Preparing Your Facility for Connecticut’s PDPM Medicaid Transition
Skilled nursing leaders across Connecticut are preparing for an important shift: the transition to PDPM for Medicaid reimbursement.
While the payment model itself is changing, the real challenge for many facilities isn’t simply understanding PDPM, it’s ensuring that current clinical processes, documentation practices, and interdisciplinary workflows will perform well under the new system.
That’s exactly what providers explored during a recent webinar presented by Robin Sweeney of Celtic Consulting for the Connecticut Association of Health Care Facilities.
During the discussion, facility leaders shared thoughtful questions about how they can best position their teams for success as the transition approaches.
The Questions Many Facilities Are Starting to Ask
Every organization is at a different stage of preparation, but several important questions are beginning to surface across the industry.
These questions can help leadership teams evaluate whether their current processes are positioned to support success under PDPM Medicaid.
Are We Capturing the Full Picture During Resident Interviews?
Assessment interviews play a key role in accurately reflecting resident needs.
Facilities may want to examine their current interview strategy and ask:
- Are assessments such as the PHQ-2 and PHQ-9 consistently completed?
- Does the documentation clearly support the information gathered during those interviews?
- Are staff comfortable conducting and documenting these assessments?
Ensuring consistency in these processes can help support both clinical accuracy and appropriate reimbursement.
Have We Evaluated the Role of Restorative Nursing?
For some organizations, Restorative Nursing Programs may represent an opportunity to support resident function while also influencing nursing case mix.
Facilities may want to explore:
- Whether a restorative program currently exists
- How it is structured and monitored
- What potential return on investment it could provide under PDPM
Equally important is considering how these programs may support resident outcomes and quality measures.
Do We Have a Clear Process for Reviewing Medicaid Case Mix?
Many facilities historically held regular CMI meetings under the RUG system. As payment models shift, leadership teams may find it helpful to revisit these processes.
Questions worth considering include:
- Do we currently hold a standing Medicaid CMI meeting?
- Who participates in those conversations?
- Is there a consistent agenda for reviewing case mix and documentation?
- How are important updates communicated across the interdisciplinary team?
Strong interdisciplinary alignment can make a meaningful difference when preparing for PDPM.
How Are We Managing ICD-10 Coding Accuracy?
Another area facilities may want to evaluate is how inactive or outdated ICD-10 codes are identified and resolved. Without a clear process, coding issues can linger in the record and create challenges for both documentation accuracy and billing.
Are Our ADR and Denial Processes Working Effectively?
Facilities are also asking whether their current ADR and denial management processes are functioning as well as they could.
For example:
- Are requests for documentation handled efficiently?
- Are appeals supported by clear, thorough records?
- Do teams have a consistent approach for responding to denials?
Examining these processes now can help prevent challenges later.
Does Our Documentation Truly Reflect the Care We Provide?
Perhaps the most important question raised during the session was a simple one:
Does our documentation clearly reflect the care our team is delivering every day?
When documentation accurately reflects the services provided, it helps ensure that both clinical care and reimbursement are appropriately supported.
Preparing Your Team for the Road Ahead
The transition to PDPM Medicaid represents more than a technical payment change.
For many facilities, it is an opportunity to evaluate and strengthen the systems that support accurate case mix, strong documentation practices, and effective interdisciplinary collaboration.
Facilities that begin reviewing these areas early often feel more confident navigating the transition when implementation arrives.
How Celtic Consulting Supports Facilities
Every facility’s starting point is different.
Some organizations are looking to educate their teams about PDPM Medicaid, while others want to evaluate whether their current processes are fully aligned with the new model.
Celtic Consulting works alongside skilled nursing providers to support this preparation through:
- Education sessions for interdisciplinary teams
- Reviews of documentation and case-mix capture processes
- Operational guidance to help facilities prepare for PDPM Medicaid
Our role is to help facilities clarify the path forward and strengthen the systems that support their success.
If your team is beginning to plan for the transition, we would welcome the opportunity to discuss how we can support your preparation.
