Axxess-BKD Trends Report Confirms PDGM Is Key Industry Concern


a nurse discussing pdgm home health with patients

The potential impact of The Patient-Driven Groupings Model (PDGM) has led to a lot of uncertainty among home health providers, and a new industry poll shows adapting to the new payment model and other regulatory changes is considered the greatest challenge for the industry this year.

A joint survey conducted by Axxess and home healthcare consulting firm BKD of thousands of home health, hospice, and home care providers from agencies of all sizes in late 2019 confirmed that most agencies are at least somewhat concerned about the impact of PDGM, but there is more confidence among larger agencies that they will manage the change effectively.

The survey, conducted over several weeks, confirmed that PDGM will be a primary focus for agencies of all sizes this year, and that they consider technology’s primary benefit to be helping them remain compliant with regulations and streamlining documentation of care.

Based on the findings, numerous best practices to help agencies thrive in the years ahead were offered by Axxess and BKD in a report, and can be found at the end of this blog.

PDGM Will Have Long-Term Impact

The survey included respondents from all levels of organizations, including management and caregivers directly working with patients and clients, and revealed that most in the industry see the impact of PDGM continuing to be felt in the coming years, though larger agencies see risk-based population health management as also having a big impact on their organization.

Home-based care agencies of all sizes tend to be most satisfied with the quality of care they provide and the overall satisfaction of their patients and clients, while areas of their business related to the bottom line, such as operations and marketing, are areas needing improvement. Maintaining relationships with referral sources is seen as among the best opportunities to growing business in the coming year.

Respondents from agencies of all sizes also expect that their agencies will primarily rely on established business practices within their organization to help grow their business in the years ahead, though a significant number see their organization diversifying into other service lines.

Best Practices to Thrive in Coming Years

Based on survey findings, Axxess and BKD compiled some best practices for agencies to consider for thriving in the coming years.

  • Know your data. It is important for agencies to have insight into key performance indicators (KPIs) such as percentage of community and institutional referrals, early and late episodes, Low Utilization Payment Adjustments (LUPAs) length-of-stay and days to process RAPS and Finals, as well as cost-related KPIs such as visit utilization per patient characteristic, cost per visit and other similar KPIs.
  • Ensure OASIS accuracy. Questions related to functional ability will impact PDGM reimbursement and should therefore be accurate in order to ensure the agency will receive correct reimbursement and quality scores. An intra-disciplinary collaborative approach is recommended when completing OASIS functional questions.
  • Tighten all operations to ensure that documentation accurately reflects the patient characteristics and is completed in a timely manner. This will impact a home health agency’s ability to maintain cash flow through RAP and Final, as well as the ability to control missed visits and therefore prevent avoidable LUPAs. Clinical documentation must continue to stand alone. Emphasis should be placed on medical necessity of care and documentation of skilled intervention with each visit note. Detailed operational guidance should be in place when non-groupable codes are received during intake. The process should outline continuation of patient care as well as care coordination with the referral source.
  • Ensure billing accuracy for PDGM-related billing and payment elements by beginning concurrent billing at the start of the billing episode. Ensure processes are in place to document medical necessity of a change in condition that supports a change in primary diagnoses. Ensure diagnoses changes for primary and secondary diagnoses and other key elements, such as change from institutional to late, are accurately documented on claims for each 30-day payment period.
  • Strengthen your referral base by identifying opportunities to develop specialty programs or refocusing marketing strategies to deepen or diversify referral relationships.
  • Communicate with referral sources about the need for detailed patient information in order to ensure ICD-10 codes are specific and do not create a questionable encounter code.
  • Use technology more in all aspects of the business, including marketing, clinical, billing, financial, analytics and reporting.
  • Re-evaluate your processes and look for opportunities to make them more effective and less redundant; even automate, if possible. Create processes and systems to continuously evaluate how you operate.
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