The Patient Driven Grouping Model (PDGM) was implemented January 1, 2020 and changed reimbursement models of Medicare home health services from therapy utilization driven to patient characteristics. While this has allowed for a focus from quantity to quality, some home health agencies are restricting therapy visits and placing their quality measures, Star Rating, and most importantly patient outcomes at risk. CMS calculates Star Ratings through several areas therapy may influence including, ambulation, bed transfers, bathing, discharge location, and rehospitalizations.
Many clinicians in the industry are growing concerned that quality home health care may be rapidly dying under PDGM with visit cutbacks and limitations. In today’s healthcare industry, it is vital to turn to evidence-based intervention practices to guide care. With utilization no longer a factor in reimbursements, agencies have the responsibility to provide services supported through research and literature. This will support maximizing both patient outcomes and ultimately agency Star Ratings. The Medicare/CMS Star Rating System is the industry standard used to compare agencies to their competitors with outcomes and quality of care. In addition, consumer data suggests that around 70% of potential home health patients and their families look up Star Ratings online before choosing a home health provider.
It’s in the best interest for agencies to use evidence-based practices to ensure better outcome measures and higher Star Ratings. These practices will ultimately be essential in agency longevity to ensure success under PDGM. Studies indicate that therapy provides essential benefits when it comes to outcomes. A retrospective study by Taliah Cook, OTD, OTR/L and Rochelle Mendonca PhD, OTR/L found that home health care programs involving occupational therapy had a positive impact on functional independence for older adults in the home. This study especially looked at lower extremity bathing, bed mobility, and transfers, all metrics that impact Star Ratings. Another study focused on 319 people over the age of 70 with functional difficulties and found that occupational and physical therapy sessions in the home may decrease mortality risk in community dwelling elders (Cook and Medonca, 2017). A third study demonstrated occupational therapy services provided to older patients living in the community after being discharged from a hospital or post-acute setting demonstrated improved dressing, toileting, and walking scores while those not receiving occupational therapy did not improve scores (Matteliano et al. 2002). These are just a few of the current research articles supporting therapy interventions in the home.
In an attempt to counteract poor outcomes, some agencies may turn to the use of the rehab aide, or unskilled personnel through restorative programs. Although this may seem like a solution, agencies must keep in mind that these personnel are unskilled. Restorative programs are designed to maintain, not to improve, outcomes in the long-term; therefore, they will not have the desired impact on quality measures the same way skilled therapy is positioned. Promoting less therapy visits and faster transitions to restorative programs may be decreasing their chances of achieving the best outcomes possible. There is absolutely a place for restorative programs in home care; however, they cannot take the place of skilled therapy services.
Looking at opportunities to mitigate hospitalizations through skilled and licensed clinicians is another aspect to consider. Subtle changes in weight, edema, respirations, vitals, behaviors may be signs or symptoms of a potentially hazardous medical condition. Therapists are trained in assessing and observing for these symptoms. Timely identification of risks and symptoms is essential to prevent rehospitalizations. Clinical research has identified that before most exacerbations of a disease or infection, there is a period of decreased mobility with body chemistry and vital changes.. It most often takes a highly skilled clinician to be able to identify these changes and intervene.
Cost may be the biggest barrier for agencies to provide the therapy utilization that supports the best patient outcomes. However, some agencies may not realize that the benefits far outweigh these costs they cannot afford to limit therapy services. HealthPRO Heritage has completed analysis on industry claims data which indicates that across all of the new PDGM patient classifications, 4 star agencies provide more therapy than the industry average and 5 star agencies provide more therapy than 4 star agencies. While many agencies practices for cost containment under PDGM is decreasing therapy utilization, it just may be what ultimately leads to their own demise and drop in quality.
To read The Dangers of Therapy Utilization - Part 1: The CMS Perspective, click here.
Cook,T., Medonca, R. (2017). The Effectiveness of a Comprehensive Home Health Program for Functional Independence of Older Adults in the Home. American Journal of Occupational Therapy, 71, 7111515219. https://doi.org/10.5014/ajot.2017.71S1-PO2018
Gitlin, L. N., Hauck, W. W., Winter, L., Dennis, M. P., Schulz, R. (2006). Effect of an in-home occupational and physical therapy intervention on reducing mortality in functionally vulnerable older people: Preliminary findings. Journal of the American Geriatrics Society, 54, 950-955. https://doi.org/10.1111/j.1532-5415.2006.00733.x
Mary Matteliano, William C. Mann & Machiko Tomita (2002) Comparison of Home Based Older Patients Who Received Occupational Therapy with Patients Not Receiving Occupational Therapy, Physical & Occupational Therapy In Geriatrics, 21:1, 21-33, DOI: https://doi.org/10.1080/J148v21n01_02