Understanding the PDGM Rule Today to Best Prepare for Tomorrow: the Role of Telehealth

By Elena Muller, MPH

The new Patient-Driven Groupings Model (PDGM), announced in the Bipartisan Budget Act of 2018, will take effect on or after January 1, 2020. PDGM will restructure the current home health payment model by shifting the home health industry from a volume-based payment structure to a value-based one.

The Patient-Driven Groupings Model (PDGM)

Among other provisions, PDGM shifts Home Health Agencies (HHAs) from using a 60-day payment episode to shorter, 30-day payment periods*, eliminates the current payment model’s therapy threshold, and customizes the thresholds for receiving Low-Utilization Payment Adjustment (LUPA).

The National Association for Home Care and Hospice has declared PDGM the most impactful change to the home care industry in nearly 20 years. Before diving into the impacts of PDGM and the role that telehealth will play in this major transition, be sure to get caught up on the PDGM legislation.

Telehealth for HHAs in the New PDGM Era

Prominent changes to the home health payment system will take effect with the roll-out of PDGM. Primary changes include eliminating therapy volume as a reimbursement factor and halving the payment period from 60 days to a series of 30 days. The question to consider is, how can HHA’s continue to provide quality and necessary care without negatively affecting their bottom line?

The use of telehealth will be a great resource to mitigate the daunting and complicated changes that PDGM will bring in 2020. Therapy visits are not an element of care that can be cut the day this new rule goes into effect; patients will still need the same high-quality care and easy access to their clinicians as they had pre-PDGM.

Telehealth can be used to augment care and replace unnecessary in-person home health visits without compromising patient care. While enabling HHA's to better coordinate care and engage patients, this functionality will also increase reimbursement and help HHA’S be more cost-efficient and conscious.

30-Day Payment Period

The reduction to 30-day payment periods supports the movement towards alternative methods of care. To maximize patient care and cost efficiency in a shorter time span, HHAs must increase care coordination and patient oversight.

“There is a ton of opportunity for telehealth in the PDGM world,” says Nick Seabrook, managing principal for BlackTree Healthcare Consulting. BlackTree suggests utilizing telehealth to approach patient care holistically, focusing specifically on each patients’ individual needs – a case management approach.

Returning to a case management model, supported by telehealth, will allow clinicians to educate patients through pre-recorded videos or face-to-face video conferencing and engage with patients to set goals for their care plan, reinforcing positive behavioral changes. Remote monitoring of patients improves cross-communication and collects data to improve both patient care and HHA clinical workflows continuously.

Eliminating Therapy Thresholds & Getting Creative with Telehealth

The elimination of therapy volume from the payment model is arguably the most significant change HHA's will face under PDGM as agencies are de-incentivized from over providing therapy. Therapy visits will not drive revenue. This change will require therapy-centric HHAs to find creative ways to become more efficient as therapy visits are no longer a guaranteed revenue-driver. Telehealth is a tool that agencies can use to drive down the volume of in-person therapy visits, serving as a great resource for use between visits to nudge or check-in with patients.

HHAs should consider maximizing their staffing resources by using advanced physicians to remotely supervise lower-licensed clinicians (for example, physical therapy assistants) as they perform in-person visits. This allocation of resources will enable advanced clinicians to focus their time on their most high-risk patients.

The use of virtual visits reinforces the importance of patient education in delivering quality care and changing patient behavior. Clinicians can utilize video conferencing as an education tool to evaluate a patient’s technique for taking his or her vital signs or for using inhalers (which is particularly important for CHF patients). For physical therapy patients, clinicians can evaluate and demonstrate therapy through video conferencing, and upload educational content that the patient can engage with on their own. Additionally, with telehealth wound imaging, providers can track improvement and regression of post-surgical wounds virtually.

Understanding Your Agency Today

What is most important is understanding your agency today to understand best what you will look like under PDGM. A few important things to understand and key metrics to monitor include:

    • The workflow of your organization – do you have the staff levels required to implement optimal workflows under the new rule? Have you considered interdisciplinary best practice care plans?

    • What percentage of periods fall under a questionable encounter status and what percentage of periods would qualify for a co-morbidity adjustment? This will help you understand what reimbursement will look like for your HHA under PPDGM.

    • What is the composition of your patients? Which of the 432 new payment groups will they fall under?

    • Do you have a preparedness plan? It will be helpful to develop a strategic action plan and educate your team on PDGM and how it will affect workflow their day-to-day.

    • Do you understand OASIS coding? OASIS determines risk stratification, captures acuity and revenue, and provides information for effective care planning. Episode payments are based on the clinical characteristics of the patients (ICD-10 diagnosis codes), and the patient's functional score from responses to 8 OASIS items.

    • What is your current referral and documentation process? Under PDGM, correct coding at intake will be essential. It will be important to document everything from the first face to face visit until patient discharge.

    • Are you on track for hitting your milestones with your EMR for implementation and management for PDGM?

In the post PDGM world, it will be essential that agencies have data and documentation to back up their processes, to justify any operational changes that they make because of PDGM. Agencies have an opportunity to reassess their clinical data documentation, to ensure confidence and back up their processes.

Preparing for PDGM and Understanding the Role of Telehealth

On September 17, 2019, Health Recovery Solutions and BlackTree Healthcare Consulting will partner to host a webinar: Preparing for PDGM, the Role of Telehealth. The webinar will further discuss the implications of PDGM on Home Health Agencies, and present best practices moving into 2020.

Register for the webinar here.



* OASIS still only must be done every 60 days


Tags: Best Practices, reimbursement, Industry trends

Subscribe to HRS Telehealth and Remote Patient Monitoring Blog

Subscribe to the HRS Blog