The onset of the Patient-Driven Groupings Model (PDGM) will impact every single aspect of your home health care organization. The time to prepare is now. Among other topics, it is important to keep in mind is the home health LUPA and what the LUPA threshold in 2020 will look like.

LUPA Background

It will be no surprise to you by now that Low-Utilization Payment Adjustments (LUPAs) can have a detrimental impact on home health agencies (HHAs) both clinically and financially. Clinically speaking, it is difficult to obtain the best patient outcomes with very few visits. Financially, in some cases, a LUPA can be the difference between a $2,600 payment for an episode of care and an adjusted payment of $300. Keep in mind, the Centers for Medicare and Medicaid’s (CMS’s) Triple Aim policy will also have an impact on revenue.

The Triple-Aim policy is focused on positive patient outcomes, positive experience of care, and a low per capita cost of care. As a result, Medicare pays HHAs a per-visit rate instead of a full episode rate. Over time, this can add up to a significant loss in revenue.

LUPA under the PDGM Influence

In the 2020 Patient-Driven Groupings Model environment, LUPAs will become even more complicated. This is due to the introduction of the multifaceted structure of visit requirement variables. Like so many other aspects of the new model, this change in calculation requires your attention.

Under PDGM, LUPA thresholds will be based on clinical grouping and episode timing. New LUPA episodes, which will be evaluated annually by CMS, will range from two to six visit thresholds and vary across the clinical groupings. Now, there will be a different visit threshold for each of the new 432 LUPA home health resource groups (HHRGs). In addition, LUPA potential will now be in each 30-day payment period within the 60-day episode of care.

LUPA Disagnoses

Historically, typical diagnoses prone to LUPA include heart failure, COPD, diabetes, and a range of diagnoses with a high risk for hospitalization. However, the PDGM guidance provided by Medicare provides a new range. The following LUPA threshold table provides a summary of the visit thresholds and related number of HHRGs and top clinical groups:

PDGM Lupa Impact

For your agency to be truly ready for the implementation of this new structure, begin analysis now. It is imperative that prior to this change you understand the impact the new model will have on your LUPAs. This preparation includes conducting an intense review of your current LUPAs. In addition, the review will further your understanding of the impact that 30-day periods of care will have after the model is implemented.

STEP ONE: Conduct an Internal LUPA Review

First, understand factors that are causing LUPAs in your patient population well in advance of 2020. Your PDGM committee should begin now by randomly reviewing a percentage of LUPA episodes with varying diagnoses. Continue this review process monthly for the next three to four months.

LUPA Review Process

The review process should consider the following questions:

  1. Was the episode front-loaded at the start of care (SOC) and resumption of care (ROC)? As you know, this could potentially reduce the chance of rehospitalization. Note: Frontloading is typically at least three visits within the first seven days of care.
  2. Does the patient’s clinical picture match the visit utilization provided?
  3. Did the patient require more visits to meet goals and improve outcomes?
  4. Was the LUPA a result of missed visits, staffing issues, patient refusal, and/or scheduling issues?
  5. Homebound status: was it confirmed correctly at SOC? Did t home health team utilize the patient-stated goal to drive the plan of care?
  6. Were the right disciplines added at SOC/ROC?

Examples may include:

  • Occupational therapist ordered for respiratory and COPD cases
  • Physical therapy for functional issues, falls risk, and safety concerns
  • Nursing for medication management, pain, self-management education needs
  • A medical social worker for depression counseling or family conflict resolution
  • Home health aides or other ancillary staff ordered to support care practice

From the findings of your internal LUPA review process, first, analyze your results and identify whether the LUPA could have been avoided. Second, investigate trends in avoidable versus unavoidable LUPA cases. Finally, start developing processes to correct avoidable LUPAs and begin educating your staff on these best practices for care.

STEP TWO: Know the Impact of 30-day Periods of Care

It’s imperative to begin thinking about the management of PDGM visit utilization in 30-day periods of care. For example, for LUPA visits of two or less in a second 30-day period, determine if this low visit count is impacting clinical outcomes. Then consider how moving those one or two visits into the first 30-day period would impact the patient’s outcomes. Certainly, it is possible that the first 30-day care plan with additional visits might produce better outcomes. In this case, the second 30-day period may not be needed and will not transform into a LUPA.

One way to analyze your risk for LUPAs within the second 30-day period would be to look at your organization’s 2017 data. First, compare previous data with what it may look like in the new payment model with the use of a LUPA threshold calculator. This will give insight into which 30-day periods and what types of episodes would fall into LUPA home health categories in a PDGM environment. Moreover, this type of impact analysis can help agencies understand what their strengths and weaknesses are moving forward. Sometimes a LUPA is inevitable. So, it is important to consider the big picture as you think about your 2020 case-mix strategy.

Preparation, Education, Documentation

Under PDGM, with a 30-day period to assess and treat a patient efficiently, we should front-load these patients with three visits in the first seven days of care. Similarly, organizations should utilize a comprehensive SOC assessment to determine the need for additional disciplines and obtain orders quickly to support the patient’s needs. If remote patient monitoring is available, this will also be a vital tool to help manage the 30-day period.

You must prepare and educate your staff. In addition to the new LUPA threshold in home health, there are other changes under the new payment model. For instance, make your staff aware of what behavioral adjustments are meant to correct. Schedule education sessions that teach the importance of accurate primary diagnoses and appropriate grouping. Invest in coding ed