You’ve been preparing for PDPM for a while now. You’ve educated your team, you’ve ensured that your technology partners are ready, you’ve reviewed all the information from the Centers for Medicare and Medicaid Services (CMS). This new reimbursement model is going to be a big shift for your skilled nursing facility (SNF) and you’re doing what you can to prepare, which is exactly what you should be doing! There is one piece however, that many SNFs don’t think to implement in preparation for PDPM – an interdisciplinary team (IDT).

In our recent white paper, Phase II through PDPM: Connecting the Dots, our experts review how to  improve communication within an organization and with referral partners, ways to build and implement an interdisciplinary team, and more. This blog will walk you through the higher points of building that IDT, but please download the white paper for a deeper dive and even more information on PDPM.

Techniques for increasing the effectiveness of internal task forces and tiger teams within various industries are perfectly adaptable for running an IDT at a SNF. The first rule is that collaboration won’t happen without regular meetings to allow for communication. Your IDT staff members should be actively participating in at least two types of meetings: Weekly IDT Meetings and Daily ‘Stand Up’ Meetings. We offer more on these meetings below.


  1. Weekly IDT Meetings – Review each resident and discuss his or her individual needs related to the skilled services being provided and discuss any changes that may impact the resident’s outcome or change in reimbursement under PDPM.

The Agenda – Discuss, report upon, and set next-step goals for the following areas:

  • Timeliness of visits
  • Accuracy of diagnosis and supportive documentation
  • Pharmacy collaboration
  • Therapy collaboration
  1. Daily ‘Stand Up’ Meetings – To update IDT members with urgent and important information in a brief meeting of 15 minutes or less.

  The Agenda

  • A 24-hour report from the day before 
  • Any significant changes that would warrant an IPA 
  • Administrative announcements

Having the right people at the above meetings is critical. This is going to be more than just meetings, it’s a cultural shift, which can sometimes be met with resistance. Providing background on why this shift is occurring and being part of the shift yourself can help ease tension and resistance. Make sure your team knows that this new culture and the meetings are aligned with your facility’s overall strategy and that being successful under PDPM is paramount to the sustainability of your facility. Flexibility will be key as well, as many facilities won’t truly see how PDPM is going to affect them for anywhere between 4-6 weeks after it goes into effect. Having the right people on your IDT is also going to be a large part of your success.

Who Should Attend IDT Meetings?

  • Speech Therapists and Dieticians
    • They contribute: Brief Interview for Mental Status (BIMS)/ Cognitive Performance Scale (CPS) education, identification of comorbidities, judgement on adding physician involvement as needed.
  • Nurses
    • They contribute: Documentation skills to support diagnosis and functional scoring, collaboration, and communication between therapies for patient carry-over and functional use of skills throughout each day.
  • MDS Coordinators
    • They contribute: Clinical assessment and coding skills, documentation to support active conditions and resident modalities.
  • Physical and Occupational Therapists
    • They contribute: Identification of therapy needs, communication and care plan development based on patient-driven skilled vs. unskilled needs, ability to integrate with nursing, restorative therapy planning, and activities for a functional patient-centered Clinical Skills (CS) days/minutes approach.
  • Billing Representatives
    • They contribute: Medicare three-way audits to validate coding.
  • Social Services Representatives
    • They contribute: Familiarity with all aspects of human services, including regulatory compliance, assessments, the MDS, discharge planning, and documentation requirements.

If there was ever a great window of opportunity to create a transformation of culture change, it’s now. Your facility and staff are looking to you for leadership. It’s on you to be supportive of them in a challenging yet exciting time by providing a clear strategy and consistent communication.

Lastly, remember that Cantata Health has your back! We’re here to help answer your questions and operationalize your PDPM success plan. For more PDPM education like this white paper, visit our PDPM resource center, or email us at

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