How is PDGM Working for Home Health Providers?

The first full quarter of using the Patient Driven Groupings Model (PDGM) is in the books for home health providers – but those books were full of unexpected twists and turns due to COVID-19. Regardless, we at Transcend wanted to learn what data trends may reveal about how the new system is working for home health agencies nationally.

So, we talked with Jess Stover, principal, and Erin Masterson, consulting director, at BlackTree Healthcare Consulting – a firm that leverages big data to provide strategies and resources that improve clinical, operational and revenue cycle management for its clients.

In our conversation with Jess and Erin, four key themes emerged. Here are the highlights:

1. Coding is more accurate and comprehensive. “This is something we were anticipating, because agencies were preparing for this,” Erin said. “Less than 1 percent of periods that are being submitted are categorized as that questionable encounter.”

“With shifts from higher pay categories to comorbidities, we saw high functional scoring and higher payments coming out on that end as well,” added Jess.

2. RAPs are being submitted earlier. “RAP was a large focus for agencies and a lot of our clients were improving on that,” Erin said. “When COVID-19 hit, the priority shifted (to staff and patient safety), but there are agencies still performing well and they’re still getting their RAPs in the seven days that we like to see it.”

Before PDGM, CMS data showed that the median for RAP submission was 12 days. So if that is indeed being shifted downward toward seven days, it can have a significant impact of higher reimbursement for “early” submissions and better cash flow.

3. LUPAs are tricky and need strong management. “Through January, February and March, we saw the LUPA percentage around 10 percent and that’s what we were anticipating,” Erin said. “However, going into Q2, we anticipate that LUPA percentage definitely increasing. We’re seeing a lot of that because we have patients refusing care. Simply, they don’t want caregivers in their home if it’s not absolutely necessary nor are their physicians advising it.”

“If you start to slip in your operations under PDGM, if you’re not looking at missed visits or refused visits or staff moving visits a day earlier/later, that could significantly change your LUPA percentage, especially under that 30-day period model,” Jess said. “So, I think those are just some key performance indicators that are really vital to manage and track under PDGM. And especially now, given the impacts of COVID, but even without COVID I think managing LUPAs just gets very tricky.”

4. Telehealth will be vital for better patient outcomes. “There’s a lot of advantages from a patient care perspective to utilize telehealth to drive better patient outcomes – and that’s what CMS under PDGM was really getting at, right?” Jess said. “I think utilizing telehealth just to get more data and be able to provide better care to patients will really be instrumental.”

“That’s just something that not all agencies were utilizing and I think that they’re going to start to trend that way,” Erin added. “And realizing how important that technology is for optimal care, and to manage those outcomes for the patient as well as be more efficient in the agency and overall operations.”

You can hear the full conversation with BlackTree Healthcare Consulting in our latest podcast episode below. Time, a lot more data, and a return from COVID-19 conditions will tell a truer story of how PDGM is working for home health providers. Meanwhile, there are positive signs that many agencies are adjusting well to the new system – with benefits for patients and their own organizations.