PDGM For Home Health

Patient driven grouping model (PDGM) is an updated version of the home health grouping model (HHGM) introduced by CMS in 2017. As the acronym suggests, the framework of the payment model focuses on patient care. It removes inconsistencies from the previous model.CMS aims at improving the current PDGM which is a case-mix adjustment payment model to a more value-based payment system. The purpose of PDGM and any improvised model is to reduce the cost of healthcare for home-based patients.

Home health agencies’ role in the healthcare sector

Treating all patients under the canopy of a healthcare facility can create chaotic experiences for clinics and hospitals. There can be a massive shortage of beds, and clinical staff will burn out addressing patient needs if such situations are not managed through effective measures. 

Home health agencies play a vital role in providing patient care in the comfort of their homes under the guidance of a practicing physician or a registered nurse. Common home health care services include nursing, physical therapy, occupational, medical-social services, and speech therapy. 

Home health caregivers help patients to regain strength by improving their mobility to be self-reliant and independent. They promote their patients’ well-being through assistance and patient engagement measures like teaching them simple tasks like wearing their RPM devices that measure blood sugar and blood pressure. They teach their patients the importance of consistency with their medication as they are susceptible to lapses in a home setting. 

There are close to 8000 home health agencies that take care of millions of elderly, disabled, and wounded patients who can be provided home-based care. However, due to barriers of ineffective training of staff and some questionable practices, the patient care reimbursements claimed by some home health agencies are not conducive and increase the home health care costs. To overcome these barriers PDGM an improved version of HHGM was implemented in January 2020. 

Changes as per PDGM

• Shorter grouping periods

The period considered for grouping is reduced from 60 to 30 days. If a patient has not received home health for more than 60 days then the first 30 days are treated as early. Any episode thereafter including the second is treated as late episodes. 

• No-more therapy volume

PDGM disregards the volume of therapy or over-therapy and goes by only the coding of the diagnosis as recorded. 

• Increase in payment groups

In comparison to the previous payment model, the payment groups are enhanced to 432 from 216 groups originally proposed in PDGM

• Sub-groups

As per the admission source, there are two sub-groups namely community and institutional. The functional level is divided into low, medium, and high. The comorbidity level is none, low or high based on the secondary diagnosis. 

• Documentation is imperative

Home health agencies have to go the extra mile and be careful when taking admissions for home-care patients. They need to document supporting notes of physician-issued diagnosis coding recommending home-based care for patients. This document is also an important reference point for skill-based care that needs to be given to the patient. For instance, if physical therapy has been recommended under the guidance of a healthcare assistant then, then the document can be referred for the duration and intensity of the PT. Discharge documentation if any also needs to be recorded to determine if the episode has to be classified as community or institutional. 

• Order management

Signed documents submitted in time determine the cash flows for home health agencies. If required, home health agencies need to assign staff exclusively to follow-up orders, and track and record them to avoid discrepancies. 

• Anticipated payments

The request for anticipated payments (RAP) must be made after the completion of the first home visit to the patient. The concerned episode has to be locked and a completed POC needs to be sent to the physician. 

• LUPA adjustments

The LUPA threshold will reset every 30 from the first day of incidence. As per PDGM, a home health agency will receive payment based on the volume of the visits within the thirty days payment period. Each of the 432 case mixes has its number of LUPA threshold levels that can range between 2 to 6 visits within a period. 

Summing it up

At the core, PDGM is a progressive model that addresses the need to bring down the costs of healthcare while not compromising on the quality of the care. Reimagining healthcare through telehealth services will help agencies address any further issues.