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Will You Sink or Swim in PDGM? Care Pathways to Success

Is your current therapy company or in-house therapy team equipped to help you prepare, execute and succeed under PDGM?

Prepare.
As leaders in the post-acute care industry, HealthPRO® Heritage has engaged in discussions and strategy sessions with industry experts and formulated the following goals to ensure success under PDGM:

  1. Mitigate Low Utilization Payment Adjustment (LUPA) risk 
  2. Set out gold standard utilization practices derived from 4 and 5 Star agencies
  3. Diminish retrospective audit risk secondary to maintaining the service levels patients deserve
  4. Deliver episodic cost management
  5. Maintain financial viability by aligning service utilization with patient presentations which ultimately determine payment
  6. Reduce the variability in clinical practice by allocating resources based on patient classification

Execute.
HealthPRO® Heritage has the expertise you need to help navigate the changes within PDGM successfully. Included in that expertise is a practical solution to ease your PDGM concerns: Care Pathways to Success. We listened to the industry response to our survey in collaboration with NAHC, which highlighted the need for office based care coordination.

We understand the need to implement a scalable and comprehensive solution to achieve the aforementioned goals. The solution seems simple, however, the wide variations in payment between the 432 different patient classifications make it challenging to ensure patients receive the care they deserve while allowing agencies to maintain fiscal responsibility.  

PDGM aligns reimbursement with patient presentation through a unique combination of the five payment factors and shifts the responsibility to determine appropriate levels of care to providers.  As seen in the table below, there is a wide range of payment within each clinical grouping. The complexity of the payment model does not allow for isolation of the five payment factors. When viewed in isolation there are instances when a community admission source may reimburse higher than an institutional or a late episodes may reimburse higher than an early episode and thus it is important that all five reimbursement factors are considered.

The following table illustrates the wide variation in reimbursement, LUPA thresholds and variations for each of the five payment factors.

PDGM Blog LUPA Table

To address the significant variances that occur based upon individual patient classification, HealthPRO® Heritage has developed Care Pathways to Success. These pathways are designed to provide agencies with a road map to tie utilization to each patient classification based on 4 and 5 star agency practice while also maintaining fiscal responsibility.  Our Care Pathways to Success tool addresses the key items to create success under PDGM including:

Financial Performance:

  • A complete data-driven case management solution that aligns care delivery by reverse engineering the payment methodology process to align service delivery with each grouping.
  • Ensures financial viability by tying specific care levels to each patient classification
  • Adds to an agency’s ability to maintain margin through revenue cycle projections
  • Delivers a cost management solution regardless of how your patients present
  • Mitigate LUPA risk for each of the 432 patient classifications

Clinical Performance:

  • Sets out gold standard utilization practices derived from 4 and 5 Star agency practices
  • Diminishes retrospective audits secondary to maintaining the service levels patients deserve
  • Reduces the variability in clinical practice by allocating resources based on patient presentation
  • Maintains financial viability by aligning service utilization with patient presentations which ultimately determine case payment

Succeed.
Need a partner to help you succeed? Want to learn more about how Care Pathways to Success can help your agency? HealthPRO® Heritage has invested extensive resources to understand what payment reform will mean to our partners, company and the industry as a whole. We are well-prepared to be an integral partner in accelerating customer and staff readiness for these significant changes, while continuing to lead the industry in clinical innovation, and patient-focused outcomes. As one of the nation’s largest post-acute therapy providers, we are privileged to have served this unique industry for more than 20 years, empowering clients with invaluable resources/insights/support to best care for their patients and improve their position in a changing regulatory environment.

Our clients will continue to thrive in the new world of PDGM. If you’re not already partnered with HealthPRO® Heritage, we invite you to talk with us about what we genuinely believe is among the industry’s most innovative and comprehensive plan to support you and your staff for success in 2020 and beyond.

#Ready4PDGM

Click here for the full printable article. 

PDGM_PrepareExecuteSucceed

Tags: CMS, Home Health, PDGM, Patient-Driven Grouping Model