The Patient-Driven Groupings Model (PDGM) challenges us to provide efficient and effective care in order to be successful financially while maintaining focus on delivering care that improves the patient’s functional abilities. Efficient and effective home health care requires skilled oversight. A successful method to ensure this oversight is case management.

The Case Management Society of America defines case management as a collaborative process involving assessment, planning, coordination and communication, implementation, monitoring and evaluation, as well as outcomes and discharge. To help home health agencies achieve efficiency and effectiveness in all steps of the case management process, we’ve outlined the below scenario that details best practices in relation to the case management model.

Case Scenario:

The patient is an 86-year-old female who lives alone. She has a history of diabetes mellitus type 2, hypertension, coronary artery disease and is newly-diagnosed with congestive heart failure (CHF). The hospital has identified her as a high-risk for re-hospitalization. She will be discharged to her daughter’s home on Friday after a heart attack. The discharge planner at the hospital sent the referral to the agency on Thursday with orders for skilled nursing (SN) and physical therapy (PT).

A per diem nurse completed the admission on Friday afternoon. Orders for occupational therapy (OT), home health aide (HHA) and medical social worker (MSW) were requested from the primary care physician’s (PCP) office via voicemail, as the PCP’s office was closed, and the on-call doctor declined to provide orders and directed the nurse to wait for a response from the patient’s PCP. The nurse wrote a visit frequency of 1w1 2w1 1w2 with focus on medications and disease process. The nurse completed her documentation in a timely manner, but her Outcome and Assessment Information Set (OASIS) accuracy has been an issue in the past.

The admitting nurse received a call approving the plan of care on Monday afternoon, but she was out of town until Wednesday. On Thursday, all the orders were confirmed with the office and SN visits were scheduled for Thursday and Friday. The patient was seen on Thursday by an licensed practical nurse (LPN) and refused the visit on Friday.

Both PT and OT evaluation visits were delayed to the following week. PT and OT both attempted to reach the patient that following Monday and Tuesday without success. On Wednesday, the daughter called the office and notified the clinical manager that the patient had returned to her own home.  Thursday, PT and OT completed their evaluation visits and a different LPN visited the patient.

PT orders were written for 1w1 2w4 and OT was written for 1w1 2w3. At this point, only one more SN visit was ordered, and a different registered nurse (RN) was scheduled to see the patient for that visit the following Monday. The RN completed a discipline discharge on Monday, as reflected on the schedule. The RN Case Manager assigned to the case never saw the patient. The patient was cooperative with PT and OT visits for two weeks, but then refused further care. When the clinical manager called to attempt service recovery, the patient stated that she was exhausted with PT and OT visiting on the same day twice a week and inquired about what had happened with the home health aide that was promised and the MSW that had been discussed. The patient was discharged without a visit and no reportable outcomes achieved.

There is a lot that can be learned from this scenario. The RN case manager was never a part of this patient’s care, although she was designated as the case manager in the record. The patient’s care was not held together by an active collaboration process and lacked coordination and communication. In hindsight, the care delivery of the patient and patient outcomes could have improved greatly if there were a case-manager-facilitated process in place that included communication and collaboration, as well as episode management best practices.

  • Opportunity was missed to collaborate on the OASIS responses with physical therapy because the initial PT evaluation was delayed beyond the five-day window. Capturing accurate OASIS responses at the start of care (SOC) ensures proper reimbursement and lays the foundation for reporting patient outcomes/improvement.
  • PT was delayed unnecessarily by the relocation of the patient from her daughter’s home to her own.
  • Skilled care was delayed because orders were not confirmed with the agency until Thursday.
  • Even though the patient was a high risk for hospitalization, the original planned SN frequency did not provide an adequate number of visits at the beginning of the episode to ensure front-loading of visits.
  • Lack of communication between the different SNs that visited the patient impacted the continuity of care that should have been overseen by the case manager, possibly ending care before all goals were met.
  • Therapists should have coordinated with each other and the case manager to ensure that the scheduling took patient preferences into consideration.
  • HHA and MSW services were not provided as ordered.

The patient’s care could have been improved substantially if the agency operated under the philosophy of primary clinician case management the case manager could have:


  • Assessed the patient within five days of the SOC.
  • Initiated early involvement and collaborated with the physical therapist, ensuring PT evaluation was made within the five-day window.
  • Facilitated the collaboration between the SOC clinician and any therapy disciplines that had performed evaluations within the SOC five-day window to ensure the OASIS responses represented the most accurate functional abilities of the patient. This would have provided accurate reimbursement and a solid foundation to build improved patient outcomes.


  • Reviewed the initial frequency for skilled nursing visits and adjusted it to ensure front-loading of visits; three visits on separate days within the first seven days of care. This would address the patients immediate goals of care, then tapering the visits to allow her additional time to understand and adopt good disease self-management skills.
  • Reviewed the plan of care to identify any potential service needs that may have been missed or overlooked, such as telehealth.

Coordination and communication

  • Intervened to confirm physician orders on Monday, eliminating delays in services.
  • Ensured collaboration on the plan of care to maximize efficiencies, ensuring each discipline was focused on specific and unique interventions to meet the patient’s overall plan of care goals
  • Communicated with the other team members, such as LPNs, on the patient’s progress with the plan of care and goal achievement.


  • Followed up on delays in secondary discipline services. In the scenario above, the patient was never seen by the MSW and HHA services were never initiated.
  • Discussed scheduling with the other disciplines involved to ensure the patient was not overwhelmed by multiple visits on the same day

Monitoring and evaluation

  • Periodically checked in with the interdisciplinary team, no later than 25 days into the first billing period, to check on progress toward goals and independence with self-management of her chronic disease.

Outcomes and discharge

  • Ensured the patient was not prematurely discharged without meeting all her plan of care goals.
  • Collaborated with therapy services to ensure that the agency is on track to discharge the patient with maximal improvements in reportable outcomes.
  • Ensured that patient care preferences were considered and respected to improve patient satisfaction. By collaborating with PT and OT, the team could have worked out a therapy schedule more agreeable to the patient, keeping her on service until the goals of care were achieved.

With an active case manager in place, the patient’s care could have been orchestrated in a more efficient and effective manner, focusing on her needs, goals and preferences. Many agencies may have staff to monitor care at certain points, such as OASIS for accuracy, diagnosis coding and scheduling. While it is arguable that everyone is responsible for their own part of the process, for optimal patient-focused care, the patient needs an advocate who is accountable if something does not go as planned.

Consider committing to primary clinician case management as the model of care. Educate and support clinicians as they learn to grow into primary case managers. Empower them to oversee efficient and effective care, rather than operating solely as visit clinicians. With this approach to episode management, your agency can realize Centers for Medicare and Medicaid Services’ (CMS) triple aim of improved outcomes, reduction in the cost of case and increased patient satisfaction. In this new world of PDGM, case management one of the key strategies agencies should have in place to not only to survive, but to thrive.

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