Six Months of PDGM Implementation

This content was originally published on June 26, 2020 

McBee thought leaders share what they have learned from agencies after the first six months of PDGM implementation.  

Industry experts knew for quite some time that implementing the patient-driven groupings model (PDGM) was going to have a massive impact on the home health industry. Consultants and national/state associations far and wide advocated for organization-wide change, with training and preparation beginning as far as a year in advance. PDGM began officially in January 2020, and the COVID-19 pandemic exploded on the scene in March, making an already challenging time for home health agencies downright overwhelming. 

With the use of the McBee platform, our coding and OASIS team tracks data and metrics via real-time reporting. McBee clinical consultants and account representatives spend hours working with agencies to improve and review workflow and processes. What did we find? Agencies who had prepared appropriately for PDGM are currently experiencing more straightforward navigation in PDGM and reacted well overall to the clinical impacts of COVID–19. 

Conversely, agencies with little or no preparation – especially line staff- are experiencing difficulties with data collections, timeliness, and claims preparations; COVID-19 costs have negatively impacted agency budgets, and playing catch-up is not going well. 

What We’ve Seen 

Preparation Equals Results 

Agencies were moving along reasonably well until COVID-19 hit. Drawing from anecdotes and data, we found that for our agency partners, the more prepared they were for PDGM, the better they have done after January 1, 2020. Our definition of preparation? Their EMR was ready; they had provided sufficient education to their staff and referral sources; clinical or middle managers were appropriately pivotal in assisting clinicians in managing the 30-day period of care. 

Therapy Utilization in PDGM Implementation 

Therapy utilization may not match the OASIS. We are seeing situations where the patient’s functional assessment should require more therapy than the patient is receiving – an actual under utilization of therapy services. We are also hearing from professional organizations of significant therapy layoffs. 

Virtual Visits 

A significant number of agencies are performing virtual therapy visits. This transition to virtual care was not a direct result of PDGM, but rather because of the novel coronavirus public health emergency. Unlike any other visit, a virtual therapy visit does not carry the cost of travel time and mileage attached to the visit. Therapists go through the home exercise program with the patient, and nursing can provide education through this means as well. 

Documentation Improvement 

In the runup to this new payment model, one of McBee’s thought leaders, Laura Page-Greifinger, said that PDGM would force agencies to stop doing things “the old way.” However, while it is improving, documentation is still problematic. The clinicians often fail to capture the care being provided and, in essence, the skill required to meet Medicare COPs. There is insufficient documentation of both the education provided and of the patient’s understanding of said education. Unfortunately, we have seen some woefully inadequate plans of care. Documenting homebound status to meet the required criteria is an issue for some agencies. 

What This PDGM Implementation Means for Agencies Now 

Operationally Speaking 

• Agencies were “moving along well” in PDGM until COVID-19 hit 
• Telehealth is becoming more accepted – even by skeptics – it now must become a paid visit. 

• Order tracking is improving, but those orders tend to be slow to get out of the door. Additionally, there has been more portal utilization for the clinician signature.  

Clinically Speaking 

• POCs are still being written the same way – there is no change in that it is not patient-centered for that patient. There still exists a great deal of canned language from EMR libraries. Remember, SN 1 x 9 is no longer an appropriate home care plan. 
• Therapy utilization may not match OASIS. 

• More virtual visits. Staff is concerned they are not gathering all the right information. We highly recommend the creation of a document to track a virtual visit accurately. 

Financially Speaking 

• Days-to-RAP have not changed much for most agencies. With the 5 day RAPs the best practice is 3days. 
• Days-to-Final have also not changed much for most agencies – that will become a problem if this trend continues. 
• Staff not costing out the POC, which results in reimbursement not covering the care provided. 

• Few returns to the provider (RTP) are happening due to nonvalid diagnosis codes being sent as primary – there is no hard stop in some EMRs. 

Where Do We Go From Here With PDGM in Implementation? 

Ultimately, those agencies with excellent cash flow before PDGM due to 3-5 days to RAP remain in a high position. Those who did not are now experiencing a crunch. The impact of having 30-day periods and the 5 day RAP requirement will continue to mount on top of each other. The same principle applies to days-to-final. Agencies must get their timelines under control. Some EMRs were unprepared for the change, and the agencies suffered because of this, explicitly billing those 30-day periods. If you haven’t already, insist that your EMR update accordingly. For instance, an area where EMRs could/should have helped was with hard stops for questionable encounters. We still see agencies code diagnoses unacceptable in PDGM; the claim gets returned to the provider (RTP). This process creates rework,  RAP non compliance and penalties. 

Return to PDGM’s original tenet: a focus on patient care. With PDGM, P is for Patient, yet we see plans of care written that are not patient-specific or patient-centered. Both the plan of care and the narrative must paint a picture of the patient. Reworking the process and fine-tuning documentation will go a long way in changing your outcomes in PDGM. 

Coding and OASIS in PDGM with McBee 

Expert Hands-On Help 

To help you cope with PDGM, McBee reviews your agency’s coding and OASIS and provides an assessment of what reimbursement will look like with your processes. 

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