||# with “problematic” score||% Impact|
Factors such as depression, hearing loss, medication management, cognitive impairments, and poor sleep all impact a patient's risk for falls as well as their ability to report them in a timely fashion. Good clinical practice dictates determining whether these risk factors play a role in the care of the patients in SNFs. Approximately 60% of older adults with cognitive impairment fall annually, almost two times more than their peers without a cognitive impairment (Eriksson, et al., 1993). Among individuals with dementia, fall frequency can even reach as high as 80% (Shaw et al., 2003). The high prevalence of falls among patients with dementia, despite relatively intact motor function, highlights the idea that falls are often not just a motor problem (Van Iersel, et al., 2006). Risk of persistently high expenditures for fall-related injuries among older Medicare community-dwelling fee-for-service beneficiaries, is significantly higher for individuals with cognitive impairments, which leads to hospital/facility readmissions (Hoffman, et al., 2017).
SLPs can help detect cognitive impairment to identify older adults who are at higher risk for falling. Cognitive impairment can be a risk factor for falls and a barrier to safe/independent discharge to prior living environments consequent to the fall. SLPs have a critical role in assessing cognitive-communication and cognitive deficits in patients of all ages including patients who have had a stroke, traumatic brain injury, or suffer from a neurodegenerative condition such as Parkinson's Disease, and all forms of dementia. Appropriate referrals can help SLPs design interventions so the patient can reduce their fall risk (e.g., designing memory aids and cues to help the individual follow safety precautions and self-regulate impulsive behaviors). Emerging evidence indicates that cognitive interventions have effects that carry over from the cognitive to the physical domain to enhance gait, and may reduce fall frequency (Segev-Jacubovski, et al, 2011).
SLPs can help increase the rate of discharge back to the community and decrease avoidable re-hospitalizations. Specifically, SLPs can positively influence the following factors that contribute to discharge back into community:
Communication: A primary purpose for addressing communication and related disorders is to affect positive measurable and functional change(s) in a person's communication status so that they may participate in all aspects of life—social, educational, and vocational. Key considerations for treatment include maximizing improvement and/or maintenance of functional communication, evaluation of communication outcomes, and enhancement of quality of life. SLPs recognize that communication is always an interactive process and that the focus of intervention may include training of communication partners (e.g., caregivers, family members, peers, educators) and modification of communication in schools, workplaces, and other settings (ASHA, 2003). Communication is central to discharge back into the community, especially in individuals with speech/language impairments or cognitive deficits associated with a variety of diagnoses. Several studies have indicated that communicative competence predicts individuals' safe discharge back to the community. For example, a 2013 study found that deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a health care facility (e.g., SNF), rather than to a community-based environment, after adjustment for physical therapy and occupational therapy recommendations (González-Fernández, et al., 2013). Functional dependence and comorbidities, such as chronic aphasia, have been found to be a significant predictor of a non-home-based discharge setting in post-stroke individuals (Mees, et al., 2016). The SLP's scope of practice and unique training specifically equips them to prepare individuals to return home with appropriate communication facilitators, as needed, ensuring maximum safety.
Cognition: Cognition is an important predictor of safety and functional independence in determining discharge to home, even in individuals undergoing purely orthopedic related rehabilitation (Ruchinskas, et al., 2000). Several studies emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients (MacNeill, et al., 1997). The Scope of Practice in Speech-Language Pathology (ASHA, 2016), as it relates to cognitive-communication impairments, indicates that the practice of speech-language pathology includes providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up for disorders of cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions). CMS has reinforced the role of SLPs in providing cognitive treatment as outlined in a response to ASHA seeking clarification of billing for cognitive treatment.
Swallowing: SLPs with appropriate training and competence diagnose and manage oral and pharyngeal dysphagia. SLPs also recognize causes, signs, and symptoms of esophageal dysphagia, and make appropriate referrals for diagnosis and management. The SLP's specific role and level of involvement may vary for each clinician and across patients, work settings, and institutions. Presence of dysphagia represents a significant barrier to returning home, specifically in neurogenic diagnoses. Those individuals with dysphagia, post-stroke, are more likely to be discharged to institutional settings, such as SNFs, after inpatient stroke rehabilitation, and experience longer stays at these facilities (Nguyen, et al., 2015). Aside from the significant costs resulting from chronic dysphagia and associated care, these conditions have a negative impact on an individual's quality of life.
Health Literacy: More than just a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual knowledge. According to the IOM report (2004), health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.” Inadequate health care literacy affects all population segments but is predictably more common in certain demographic groups such as the elderly, those with limited education, members of minority groups, and recent immigrants to the United States. Patients with aphasia or other neurological disorders affecting speech, language, or cognition, or those with severe hearing loss, are at risk when presented with vitally important written or verbal medical information. In addition, patients who face the stress of a medical crisis, possibly without an advocate or significant other being present, or while in a state of pain, confusion, or depression, may have difficulty understanding written or verbal medical information. SLPs have a vital role in effective patient-provider communication. As federal laws, regulations, guidelines, and accreditation standards mandate improved patient provider communication, it is vital to maximize the SLP's contributions to this significant area of practice that impacts patients' safe discharge back to the community. Nearly half of all adult Americans—90 million people—have difficulty understanding and using health information. Further, the rate of hospitalization and use of emergency services is higher among patients with limited health literacy (Kindig, et al., 2004). Limited health literacy may lead to billions of dollars in avoidable health care costs and, more importantly, impact thousands of lives. Inadequate health literacy directly affects the physical aspects of patient safety and negatively affects the fiscal aspects of health care delivery. The costs of poor health care literacy are staggering due to longer and more frequent hospital stays, ineffective use of prescriptions, and misunderstanding treatment plans. SLPs can assist with discharge planning while considering an individual's health literacy to minimize these costs (Rasu, et al., 2015).
Functional person-centered goals in rehabilitation directly impact an individual's return to home and participation in activities of daily living (ADLs) with maximum independence. SLP intervention in the domains of communication, swallowing, and cognition help address questions in relation to rehabilitating, maintaining, or compensating for an individual's functional abilities, such as:
Being "certified" means holding ASHA's Certificate of Clinical Competence (CCC), a nationally recognized professional credential that represents a level of excellence in the field of audiology (CCC-A) or speech-language pathology (CCC-SLP). Those who have achieved the CCC, have voluntarily met rigorous academic and professional standards, typically going beyond the minimum requirements for state licensure. They have the knowledge, skills, and expertise to provide high quality clinical services, and they engage in ongoing professional development to keep their certification current.
The standards for certification for speech-language pathology are established by SLPs who are members of ASHA's Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). Certificate holders are expected to uphold these standards and abide by ASHA's Code of Ethics.
Contact ASHA Staff:
Sarah Warren, ASHA's Director of Health Care Policy, Medicare
Share our clinician resources with your SLPs: The Medicare PDPM in SNFs
Eriksson, S., Gustafson, Y., & Lundin-Olsson, L. (2008). Risk factors for falls in people with and without a diagnose of dementia living in residential care facilities: a prospective study. Archives of gerontology and geriatrics, 46(3), 293–306.
Tinetti, M.E. (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348(1), 42–49.
Van Dijk, P.T., Meulenberg, O.G., Van de Sande, H.J., & Habbema, J.D.F. (1993). Falls in dementia patients. The Gerontologist, 33(2), 200–204.
Van Iersel, M.B., Verbeek, A.L.M., Bloem, B.R., Munneke, M., Esselink, R.A., & Rikkert, M.O. (2006). Frail elderly patients with dementia go too fast. Journal of Neurology, Neurosurgery & Psychiatry, 77(7), 874–876.
Hoffman, G.J., Hays, R.D., Shapiro, M.F., Wallace, S.P., & Ettner, S.L. (2017). The costs of fall‐related injuries among older adults: Annual per‐faller, service component, and patient out‐of‐pocket costs. Health Services Research, 52(5), 1794–1816.
Segev-Jacubovski, O., Herman, T., Yogev-Seligmann, G., Mirelman, A., Giladi, N., & Hausdorff, J.M. (2011). The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk? Expert Review of Neurotherapeutics, 11(7), 1057–1075.
American Speech-Language-Hearing Association. (2003). Evaluating and treating communication and cognitive disorders: approaches to referral and collaboration for speech-language pathology and clinical neuropsychology [Technical Report]. Available from www.asha.org/policy/.
González-Fernández, M., Christian, A.B., Davis, C., & Hillis, A.E. (2013). Role of aphasia in discharge location after stroke. Archives of Physical Medicine and Rehabilitation, 94(5), 851–855.
Mees, M., Klein, J., Yperzeele, L., Vanacker, P., & Cras, P. (2016). Predicting discharge destination after stroke: A systematic review. Clinical Neurology and Neurosurgery, 142, 15–21.
Ruchinskas, R.A., Singer, H.K., & Repetz, N.K. (2000). Cognitive status and ambulation in geriatric rehabilitation: walking without thinking? Archives of Physical Medicine and Rehabilitation, 81(9), 1224–1228.
MacNeill, S.E., & Lichtenberg, P.A. (1997). Home alone: The role of cognition in return to independent living. Archives of Physical Medicine and Rehabilitation, 78(7), 755–758.
Nguyen, V.Q., PrvuBettger, J., Guerrier, T., Hirsch, M.A., Thomas, J.G., Pugh, T.M., & Rhoads 3rd, C.F. (2015). Factors associated with discharge to home versus discharge to institutional care after inpatient stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 96(7), 1297.
Kindig, D.A., Panzer, A.M., & Nielsen-Bohlman, L. (Eds.). (2004). Health literacy: a prescription to end confusion. National Academies Press.
Rasu, R.S., Bawa, W.A., Suminski, R., Snella, K., & Warady, B. (2015). Health literacy impact on national healthcare utilization and expenditure. International Journal of Health Policy and Management, 4(11), 747.