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Measuring PDGM Success - Industry Expert Weighs In

With one month since the PDGM transition, the industry asks, “How can we assure and measure whether our teams are successfully navigating the transition to PDGM?” Jason Sasser, PTA/CWT/CSST/ COQS, Vice President of Clinical Strategies, HealthPRO Heritage at Home, reflects on the industry’s most pertinent questions related to PDGM best practices and how to measure success. 

Q: What is the first step to streamlining, or simplifying revenue cycle efficiency and claim processing?

A: First, make sure referrals include all new, pertinent information required to admit and bill.  Ideally, every referral should have the new MBI (Medicare Beneficiary Identifier) number, accurate patient demographics, specific physician orders, and evidence to support the need for home health intervention.

In addition, executing on processes to streamline revenue cycle management will be especially important in 2020 for many reasons, not the least of which is because the RAP was cut significantly to 20% for 2020.  To optimize cash flow, agencies should start by analyzing current days to RAP and days to Final Claim submissions and comparing their own trends to industry benchmarks: 

  • Initial RAP at 5 to 7 days after admission
  • Final Claim at 10 to 14 days after discharge

There are several factors that impact revenue cycle including:  timing of data collection for each 30-day payment period; coding turnaround timelines per 30 day period; documentation management and timeliness; visit and non-routine supplies, documentation confirmation; and personnel demands secondary to additional billing & payment posting transactions. Nevertheless, perhaps the most challenging factor related to revenue cycle efficiency is the timeliness of verbal and signed physician orders. A final claim cannot be generated without first obtaining all necessary orders, and the turnaround time in receiving signed orders will play a large part in the delay of cash flow.

Q: There are important changes related to the allocation of therapy and nursing care.  What best practices exist for how home health providers should allot the optimal amount and intensity of services under the new system?

A: Under PDGM, home health providers are held accountable to delivering the most appropriate frequency and intensity of intervention based on patient characteristics.  In order to assure optimal outcomes under this new model of care, it was necessary for HealthPRO Heritage at Home to develop two sophisticated, yet simple solutions:  

HealthPRO Heritage’s Care Pathways to Success classifies each patient based on unique characteristics in order to determine target utilization for each therapy discipline.  There are several advantages to using these pathways, including:

  • Mitigates LUPA risk for each of the 432 patient classifications
  • Assures Gold Standard utilization practices derived from 4 and 5 star agency practices
  • Diminishes retrospective audits secondary to maintaining the service levels patients deserve
  • Reduces variability in clinical practice by allocating resources based on patient presentation
  • Assures efficient episodic cost management (because large variations in payment exist between the 432 different patient classifications, making it a real challenge to assure appropriate patient care AND empower agencies to operate efficiently.)

HealthPRO Heritage’s PDGM Calculator utilizes three key patient characteristics identified during the initial evaluation (Specifically:  (1) Principal Diagnosis, (2) Admission Source, and (3) Admission Timing) to generate a “recommended” number of visits for nursing and therapy. Integrated into our Care Pathways to Success, this simple, but sophisticated PDGM Calculator projects care needs, minimizes time required for verbal orders, and facilitates good documentation practices as well.

Q:  The PDGM system suggests home health clinicians will be seeing more clinically complex patients in 2020 and beyond.  How are home health agencies reacting to this important shift?

A: We are indeed admitting patients “quicker and sicker” to home health services.  HealthPRO Heritage at Home recommends that agencies must raise the bar on staff competencies, clinical skills, and treatment interventions. For example, our team is committed to providing on-going, comprehensive education for all staff and our client partners.  Webinars, clinical education sessions/materials are routinely provided that tackle challenging scenarios (e.g.: the clinically complex orthopedic patients; chronic wound care patients; or cardiopulmonary patients with co-morbidities) and empower our clinical frontline teams with all the resources and knowledge needed to treat higher acuity patients.  What is really comes down to is that therapists and nurses will have to be better case managers by having an interdisciplinary approach and be willing to do everything within their scope of practice to meet their patients’ needs. (Contact HealthPRO Heritage at Home for more details about our proprietary education/training series.)

Q: Can you provide an example of how success will be measured under PDGM?

Agencies should be advised to educate and empower their therapy/nursing staff with tools to drive strong functional performance outcomes that will ultimately serve to drive key performance metrics that are important to upstream referral sources.  Remember:  The intent of PDGM is to incentivize providers to focus on delivering more “value” than “volume.” As such, home health agencies must consider that upstream providers are more focused than ever on metrics such as rehospitalization rates, episodic costs and length of stay. 

This might mean investing time and resources into training your clinical teams on evidence-based treatment protocols and interventions.  The ‘new norm’ will be for therapists to work above & beyond traditional expectations by using tools, tests and measures that are well supported by evidenced based practice White Paper studies and research.    

HealthPRO Heritage at Home is focusing on strategies to assure positive functional outcomes in 2020 & beyond.  Because it is the right thing to do to drive value (as well as minimize risk with ADR activity), but more importantly, because it is the absolute right thing to do for patients we have the privilege of serving.   

Check back with HealthPRO Heritage in the weeks to come for more intel & insights.  As PDGM unfolds, we promise to share best practices and lessons learned.  After all, now is the time for increased collaboration and communication among our industry’s thought-leaders.  In the interim, share your comments on Jason’s interview here.  Thanks in advance!

Click here for the full printable article. 

Tags: Home Health, PDGM, Patient-Driven Grouping Model, CMS Update 2020