Patient-Driven Groupings Model (PDGM): What Home Health Agencies Should Know

Home health agencies have a lot to look forward to when it comes to upcoming regulatory requirements for reimbursements as proposed by the Centers for Medicare and Medicaid Services (CMS). Let’s dive in to learn more about what they can do now to prepare for new payment changes in 2020.

What is Patient-Driven Groupings Model, or PDGM?

PDGM has roots from the previously proposed Home Health Groupings Model, or HHGM, which CMS has described as focusing on the value versus volume of care, better serving all individuals. PDGM ushers in new payment episode timings and removes therapy visits to determine payment. In short, this is the most radical update to home health payment since PPS went into effect nearly 20 years ago.

Notable updates

The changes to care payment for home health providers include:

• 60-day payment episodes replaced with 30-day periods
• Therapy visits are no longer included in determining reimbursement
• Changes to Low Utilization Payment Adjustments (LUPAs)
• Adjustments to HHRGs from 153 to 432 categories, including updated measurements

What does it mean for my organization?

The intent of the anticipated updates is to enable home health agencies to focus less on administrative duties and more on delivering care. This is essential to the benefit of both providers and patients. When clinicians can deliver more focused care, they can achieve better outcomes, the basis of success in the value-based care landscape to which all of healthcare is shifting.

What should we do to prepare for the shift to PDGM?

Organizations that take steps today will find success in PDGM tomorrow. Take time to evaluate the current state of your organization’s operations and start by asking if they can support the following:

• Increasing understanding and use of ICD-10 coding
• Collecting complete health histories with a complete recording of comorbidities
• Collaborating between cross-functional teams to provide coordinated care
• Developing a strong understanding of OASIS requirements by clinicians and coders
• Developing a sense of urgency and laser focus on the care to be provided and discharge plan

2020 will be here faster than we know it and next year may see further refinement of the regulation before it goes into effect. Teams across Netsmart will continue to evaluate 2019 CMS final rule to determine how we can support our clients’ success with the regulation.

Follow us on CareThreads for helpful information on how to navigate the updates and changes with ease. In the meantime, check out our webinar with Strategic Healthcare Programs as we dive deeper into the intricacies of PDGM and what organizations should do to prepare for the 2020 updates.