PDGM periods show overutilization and under-utilization of visits

In this world of the Patient-Driven Groupings Model (PDGM), home health providers are becoming accustomed to dealing with the 60-day episode of care as two 30-day billing periods.

In the time since PDGM’s implementation, McBee has identified a consistent trend within the new model. The first 30-day home health PDGM period is often heavily scheduled with disciplines and visits, while the second 30-day period often becomes a Low Utilization Payment Adjustment (LUPA) with only one visit completed or a nonbillable period with no visits completed. At the start of care, providers complete a comprehensive assessment for a 60-day episode so the patient’s plan of care should take into account the full 60-day episode of care.

It’s apparent that home health providers are struggling with efficient visit utilization under PDGM. By leveraging best practice episode management strategies, however, providers can drive efficient  PDGM visit utilization, deliver high-quality care and ensure financial viability.

Best practice PDGM visit utilization for a full 60-day episode

To reduce re-hospitalization, best practices include front-loading the episode, scheduling visits for the entire episode of care, then tapering visits as we prepare for patient discharge. This type of episode management gives the patient extra support during the fragile first seven to 10 days post-acute, then allows for discharge planning as patients stabilize and visits are tapered down until the end of the 60 days.

Leveraging case management is vital in episode management and discipline utilization

Now more than ever, case managers must take the lead in collaboration with care efforts. Interdisciplinary communication and teamwork will be vital to help manage discipline utilization efficiently.

Again, trends observed in PDGM demonstrate that disciplines are not communicating well regarding the plan of care. Trends show us that physical therapists (PT) and occupational therapists (OT) are often seeing the patient on the same day and that, at times, care goals overlap. We have also identified that nursing visits may be plotted heavily during the first month, yet the primary goals for the patient are functional in nature.

Case management best practices dictate that the lead clinician collaborate and communicate with the care team across disciplines to set the best plan for patient outcomes. The case manager should involve the clinical manager team leader after the initial interdisciplinary review and should recommend the primary disciplines for care.

For example, if falls risk is high, and it is decided that the goal of reducing the likelihood of a fall is paramount, then the case manager should recommend that PT lead the case. Physical therapy, in this effort, will be the most prevalent early in the plan of care. If RN and OT are ordered for this patient, they can provide an additional assessment of patient needs and coordinate their frequencies with any other disciplines involved. Tapering may look different – for example, RN may enter the episode at a lower frequency tapering up, as PT tapers down.

Analyzing LUPA trends to improve episode management efforts

PDGM and the COVID-19 pandemic have created the perfect storm for home health providers. Managing LUPAs proves to be a common pain point for providers of all sizes. The varying 2 to 6 visit threshold and obstacles with managing missed visits and scheduling pose challenges each day, which may result in an unintentional LUPA.

In our recent Home Health LUPA Trends at a Glance download, McBee identified key trends emerging from our analysis of CMS Q1 2020 PDGM claims data. Most importantly, we saw that 81.12% of subsequent period LUPAs were one visit away from meeting the LUPA visit threshold and that there is a strong correlation between lower LUPA rates, reduced number of average visits, and increased star rating.

Understanding the takeaways from our Home Health LUPA Trends at a Glance download is key for discovering opportunities to mitigate avoidable LUPAs, optimizing reimbursement, and establishing new care patterns into culture with our most recent insights. Download the full report for more information on these key takeaways.


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