Renee Kinder

New Year, new reimbursement model … for our home health counterparts, that is.

Just as skilled nursing providers have settled in to the shift associated with the Patient Driven Payment Model (PDPM), we see a similar wave of changes impacting the setting we often discharge our Medicare Part A patients to following their SNF stay. 

Think the changes will not impact you? Think again.

These are the key elements of the Patient Driven Groupings Model (PDGM) for home health providers that SNFs need to remain keenly aware of: 

  1. The PDGM effective date was 1-1-2020 (i.e. Wednesday!) and the change is the largest shift in home health reimbursement since 1993. 
  2. PDGM changes, like PDPM, are a result of shifts in the industry associated with the IMPACT Act. Therefore, many of the positive elements we see move us to a more holistic focus on the person and his or her clinical presentation.
  3. Like PDPM, PDGM does not change Part A eligibility requirements. However, billing is reduced to 30-day periods. 
  4. PDGM reimbursement is driven by patient clinical characteristics documented in OASIS and payment is adjusted based on timing of the episode and discharge location to the home health agency, functional level of the patient, and comorbidities. 
  5. PDGM reimbursement is not impacted by volume of services (i.e. visits)

Now that you know the basics, what are some ways we can support our patients and their next level of care, thereby honoring the IMPACT Act and skilled benefit across the entire post-acute episode? 

On a very basic level, and like PDPM, communication of diagnoses and functional status across care teams matters!

We have asked our acute-care partners to step up their game when reporting diagnosis and function on discharge summaries and it is time for us to do the same!

The clinical groupings under PDGM are defined below. Proper communication with your home health partners will be essential to ensure they are able to appropriately identify the area which best reflects their patients’ needs. 

Musculoskeletal Rehabilitation: Therapy provided (OT, PT, SLP) for a musculoskeletal condition

Neuro/Stroke Rehabilitation: Therapy provided (OT, PT, SLP) for a neurological condition or stroke

Wounds: Assessment, treatment and evaluation of a surgical and non-surgical wounds, burns, ulcers and other lesions

Behavioral Health Care: Assessment, treatment and evaluation of psychiatric conditions including substance use disorders

Complex Nursing Interventions: Assessment, treatment and evaluation of complex medical and surgical conditions including IV, TPN, enteral nutrition, ventilator and ostomies

Medication Management Teaching and Assessment: Assessment, evaluation, teaching and medication management

Furthermore, reporting of functional status is essential when communicating with HHAs as they will also be collecting baseline status on the OASIS for the following areas: grooming, current ability to dress upper body safely, current ability to dress lower body safely, bathing, toilet transfers, transferring, ambulation/locomotion, and risk for hospitalization. 

In supporting functional status, consider what practices can be adjusted to refine and improve your therapy teams’ home evaluation process prior to discharge from skilled SNF care. 

And finally, like PDPM, the Centers for Medicare & Medicaid Services has recognized comorbidities as an important determinant of needs, therefore adding a comorbidity adjustment for the following: heart disease, cerebral vascular disease, circulatory disease and blood disorders, endocrine disease, neoplasm, neurological diseases and associated conditions, respiratory disease and skin disease.

In closing, my hope is that 2020 will be another year of continued clinical focus across care teams, improving the ability to achieve outcomes for those we serve and effectively transitioning to the safest and least restrictive settings of care.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).