By Susan Saldibar

For those of you who provide home health services, work with a home health service, or are thinking about doing so, there are things you need to know about PDGM (the Patient Driven Groupings Model). The first is that it takes effect January 1, 2020. The question is: Are you ready? And how can you use PDGM to improve quality of life for your clients/patients? 

I’ve been speaking with Aegis Therapies (a Senior Living Foresight partner) that has been actively involved in both the Patient Driven Payment Model (PDPM) and PDGM for months and months. They even contributed input when the proposed rule was in its comment period.

So, for those of you finding yourselves scurrying to understand and work within the new PDGM framework, here’s a quick review: 

  • PDGM is the new Medicare payment rule for home health agencies. What that means is, like PDPM, volume of care is being replaced by “value” of care. So, the quantity of therapy visits will no longer be considered in determining reimbursement to the agency providing the care.
  • PDGM has changed the payment structure from a 60-day episode payment model to two 30-day payment periods within the same 60-day certification period.
  • PDGM has arrived at five different case-mix components for varied needs and characteristics of a patient’s care. They are admission source, episode timing, clinical grouping (12 groups/subgroups), functional level, and comorbidity adjustments. You can get details on each of these here.

Can PDGM Help Reduce Rehospitalizations?

One area CMS and home health care providers are hoping PDGM can help is with reducing rehospitalizations. Among the many documents in the Aegis Resource Library is one that looks at how home health service providers can leverage PDGM to better position themselves with acute care providers and physician’s groups. One document cites some startling numbers from a study in the New England Journal of Medicine. According to the report, one in five elderly patients will be readmitted to the hospital approximately 30 days after being released. This is why we’re seeing over $17 billion in annual Medicare costs.

What should home health providers and those who work with them be doing to make the best use of PDGM as well as improve their own quality of care? One thing Aegis recommends is that providers reassess and make sure they have a strong physical therapy (PT/OT/ST) partner that is dedicated to reducing rehospitalizations and to providing high quality of care to your patients. Here’s what your PT should be doing:

  • Primary diagnosis: Your PT should be in on the discussion surrounding the determination of the primary diagnosis for your client/patient. That way they will be better able to choose assessment tools that can measure progress for that particular primary medical diagnosis. They will also be more aware of influencing factors that could lead to rehospitalizations.
  • Prevention: Therapists should be taking vital signs before, during, and after physical activity. That way they can analyze them on the spot and quickly assess how the activity is impacting clients’ health.
  • Best practices: The therapy team should understand scoring methodologies and collaborate with home health providers to ensure compliance with the Outcomes and Assessment Information Set (OASIS) items on the Home Health Quality Measures List. This includes the functional M items that make up the Functional Impairment grouping and the Section GG items that many feel will replace the M items in the future.
  • Durability of response: The therapist should be able to determine, with a high degree of accuracy, whether a patient will be able to maintain any gains achieved from therapy after the therapist is no longer working with them. 

Aegis has built a pretty impressive resource library chocked full of documents, checklists, podcasts, and videos to help home health agencies and those who partner with them keep ahead of the CMS/Medicare curve and the various twists and turns of PDGM. You can access the library here.

For more information on Aegis Therapies, please visit their website.