Without a doubt, the recently published CMS Patient-Driven Groupings Model (PDGM) is the largest home health regulatory challenge facing the industry. It is the most far reaching Medicare payment rule since the initiation of the Home Health Prospective Payment System (HHPPS) in 2000. More than any of the very complex modifications contained in this new rule, the most important enhancements emphasize the dire need for all agencies to have a solid and well-functioning episode management program in place before January 1, 2020.

PDGM only heightened the long-standing inferred focus for agencies to provide the best quality of care. Episode Management as a continuous, proactive episode review process helps to demonstrate a patient-centered approach to care delivery and the pursuit of Medicare’s Triple Aim.  The episode management strategies are aimed at improving the patient experience of care (patient satisfaction) and patient health (outcomes), all while decreasing the per capita cost of health care delivery.

The key elements that will need to be modified by agencies to ensure compliance with PDGM are as follows:

  • Care management collaboration between all clinical disciplines, which are typically led by both RNs and Therapists. This will foster the coordination of ongoing patient care needs from intake and scheduling, through care delivery and discharge planning.
  • Management of the most appropriate level of clinical care called for by each patient’s individualized Plan of Care (and NOT just by generic care pathways). This includes clinical education on best practice strategies.
  • Collaboration of the quality assurance and compliance team members with the direct patient care clinical leaders to ensure that quality is NEVER compromised.
  • Clinical process improvement throughout the development of all processes to meet the cost-efficient nature of the agency’s overall care delivery WITHOUT jeopardizing quality of care outcomes.
  • Tracking of reporting metrics critical to reimbursement such as diagnoses (comorbidity adjustments), referral sources (where the patient was receiving care 14 days prior to the home health episode starting), episode timing (early or late) and patient functional status.

A solid and well-functioning episode management program will positively impact clinical and financial outcomes in the PDGM environment. This will ensure that the most efficient, effective quality care is being consistently provided to patients.  At the forefront, quality care is key in driving improved clinical outcomes and reduced rehospitalizations.