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The Effect of PDGM on Clinicians

Since the Patient-Driven Groupings Model (PDGM) went into effect on January 1, many clinicians have probably asked themselves the same question I have: How does PDGM affect me? It is a reasonable question given that there was so much discussion about this considerable change during 2019. The Centers for Medicare and Medicaid Services (CMS) had not overhauled its methodology for home health agency reimbursement in almost 20 years. Change is hard, and a lot of clinicians were nervous about PDGM and what it would mean for them. Thankfully Axxess was here to help with education and resources. I try to remind clinicians I speak with that PDGM is a good thing for us, keeping in mind that the goal is to focus more on high-quality healthcare and fulfilling the needs of the patient versus simply delivering a high volume of care.

PDGM From the Clinician’s View

So how does PDGM impact clinicians providing care to patients? There are a lot of ways it has impacted clinicians. A Request for Anticipated Payment (RAP) must now be completed within five days, or the agency could lose out on reimbursement. This means that the clinical staff is under more pressure to complete documentation quickly. Thankfully, many in the industry have become familiar with documenting at the point of care, which is easier when using a home health software.

Therapy Changes Under PDGM

Since PDGM no longer reimburses for therapy based on the number of visits, there was a lot of speculation that therapy services would be cut altogether. Indeed, there are reports from some agencies that cuts to therapy services have been made. But clinicians must keep in mind that PDGM is not eliminating payment for therapy. Instead, CMS eliminated the volume of therapy visits being the determinant of payment for home health agencies.

The change to therapy reimbursement has caused many agencies and therapists to focus on the care and the needs of the patient. That means they must deliver care in a scaled timeframe without drastic pattern changes. The patient-centered model groups periods of care in a manner consistent with how clinicians differentiate between patients and the primary reason patients need home healthcare.

There has also been a concerted effort to focus on the delivery of care. Under PDGM, every visit is important, and the field staff must make certain each visit has a goal that aligns with the Plan of Care. Home health aides and nurses have also been tasked with fulfilling therapy roles, like monitoring a patient’s home exercise program.

The Functional Assessment

PDGM requires therapists to focus on the importance of the functional assessment. If multiple clinicians are providing care for the patient, they will need to collaborate on the Plan of Care. The clinician must complete the OASIS assessment accurately by providing thorough documentation with correct coding. This will make a huge difference with reimbursement under PDGM because the functional assessment is the only piece of information from the OASIS that is needed to submit a billing claim.

As we all have prepared ourselves for the change, we must remember to educate ourselves on PDGM and revise our workflow processes to deliver quality care to the patient. Axxess offers many resources to help staff and referral sources adjust to the new payment model. The PDGM Resource Center offers answers to frequently asked questions and tools to train staff. The home health software available from Axxess also features many enhancements that deliver valuable insight into patient care under PDGM, including a custom dashboard that shows real-time information. Using this data, clinicians can see how their work changes under PDGM and feel empowered to focus more on delivering quality patient care.


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